Lesson 3 Therapeutic Relationship

• A therapeutic relationship is one of the most important skills for nurses.
• These relationships are crucial to the success of interventions with clients needing psychiatric care.

Components of a Therapeutic Relationship

• Trust involves caring, interest, understanding, consistency, honesty, keeping promises, treating the client as a human being, and listening.
• Congruence is also key to trust.
• Genuine interest requires the nurse to be open, honest, and "real" in interactions.
• Clients can detect dishonest behaviors.
• Nurses may need to engage in self-disclosure.
• Empathy involves perceiving and communicating an understanding of the client’s meanings and feelings.
• Empathy focuses on the patient's feelings.
• Empathy is different from sympathy, which involves feelings of concern or compassion and may involve projecting the nurse’s personal feelings.
• Acceptance is important to be nonjudgmental and to set boundaries.
• Positive regard is demonstrated in an unconditional, nonjudgmental attitude, which implies respect.
• Calling the patient by their preferred name and pronouns shows respect.
• Spending time with the patient and being open and honest, even when difficult, fosters positive regard.
• Listening to the patient's ideas, preferences, and requests and encouraging collaborative decisions shows positive regard.
• Striving to understand the motivations behind the patient's behavior, even if unacceptable is key.

Self-Awareness

• Self-awareness is important to know oneself
• Values are a sense of right and wrong and a code of conduct for living.
• Beliefs, attitudes, and cultural awareness are also important.

Therapeutic Use of Self

• Therapeutic use of self involves using aspects of personality, experience, values, feelings, intelligence, needs, and coping skills to establish relationships with clients.
• H. Peplau developed the concept, noting that personal actions arise from conscious and unconscious responses. The Johari window is a tool to learn about oneself.
• The tool contains four quadrants: open/public self, blind/unaware self, hidden/private self, and unknown.
• Qualities from quadrants 2, 3, and 4 should be moved into quadrant 1.
• Quadrant 1: Open/public self—qualities one knows about oneself and others also know.
• Quadrant 2: Blind/unaware self—qualities known only to others.
• Quadrant 3: Hidden/private self—qualities known only to oneself.
• Quadrant 4: Unknown—an empty quadrant to symbolize qualities as yet undiscovered by oneself or others.

Patterns of Knowing

• Patterns of knowing include ways of observing and understanding client interactions
• Carper identified 4 patterns of knowing:
• Empirical: derived from nursing science
• Personal: from life experiences and self-awareness
• Ethical: from moral nursing knowledge
• Aesthetic: from the art of nursing
• Munhall identified a fifth pattern: unknowing
• Unknowing involves the nurse admitting a lack of knowledge of the client or the client's subjective world.

Types of Relationships

• Social relationships are for friendship, socialization, companionship, or task accomplishment.
• Social relationships focus on sharing ideas, shifting roles, and rarely assessing outcomes.
• Intimate relationships involve an emotional commitment between two people. Individual needs are met; assistance is provided in helping each other meet needs.
• Therapeutic relationships focus only on the needs, experiences, feelings, and ideas of the client.
• Nurses use communication skills, personal strengths, and an understanding of human behavior.
• Joint agreements are made on areas to work on and to evaluate outcomes.
• A nurse's level of self-awareness can benefit or hinder the therapeutic relationship.

Establishing a Therapeutic Relationship

• Peplau's model includes 3 phases: orientation, working, and termination.
• The phases overlap and interlock.
• Pre-interaction phase involves preparation for the first encounter with the patient.
• Tasks in this phase include obtaining available information about the patient and completing a self-assessment.
• During the orientation phase, the nurse and client meet.
• Nurse-client contracts are established.
• These contracts include:
• roles,
• discussion of purposes,
• parameters of future meetings
• nurse helping patient in identification of client's problems
• clarification of expectations
• Confidentiality and self-disclosure are also discussed.
• The contract contents include time, place, length of sessions, when sessions will terminate, and who will be involved in the treatment plan.
• The contract also defines client responsibilities, such as arriving on time, and nurse responsibilities such as arriving on time, maintaining confidentiality, evaluating progress, and documenting sessions.
• Problem identification is key during the working phase.
• The client participates in identifying issues or concerns causing problems.
• Exploitation involves guiding the patient on examination of feelings and responses.
• Trust already established when the goal is development of better coping skills, more positive self-image, behavioral change, and independence.
• Possible transference/countertransference can occur.
• Termination begins when the client's problems are resolved.
• Termination ends when the relationship ends.
• Clients may feel termination is an impending loss.
• Clients often try to avoid termination, which can be a main concern.

Avoiding Behaviors That Diminish Therapeutic Relationships

• Inappropriate boundaries can lead the relationship to become social or intimate.
• One risk factor is a nurse's overconfidence.
• Feelings of sympathy can encourage client dependency
• Factors that diminish therapeutic relationships:
• Nonacceptance and avoidance
• Warning signs of abuse of the nurse-client relationship.

Therapeutic relationships are vital for nurses, especially in psychiatric care. Key components include trust, genuine interest, empathy, and acceptance. Building trust involves honesty, consistency, and treating clients with respect. Empathy requires understanding the client’s feelings without projecting personal emotions.