Therapeutic Relationship/Alliance PDF

Therapeutic Relationship/Alliance The therapeutic relationship is not concerned with the skills of the mental health professional but rather the attitudes and the relationship between the mental health professional and t...

Therapeutic Relationship/Alliance The therapeutic relationship is not concerned with the skills of the mental health professional but rather the attitudes and the relationship between the mental health professional and the client. This relationship comes out of the creation of a safe environment, conducive to communication and trust. An alliance is formed when the professional and the client are working together cooperatively in the best interest of the client. The therapeutic relationship begins the moment the mental health professional and client first meet (Shea 1999). 10/03/2024 Ahmad M. Al Sayeh 3 Core Elements of a Therapeutic Relationship Communication/rapport - It is important to establish a connection before a relationship can develop. Encouraging the client to speak, using open-ended questions, is helpful. Asking general (not personal) questions can relax the client in an initial session. It is important to project a caring, nonjudgmental attitude 10/03/2024 Ahmad M. Al Sayeh 4  Trust - A core element of a therapeutic relationship is trust. Many clients have experienced disappointment and unstable, even Core Elements of abusive relationships. Trust develops over time a Therapeutic and remains part of the process. Without trust, a Relationship therapeutic relationship is not possible. Other important elements are confidentiality, setting boundaries, consistency. 5 Ahmad M. Al Sayeh 10/03/2024  Dignity/Respect - Many clients have been abused and humiliated and have low self- esteem. If treated with dignity through the therapeutic relationship, clients can learn to regain their dignity. Core Elements of Empathy - Empathy is not sympathy a Therapeutic (caught up in client's feelings) but is, rather, Relationship open to understanding the "client's perceptions" and helps the client understand these better through therapeutic exploration. 6 Ahmad M. Al Sayeh 10/03/2024  Genuineness - In some way genuineness relates to trust because it says to the client: I am honest and I am a real person. Again, it will allow the Core Elements of client to get in touch with her/his "real" feelings and to learn from and grow from the relationship. a Therapeutic Therapeutic Use of Self Relationship Ability to use one's own personality consciously and in full awareness to establish relatedness and to structure interventions (Travelbee 1971). Requires self awareness and self understanding. 7 Ahmad M. Al Sayeh 10/03/2024  Phases of Relationship Development Orientation phase This is the phase where the mental health professional and client first meet and where initial impressions are formed. ✓ Rapport is established and trust begins. ✓ The relationship and the connection are most important. ✓ Client is encouraged to identify the problem(s) and become a collaborative partner in helping him/herself. ✓ Once rapport and a connection are established, the relationship is ready for the next phase. 10/03/2024 Ahmad M. Al Sayeh 8  Identification phase -In this phase the mental health professional and Client are :- 10/03/2024 Development Relationship Clarifying perceptions and setting expectations, in and for the relationship. Phases of Ahmad M. Al Sayeh Getting to know and understand each other 9  Phases of Relationship Development Exploitation (working) phase - The client is committed to the process and to the relationship and is involved in own self help; takes responsibility and shows some independence. ✓ This is also known as the working phase, because this is where the hard work begins. ✓ Client must believe and know that the mental health professional is caring and on his/her side when dealing with the more difficult issues during therapeutic exploration. 10/03/2024 Ahmad M. Al Sayeh 10  Phases of Relationship Development Resolution phase - The client has gained all that he/she needs from the relationship and is ready to leave. ✓ This may involve having met stated goals or resolution of a crisis ✓ Be aware of fear of abandonment and need for closure. ✓ Both mental health professional and client may experience sadness,which is normal Dependent personalities may need help with terminat- tion, reflecting upon the positives and the growth that has taken place through the relationship. (Peplau 1992) 10/03/2024 Ahmad M. Al Sayeh 11 Phases of Relationship Development Nonverbal communication may be a better indication of what is going on with a client than verbal explanations. Although verbal is important, it is only one component of an evaluation. Equally important to develop your skills of observation. Some clients are not in touch with their feelings, and only their behaviors (clenched fist, head down, arms crossed) will offer clues to feelings. 10/03/2024 Ahmad M. Al Sayeh 12  Nonverbal communication Nonverbal communication may offer the client clues as to how the mental health professional is feeling, as well. Physical appearance- A neat appearance is suggestive of someone who cares for him/herself and feels positive about self Clients with schizophrenia or depression may appear disheveled and unkempt. 10/03/2024 Ahmad M. Al Sayeh 13  Nonverbal communication Body movement/ posture - Slow or rapid movements can suggest depression or mania; a slumped posture, depression. Medication induced body movements and postures include: pseudoparkinsonism (antipsychotic); akathisia (restlessness/moving legs [antipsychotic]). Warmth (smiling) and coldness (crossed arms)are also non-verbally communicated. 10/03/2024 Ahmad M. Al Sayeh 14  Nonverbal communication Touch - touch forms a bridge or connection to another. Touch has different meanings based on culture, and some cultures touch more than others. Touch idea/bel can have a very positive effect, but touching requires permission to do so. Many psychiatric clients have had" boundary violations," and so an innocent touch may be misinterpreted. 10/03/2024 Ahmad M. Al Sayeh 15  Nonverbal communication Eyes - The ability to maintain cye contact during conversation offers clues as to social skills and self esteem. Without eye contact, there is a "break in the connection" between two people. A lack of eye contact can suggest suspiciousness, something to hide. Remember cultural interpretations of eye contact. 10/03/2024 Ahmad M. Al Sayeh 16  Nonverbal communication Voice – voice can be a clue to the mood of a client. Pitch, loudness, and rate of speech are all important clues. Manic clients speak loudly, rapidly, and with pressured speech. Anxious clients may speak with a high pitch and rapidly. Depressed clients speak slowly, and obtaining information may feel like "pulling teeth. 10/03/2024 Ahmad M. Al Sayeh 17 Therapeutic Communication Techniques 10/03/2024 Ahmad M. Al Sayeh 18 Therapeutic Communication Techniques 10/03/2024 Ahmad M. Al Sayeh 19 Therapeutic Communication Techniques 10/03/2024 Ahmad M. Al Sayeh 20 Therapeutic Communication Techniques 10/03/2024 Ahmad M. Al Sayeh 21  The Holistic Psychosocial Assessment Psychosocial Assessment: Is a process or tool used to assess the client's level of psychological and sociological ha functioning for the purpose of eliciting evidence of dysfunction and helps in detecting and identifying etiological factors of psychopathology. It provides more specific, and accurate information about current behavior and mental capabilities. This tool assists the therapists to formulate a care plan for a client. Ahmad M. Al Sayeh 10/03/2024 22  Psychosocial Assessment: For a comprehensive holistic assessment, the seven dimensions of the person have to be assessed: (physical, emotional, intellectual, social, spiritual environmental and occupational). Ahmad M. Al Sayeh 10/03/2024 23  Psychosocial Assessment: Meanwhile, the person is more than the simple combination of these dimensions. A holistic framework includes all aspects of the person and how these aspects interact to affect the whole person in cases of health and illness. The balance in all dimensions of a person is valued, and no dimension can be considered in isolation from the others. 10/03/2024 Ahmad M. Al Sayeh 24  First: Physical Dimension Assessment of physical dimension includes: talking history, doing physical examination, and examining the diagnostic tests. It involves everything associated with a person's physical body (demographic data, diet, sleep, physical activity , sexual activity, habits, genetics, health history, family health history, review of systems..... etc). All these aspects interact constantly with each other. 10/03/2024 Ahmad M. Al Sayeh 25  General Appearance 1. Facial expression: may be animated, masked, sad or depressed, angry, color of face (pale, reddened... etc ). a. Blank: Empty, showing no response to any thing, showing no meaning. b. Fear: Is an emotional response to a consciously recognized external threat or danger. Ahmad M. Al Sayeh 10/03/2024 26  General Appearance c. Anxiety: apprehension and a marked continuous feeling of threat to some value, which the individual holds essential to his or her existence although external events do not justify it. 2. Posture: Is the way that a person hold his body and is often an indication of how he is feeling, for example: Relaxed, Tense, Erect, Slouching (leaning away from the care giver), sitting, lying... etc. 10/03/2024 Ahmad M. Al Sayeh 27  General Appearance a. Catatonia: Type of schizophrenia characterized by immobility with rigidity or inflexibility. b. Waxy flexibility: a condition found in catatonic schizophrenia in which the Extremities have a wax like rigidity and will remain for long periods in any placed positions, no matter how uncomfortable. a. Mannerisms: Habitual repeated small movements and not in themselves abnormal. b. Narcissism: Excessive love of self and preoccupation with one's own needs accompanying in attention to the needs of others. It is frequent in some immature personalities 10/03/2024 Ahmad M. Al Sayeh 28  General Appearance 2.Dress: Refers to the way a person feels about himself, and his capacity for social judgment is usually reflected in the way he dresses, for example: Neat, Careless, Smelling, Soiled.... etc. 3.Motor activity: The way in which a person moves his body, for example: Agitated , Restless, Tremors, Motor retardation (slow movement), Akathisia (extreme restlessness), Akinasia. (complete or partial loss of muscle movement), Dyskinesia (excessive movement of mouth, protruding tongue, facial grimacing; (common side effect of the major tranquilizers); Parkinsonian movement (fine tremor accompanied by muscular rigidity). 10/03/2024 Ahmad M. Al Sayeh 29  General Appearance a. Overactivity : It's physical activity that is described as restlessness, this varies from mild activity to an inability to sit still or relaxed. In severe cases the client can do nothing constructive and may break into violent and destructive attacks. b. Under-activity: Retardation - General slowing down of activity. Stupor - A state of lethargy and unresponsiveness in which a person seems unaware of his surroundings, but he Is conscious. This condition occurs in neurological as well as psychiatric disorder. 10/03/2024 Ahmad M. Al Sayeh 30  General Appearance c. Compulsion: An irrational way to act that is usually contrary to one's ordinary judgments or standards. Yet results in over anxiety if not completed. Special patterns of motor activity: Stereotype - the use of monotonous repetition of verbal, intellectual, emotional or motor activity. Example "echopraxia, echolalia. Echopraxia: Meaningless limitation of motions or actions made by others. Echolalia: Automatic repetition by one person of what is said by another. 10/03/2024 Ahmad M. Al Sayeh 31  General Appearance Negativism: Strong resistance, and consistently doing the opposite of what they are told. "Suggestion or advice“. Ambivalence: Opposing emotions, desires or attitudes at the same time toward an object, person, goal or situation. 5. Reaction to Caregiver: Includes the way that a patient relates with or responds to a caregiver, for example: Friendly, Hostile, and Suspicious. 10/03/2024 Ahmad M. Al Sayeh 32 Ahmad M. Al Sayeh The components of 1. Individual's 2. Client's self- the emotional affect (happy, sad, report of his Second: dimension include: angry, anxious...). feeling. Emotional 4. The 5. Duration and Dimension 3. The congruency of affect with the appropriateness of quality of the affect to the person's emotional client's self-report situation. responses. 6. Posttraumatic responses 10/03/2024 33 Second: Emotional Dimension The ability to make decisions is influenced by a person's feelings. Feelings affect relationship with others, physical functioning, ability to make judgments, and ability to become self-actualized. Affect: is a person's display of emotion or feelings that he is experiencing. Mood: is the subjective way a client explains his feelings. 10/03/2024 Ahmad M. Al Sayeh 34 Second: Emotional Dimension 1. Inappropriate affects: a. As an observer, you see a client who is not responding as expected in a given situation. b. The content of a person's discussion does not fit with the emotions accompanying his statements ( inconguency ) 2. Pleasurable affects: a. Euphoria-excessive and inappropriate feeling of well-being. b. Exaltation - intense elation accompanied of grandeur 10/03/2024 Ahmad M. Al Sayeh 35 Ahmad M. Al Sayeh Second: Emotional Dimension 3. Unpleasurable affects a. Depression - b. Anxiety-feeling c. Fear-excessive d. Agitation- (dysphoria): hopeless feeling of of apprehension fright of Anxiety sadness; grief or that is caused by consciously associated with mourning; conflicts of which recognized severe motor prolonged and excessive sadness the client is not danger. restlessness associated with a aware. loss. 10/03/2024 36  Second: Emotional Dimension e. Ambivalence-Alternating and opposite feelings occurring in the same person about the same object f. Aggression-range, anger or hostility that is excessive seems unrelated to a person's current situation. j. Mood Swings (liability) alternating periods of elation and depression or anxiety in the same person within a limited time period. 4. Lack of affects: Blunted or flat affect a normal range of emotions is missing. This can be found in depression, some forms of schizophrenia, and some types of organic brain syndrome. 10/03/2024 Ahmad M. Al Sayeh 37 emotional dimension? 1.Affect: Observe the client's predominant feeling (anxious, sad, or angry), affect (flat or blunted), or indifference to feelings. How to assess 2. Client self report: "What are your feelings at this time?" If he responds with "better" follow up on what he was Ahmad M. Al Sayeh feeling before he was better, and ask him what contributed to his better feelings. Ask what he means by "better," that is, what is better (his mood, his appetite) 10/03/2024 38  How to assess emotional dimension? 3. Congruency of affect with client's self- report: "You say you're fine, but you look very worried (sad, annoyed).“ 4.Appropriateness of affect to situation: Considering the situation, are the client's feelings appropriate? For example, is the client crying over her husband's death 12years ago (inappropriate)? 5. Duration: "How long have you been feeling this way?“ 6. Quality: Do the client's feelings seem shallow and superficial? 10/03/2024 Ahmad M. Al Sayeh 39  How to assess emotional dimension? Do the client's feelings seem appropriately intense? Does the client's expression of feelings scem childlike or juvenile (pouring)? Does the client's mood swing from happy to sad (labile) quickly? Is the client's mood reasonably stable? 7. Posttraumatic response: Symptoms that develop following a psychological distressing that outside the range of usual human experience (illnesses, injuries, disasters, war experiences, panic attack). Ahmad M. Al Sayeh 10/03/2024 40  Third: Intellectual Dimension The components of this dimension include: 1. Perception: has a particular significance for clients with psychiatric problems since determinations are made concerning the reality or distortion of the client's perception. 2. Cognition: aspects of cognition include memory, orientation, fund of information ability to think abstractly, defense mechanisms, and providing information about the client's mental status. 10/03/2024 Ahmad M. Al Sayeh 41  Third: Intellectual Dimension 3. Communication: includes manner of speaking, quality and quantity of speech, degree of flexibility in thinking. 1. Perception: Hallucination is a false sensory stimuli in the absence of an actual external stimuli, are not under the control of the client they are usually real to him. Types of hallucination: Auditory, Visual, Olfactory, Gustatory, and Tactile. Illusion: is a false perception and misinterpreting of actual external stimuli. 10/03/2024 Ahmad M. Al Sayeh 42 How to assess perception? ✓ Assess for the presence of disturbed thinking such as phobias, obsessions, illusions, or delusions during the course of the interview. ✓ Determine the presence or absence of hallucinations by asking, "Do you ever hear voices that others do not hear or see things others do not see?“ 10/03/2024 Ahmad M. Al Sayeh 43 Third: Intellectual Dimension Cognition: Thinking It is the process or way in which the person thinks; the reasoning he uses about the world; the way he connects or associates these thoughts; and his over all organization of thoughts. 10/03/2024 Ahmad M. Al Sayeh 44  Third: Intellectual Dimension Some examples of thinking disorders: 1. Disturbance in thought process: a. Loose associations when a person's thoughts are poorly connected or poorly organized. b. Circumstantiality the person frequently digresses, but eventually reaches a conclusion. c. Tangentiality-the person frequently digresses and finally forgets his initial reason for beginning a discussion. 10/03/2024 Ahmad M. Al Sayeh 45  Third: Intellectual Dimension d. Flight of ideas - rapid Preservation connected speaking with quick thought; frequently seen changing from one in manic patients. thought to another f. Blocking-occur when e. Preservation-repetition the mind ceases to of the same word in reply produce thoughts for no to different questions apparent reason. 10/03/2024 Ahmad M. Al Sayeh 46 Ahmad M. Al Sayeh Third: Intellectual Dimension L. Poverty of thought: h. Confabulation: a few verbal g. Neologism: A communications or The fabrication of word that is ones that convey little stories in response invented or made up information because to questions or by condensing other of vagueness, empty, events that are not repetition or words into new one. recalled. stereotyped or obscure phrases. 10/03/2024 47  1.Disturbance in thought content: 1.Delusions: c. Delusion of guilt: Incorrect beliefs about a. Delusion of being controlled; the person an event that happened in the past and believes his actions and thoughts are not his which the client considers it a sinful behavior own, but put upon him by external sources. b. Persecutory delusions: A false hut unshakably held belief those others deliberately in tent to harm one 10/03/2024 Ahmad M. Al Sayeh 48  1.Disturbance in thought content: d. Grandiose delusion: A false but unshakably held beliefs of a person that he or she is far more important and powerful than he or she actually is. In correct belief and firmly held ideas of great power, health, wealth and influence. e. Hypochondriacal delusions: Excessive complaining about many different bodily aches and pains. f. Nihilistic delusion: Means "delusion of nothingness". Non-existence of the self or part of the self. 10/03/2024 Ahmad M. Al Sayeh 49  1.Disturbance in thought content: 2. Ideas of reference - False but strongly held beliefs that much of what others say and do refers to oneself 3. Depersonalization: The experience of feelings of un-realness about the self for the environment related to Nihilistic delusion. 4. Passivity feeling: the belief of influence by others - the client may develop the idea that his body, his thoughts and his feelings are all controlled by someone powerful. 10/03/2024 Ahmad M. Al Sayeh 50 1.Disturbance in thought content: 5.Overvalued ideas: It is the exaggeration of a particular aspect of the person's life appearance or personality which has a definite factual base 6.Obsession - Persistent thought or idea with which the mind is continually and in voluntarily preoccupied and which suggests an irrational act. The thought cannot be eliminated by logic or reason and usually gives rise to a compulsion 10/03/2024 Ahmad M. Al Sayeh 51  Types of phobia: 8. Phobia: irrational fear of an object or an environmental situation. Types of phobia: A. Acrophobia-fear from heights. B. Claustrophobia-fear from closed places C. Mysophobia fear from dirt D. Nyctophobia fear from dark. E. Pyrophopia fear from fire 10/03/2024 Ahmad M. Al Sayeh 52