1. THERAPEUTIC RELATIONSHIPS
Patient -nurse relationship
Building rapport
Professional Boundaries
Communication skills
Interviewing

2. Types of relationships
Social
Intimate
Therapeutic
social relationships are primarily initiated for the purpose of friendship, socialization, enjoyment, or task accomplishment. Characteristics include mutually met needs and superficial communication. Communication techniques include giving advice and meeting dependency needs. Little evaluation of the interaction occurs.
Intimate relationships; occur between two individuals who have an emotional commitment to each other. Each reacts naturally to the other. Mutual needs are met; personal information, intimate desires, and fantasies are shared. Short- and long-range goals are usually mutual.
Therapeutic relationships focus on client needs rather than nurse needs. Client issues, problems, and concerns are explored and potential solutions are discussed. New coping skills develop and behavioral change is encouraged. The nurse uses communication skills, understanding of human behavior, knowledge of the stages and phenomena occurring in a therapeutic relationship, and personal strengths to enhance client growth. Nurses’ roles include teacher, counselor, socializing agent, liaison, etc.
A therapeutic relationship incorporating principles of mental health nursing is clearly defined and different from other types of relationships. It has specific goals such as facilitating communication of distressing thoughts and feelings; assisting clients with problem solving to help facilitate ADLs; helping clients examine self-defeating behaviors and test alternatives; and promoting self-care and independence.

3. Therapeutic Relationship
An interaction between two people in which input from both participants contributes to a climate of healing, growth promotion and/or illness prevention

4. Nurse client relationship
Therapeutic nurse client alliance
Takes time
requires skill
Focus is on the client
Early phase focuses on establishing an understanding that the nurse is safe, confidential reliable, and consistent

5. Goals include
Facilitating communication of distressing thoughts or feelings
Assisting clients with problem solving
Helping clients examine self defeating behaviors and test alternatives
Promoting self care and independence including coping skills
Focus is consistently on clients problems and needs
And potential solutions

6. Factors that promote growth in a client
Genuineness
Empathy (much different than sympathy)
Maintain objectivity, emotionally separate
Positive regard (attitude and action)
genuineness is awareness of feelings as they arise in the relationship and the ability to communicate them when appropriate. Genuineness, or congruence, would be demonstrated by not hiding behind the role of nurse, by listening to and communicating without distorting others’ messages, and by being clear and concrete.
Helps to develop rapport and trust
Trust must be earned,
Keep in mind that many psychiatric clients experience concrete thinking which focuses their thought processes on specifics rather than generalities. Examples that promote trust; providing a blanket, providing food, keeping promises, being honest, simple and clear reasons for procedures or rules, being consistent, ensure confidentiality
Nurse must convey an aura of trustworthiness. Which requires that he or she possess a sense of self confidence. Not about power,
The ability to see things from the other person’s perspective, to experience what the other is feeling, and to communicate this understanding, which denotes acceptance. It is not to be confused with sympathy, which has more to do with compassion and pity. Sympathy is not objective; empathy is objective.
To show respect is to believe in the dignity and worth of an individual regardless of his or her unacceptable behavior. Demonstrating unconditional positive regard.. The attitude is nonjudgmental,
Implying respect is the ability to view another as being worthy of being cared about, and as someone who has strengths and achievement potential. Attitudes and actions that convey positive regard are willingness to work with clients to help them develop their own resources, attending, and suspending value judgments.
One attitude through which a nurse might convey respect is willingness to work with the client.
Some actions that manifest an attitude of respect are attending, suspending value judgments, and helping clients develop their own resources.
Many psych clients have very little self respect owing to the fact that because of their behavior they were frequently rejected by others in the past. Recognition that they are being accepted and respected as unique individuals on an unconditional basis can serve to elevate feelings of self worth and self reapect
Call the client by name, spending time with client, promoting an atmosphere of privacy, always bein open and honest, striving to understand the motivation behind the clients behavior

7. DETRIMENTAL NURSE-CLIENT RELATIONSHIP
nurse tries to get his or her own needs met
nurse tries to solve the client’s problems
nurse takes the role of a friend or family member of the client
lack of boundaries in the relationshiP

8. Factors Hampering Nurse-Client Relationship
Lack of nurse availability or lack of contact
Lack of nurse self-awareness
Nurse's negative feelings about client (counter transference?)
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

9. Establishing boundaries
Blurred boundaries
Overhelping
Controlling
Narcissism
Recognizing
Transference
Client unconsciously transfers or displaces feelings formed toward a person in the past to the nurse
Countertransference
Separating the client’s needs from the nurse’s needs is how the nurse role and the client role are differentiated. However, boundaries may blur when the relationship slips into a social context and when the nurse’s behavior reflects getting self-needs met at the expense of client needs. Resultant actions include overhelping, controlling, and narcissism (i.e., finding weakness, helplessness, and illness in clients in order to feel helpful).
Transference A process whereby a client unconsciously and inappropriately displaces onto individuals in his or her current life (therapist) those patterns of behavior and emotional reactions that originated with significant figures from childhood. Occurs in all relationships; however, it is intensified in relationships of authority. Examples of transference are desire for affection and respect, gratification of dependency needs, hostility, competitiveness, and jealousy.
Countertransference The opposite of transference occurs when the therapist displaces onto the client positive or negative feelings caused by people in the therapist’s past. Examples include overidentification with the client, power struggles, and competitiveness with the client. Working through transference and countertransference issues is crucial to professional growth of the nurse and positive change in the client, and is best dealt with by use of supervision by an experienced professional.

10. Understanding ourselves
Acknowledging values, feelings
Reflects our own culture, experiences
These are abstract standards representing an ideal. Values influence choices and provide a framework for life goals. They are largely culturally oriented, and are formed through the example of others (modeling). Nurses will be required to plan and implement care for clients having values that differ from the nurse’s own values; therefore, nurses must have self-awareness regarding their own values and sensitivity to the values of others
This is a process of helping people to understand and build their value system. A value may result from one of seven subprocesses, in an emotional, cognitive, or behavioral framework:
Prizing one’s beliefs and behaviors (emotional)
Cherishing the value
Publicly affirming the value when appropriate.
Choosing one’s beliefs and behaviors (cognitive)
Choosing the value from alternatives
Choosing the value after consideration of consequences
Choosing the value freely
Acting on one’s beliefs (behavioral)
Acting in accordance with the value
Acting on the value with a pattern, consistency, and repetition

11. Relationship phases Preorientation (preliminary preparation)
Orientation (get know meeting, housekeeping)
Working phase
Assessment and explore solutions
Termination phase
Preorientation; This phase involves the thoughts and feelings the nurse experiences prior to the first clinical session and planning for the first interaction with clients. Several student concerns are discussed, such as fear of physical harm and fear of saying the wrong thing.
The second phase ranges from a few meetings to a longer term, especially with chronically mentally ill clients. Initially, each interacts according to his or her background, standards, values, and experiences. Initial emphasis is on establishing trust. Four issues are addressed: (1) parameters of the relationship (i.e., purpose of the meetings); (2) a formal or informal contract (i.e., an agreement on specific places, times, dates, duration of meetings, and goals for meetings); (3) confidentiality (i.e., the information the client shares with the nurse will be shared with the treatment team, but not with others with no need to know); (4) termination (i.e., the client should know the date of termination if the relationship is not open-ended). During this phase the nurse will need to be aware of transference-countertransference issues; respond therapeutically to client “testing” behaviors; promote an atmosphere of trust; foster client articulation of problems; and establish mutually agreed-upon goals.
In the third phase, tasks include maintaining the relationship; gathering further data; promoting clients’ problem-solving skills, self-esteem, and use of language; facilitating behavioral change; overcoming resistance behaviors; evaluating problems and goals, and redefining them as necessary; and fostering practice of alternative adaptive behaviors. Unconscious motivation and needs may cause the client to experience intense emotions and prompt client behaviors such as acting out anger inappropriately, withdrawing, intellectualizing, manipulating, and denying. Transference and countertransference may be experienced

12. INTRODUCTORY/ORIENTATION PHASE
Climate Of Trust
Expectations and Responsibilities
Purpose Of Relationship
Meeting, Location, and Time
Confidentiality

13. WORKING PHASE explore Identify Stressors Coping Abilities
Problem Solving

14. TERMINATION PHASE Evaluate Client’s Progress
Decrease Length Of Appointments
Focus On The Future
Community Links and Referrals
The final stage of the relationship arouses strong feelings in both client and nurse that need to be recognized and worked through, and which will provide an excellent learning experience for both client and nurse. This is a time for summarizing goals, reviewing situations that occurred, and evaluating progress.

15. How to Begin the client Interview
Setting that enhances a feeling of security
Seating
Introductions
Setting—A setting that enhances feelings of security is best. Strive for relative privacy.
Seating—Seating should be arranged so that conversation can take place in normal tones and eye contact can be comfortably maintained, or avoided, by placing chairs at a 90- or 120-degree angle, or side by side. Avoid a desk “barrier” between nurse and client. The door should be accessible to both.
Introductions—Nurses tell the client who they are, their school name, the purpose of meeting, and how long and when they will meet. They ask how the client would like to be addressed. Confidentiality should be addressed at some point.
How to start—After introductions, give the client the lead by using an open-ended statement. Facilitate communication using general leads, statements of acceptance, and other therapeutic techniques.
Tactics to avoid—Avoid arguing, minimizing the client’s problem, praising, giving false reassurance, interpreting or speculating on dynamics, probing, joining in if client verbally attacks a significant person in his or her life, criticism of a staff member, and “selling” the client on treatment.
Helpful guidelines—Speak briefly; say nothing when you don’t know what to say; when in doubt, focus on feelings; avoid giving advice and relying on questions; note nonverbal cues; and keep the focus on the client.
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

16. Helpful Guidelines Speak briefly
When you do not know what to say, say nothing
When in doubt focus on feelings
Avoid giving advice
Do not rely on asking questions
Pay attention to nonverbal clues
Focus on the client
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

17. Effective strategies Use of silence Active listening Clarifying
Open ended questions
Use of silence can be a significant means of influencing, and being influenced by others. Possible meanings of a client’s silence include emotional blocking, unreadiness to disclose, anger or hostility, insult, and acknowledgment of nurse’s lack of cultural sensitivity. The nurse’s silence can indicate willingness to let the client set the pace, can communicate strength and support as a client regains composure, or can provide an opportunity to think.
Clarifying techniques
Paraphrasing—Paraphrasing is restating the basic content of a message using different words.
Restating—Restating is repeating the same key words the client has just spoken.
Reflecting—Reflecting takes the form of a question or simple statement, conveying the nurse’s observations of the client when sensitive issues are discussed.
Exploring—Exploring is asking the client to tell you more; to describe or give an example.

18. Not effective strategies
Asking to many closed ended questions
Asking why questions (implies criticism)
Giving approval or disapproval

19. Process recording
A tool for self evaluation of interview skill

20. Clinical supervision
refers to a formal, structured process of professional support, learning and reflective practice. It assists with: * understanding issues associated with practice * developing new insights and perspectives * improving knowledge, skills and competence * professional accountability and autonomy.