Chapter 5: Therapeutic Relationships

Therapeutic Relationship One of the most important skills a nurse can develop Crucial to success of interventions with clients requiring psychiatric care

Components of Therapeutic Relationship Trust Behaviors such as caring, interest, understanding, consistency, honesty, promise keeping, listening (Box 5.1) Congruence is essential Genuine interest Self-comfort, self-awareness of strengths and limitations, clear focus

Components of Therapeutic Relationship (cont’d) Empathy Putting oneself in client’s shoes Client and nurse giving “gift of self” Different from sympathy (feelings of concern or compassion; focus shifting to nurse’s feelings) Acceptance (no judgments; set boundaries) Positive regard (unconditional nonjudgmental attitude)

Self-Awareness Know self Values (sense of right and wrong, code of conduct for living) Values clarification Choosing Prizing Acting Beliefs Attitudes (Box 5.2 and Box 5.3)

Question Tell whether the following statement is true or false: A nurse displays empathy by showing feelings of concern and compassion.

Empathy is putting one’s self into the client’s shoes. Answer False Empathy is putting one’s self into the client’s shoes. Sympathy is showing feelings of concern and compassion.

Therapeutic Use of Self Use of aspects of personality, experience, values, feelings, intelligence, needs, coping skills, perceptions to establish relationships beneficial to clients Concept developed by H. Peplau

Therapeutic Use of Self (cont’d) Johari window: tool to learn about oneself 4 quadrants: open/public self; blind/unaware self; hidden/private self; unknown Goal: move qualities from quadrants 2, 3, 4 into quadrant 1

Therapeutic Use of Self (cont’d)

Ways of observing, understanding client interactions Patterns of Knowing Ways of observing, understanding client interactions Four patterns (Carper, 1978; Table 5.1) Empirical (derived from nursing science) Personal (from life experiences) Ethical (from moral nursing knowledge) Aesthetic (from art of nursing)

Patterns of Knowing (cont’d) Fifth pattern (Munhall, 1993): unknowing Nurse admits lack of knowledge of client or understanding of client’s subjective world

Types of Relationships Social Purpose of friendship, socialization, companionship, or task accomplishment Superficial communication; shifting roles; outcomes rarely assessed Intimate Emotional commitment of two persons Individual needs met; assistance with helping each other meet needs

Types of Relationships (cont’d) Therapeutic Focus on needs, experiences, feelings, ideas of client only Use of communication skills, personal strengths, understanding of human behavior by nurse Joint agreement on areas to work on; outcome evaluation

Question Tell whether the following statement is true or false: A social relationship involves superficial communication for the purposes of friendship or task accomplishment.

Answer True A social relationship occurs for friendship, socialization, companionship or task achievement. It involves superficial communication with shifting roles.

Establishing a Therapeutic Relationship Peplau’s model of three phases Orientation Working Termination (Table 5.3) Overlapping, interlocking of phases

Establishing a Therapeutic Relationship: Orientation Phase Meeting nurse, client Establishment of roles Discussion of purposes, parameters of future meetings Clarification of expectations Identification of client’s problems Nurse-client contracts/confidentiality, duty to warn/self-disclosure

Establishing the Therapeutic Relationship: Working Phase Problem identification: issues or concerns identified by client; examination of client’s feelings and responses Exploitation: examination of feelings and responses; development of better coping skills, more positive self-image, behavior change, independence Possible transference/countertransference

Establishing the Therapeutic Relationship: Termination Phase Begins when client’s problems are resolved Ends when relationship is ended Deals with feelings of anger or abandonment that may occur; client may feel termination as impending loss

Behaviors Diminishing Therapeutic Relationships Inappropriate boundaries (relationship becomes social or intimate) Feelings of sympathy, encouraging client dependency Nonacceptance of client, avoidance (Box 5.4)

Question During the working phase of a nurse-client relationship, which of the following would occur? Expectations are clarified Nurse-client contracts are established Feelings of loss are addressed Client feelings are examined

Client’s feelings are examined Answer Client’s feelings are examined During the working phase, the client identifies issues or concerns and his or her feelings and responses are examined. Expectations are clarified and contracts are established during the orientation phase. Feelings of loss are addressed during the termination phase.

Therapeutic Roles of the Nurse in a Relationship Teacher (coping, problem solving, medication regimen, community resources) Caregiver (therapeutic relationship, physical care) Advocate (ensuring privacy and dignity, informed consent, access to services, safety from abuse and exploitation) Parent surrogate (Box 5.5)

Self-Awareness Issues Nurse’s self-awareness: crucial to developing therapeutic relationships Helpful activities: values clarification, journaling, group discussions, reading Development of self-awareness: continual, ongoing process