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Arc

Building a Therapeutic Alliance in BriefTherapy: The Experience of Community

Mental Health Nurses

Judith A. Spiers, RN, PhD and Ava Wood, RPN, MHScN

hives of Psyc

Current mental health trends in brief therapy require a new understanding ofthe nurse-client relationship. This qualitative focused ethnography exploredthe perceptions and actions of community mental health nurses in building atherapeutic alliance in the context of brief therapy and the factors that facil-itate or impede its development. Informants were 11 nurses with at least3 years of experience in community mental health nursing primarily provid-ing brief therapy or consulting practice. Participants described therapeuticalliance as the point at which the clients recognize that the nurse is fully at-tuned to being in the moment as they connect to their own issues in a posi-tive way. Building an alliance consisted of three nonlinear overlappingphases: establishing mutuality, finding the fit in reciprocal exchange, andactivating the power of the client. Implications include recommendations toenhance intentional alliance building and directions for further research toexplore differing world views among nurses on alliance formation within thecontext of brief therapy and consultations.Crown Copyright © 2010 Published by Elsevier Inc. All rights reserved.

From the Faculty of Nursing, 6-126D Clinical SciencesBuilding, University of Alberta, Edmonton, Canada;Adult and Seniors Services, South Edmonton MentalHealth Clinic, Edmonton, Alberta, Canada.

Corresponding Author: Judith A. Spiers, RN, PhD,University of Alberta, Faculty of Nursing, 6-126D ClinicalSciences Building, Edmonton, AB Canada T6G 2G3.

E-mail addresses: jaspiers@ualberta.ca (J.A. Spiers),ava.wood@albertahealthservices.ca (A. Wood).

Crown Copyright © 2010 Published by Elsevier Inc.All rights reserved.

0883-9417/1801-0005$34.00/0doi:10.1016/j.apnu.2010.03.001

THE NURSE–PATIENT relationship has cen-tral importance in mental health nursing

practice (Hagerty & Patusky, 2003; Krauss, 2000;Peplau 1987, 1997; Werner et al., 2002). Successfulhealth outcomes are achieved through positivenurse–patient relationships (Morse, Havens, &Wilson, 1997; Peplau 1987, 1997). Traditionally,therapeutic nursing relationships have been concep-tualized as progressing in a linear, cumulativefashion, evolving through stages and taking timeand trust to develop (Hagerty & Patusky, 2003). Incontrast, brief therapy, a type of psychologicalintervention (Eckert, 1993; McGihon, 1999), usestime very differently, with more intense relationshipsformed quickly and with less attention on length oftreatment to produce change (Levenson, Butler,Powers, & Beitman, 2002). Changes in the fundingand structure of health care systems mean that morecommunity mental health nurses are incorporatingprinciples of brief therapy in their practice. However,there is little empirical research that describes

hiatric Nursing, Vol. 24, No. 6 (December), 2

development of nursing therapeutic alliances in thecontext of brief therapy. There is little guidance fornurses to reexamine their assumptions about thenurse–patient/clients relationship in this context or toexplore ways to adapt their practice to this context(Dearing, 2004; Hewitt & Coffey, 2005). Thepurpose of this qualitative focused ethnography wasto explore and describe the phenomenon of inten-tional alliance formation within the context of brief

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therapy from the perspective of community mentalhealth nurses. Our goal was to explore practiceapproaches that nurses have developed in brieftherapy by describing the experiences, perceptions,and actions of community mental health nurses inbuilding a therapeutic alliance in the context of brieftherapy and to identify factors that facilitate orimpede its development.

BACKGROUND OF THE STUDY

Brief Therapy

Brief therapies are primarily time-attentive designedmodels of therapy that focus on making everysession count, with less attention on length oftreatment (Eckert, 1993; Levenson et al., 2002).Brief therapy is highly strategic, exploratory, andsolution based rather than problem oriented. It is lessconcerned with how a problem arose than with thecurrent factors sustaining it and preventing change.Brief therapists do not adhere to one “correct”approach but rather accept that there are many paths,any of which may, or may not, in combination turnout to be ultimately beneficial. For example,solution-focused brief therapy is based on socialconstructionist philosophy. It focuses on whatclients want to achieve through therapy, an envi-sioned preferred future, rather than on the problemsthat made them seek help. It is present and futurefocused, based on the belief that change is constantand that the clinician can help clients explore howpieces of that preferred future are already happening(Hazlett-Stevens & Craske, 2002). Brief therapy isoften the mode of care in brief crisis intervention,solution-focused single sessions, consultations andreferrals, and diverse brief psychotherapies withadult and geriatric populations as part of mentalhealth clinic services. Essentially, all modes of brieftherapy are based on the assumption that introduc-ing even small changes in response to a specificproblem will continue to elicit further change longpast the point of intervention (Montgomery &Webster, 1994; Wales, 1998). The duration ofbrief therapy may range from 10 to 40 sessions, withsolution-focused and cognitive therapies on theshorter end of the spectrum than psychodynamicallyoriented brief therapies (Eckert, 1993; Peake,Meyers, & Duenke, 1997; Sexton, Hembre, &Kvarme, 1996; Wales, 1998).

Brief therapy is characterized by a number ofcatalytic factors including planning, collaboration,

timing, and empowerment (Eckert, 1993; Levensonet al., 2002). Planning encompasses a rapid accurateinitial assessment, mutual focusing, and goal settingwith the client on the targeted area of intervention,as well as the selection of treatment approaches toachieve these set goals. Collaboration refers to apositive therapeutic alliance between therapist andclient, which is purposely maintained at a highinteractional level by both client and therapist,compared with traditional treatment approaches.Empowerment is a social process of helping theclient meet his or her own needs and of negotiatingwith other people to mobilize the resources toachieve this (Hsu, 2009). Timing refers to the waytherapist should use the least amount of timenecessary to effectively engage the client andmobilize change processes (Bowles, Mackintosh,& Torn, 2001; Shapiro et al., 2003). Thus, a centralphenomenon in brief therapy, and the factor thatlargely determines its effectiveness, is the thera-peutic alliance or the extent to which the therapistand client can forge a collaborative relationship in atherapeutic way (Levenson et al., 2002).

Therapeutic Alliance

The establishment of an alliance, an interpersonalconnection that is at least partially positive, is anessential curative factor in psychotherapy treatment(Howgego, Yellowlees, Owen, Meldrum, & Dark,2003). This position is congruent with assumptionsthat the nurse–client/patient relationship is theprimary vehicle of care and is key to achievingsuccessful health outcomes (Hagerty & Patusky,2003; Krauss, 2000; Morse et al., 1997; Peplau,1987, 1997; Perraud et al., 2006). Nursingtherapeutics refers to the healing effects resultingfrom the human interactions between nurses andpatients that benefit both parties (Taylor, 1994).However, there is no single universally accepteddefinition of therapeutic alliance (Hewitt & Coffey,2005; Horvath & Bedi 2002; Howgego et al., 2003;Martin, Garske, & Davis, 2000). Generally, thera-peutic alliance is described as the mutual experi-ence and expression of feelings, attitudes, thoughts,and behaviors between the client and the therapistduring the therapeutic encounter (Saunders, 2001).It is generally thought to have three components:collaborative tasks that have been mutually under-stood; goals that are mutually derived based onclient readiness; and bonds that encompass a senseof compatibility, trust, respect, and caring, which

375BUILDING ALLIANCE IN BRIEF THERAPY

also vary according to the nature of the activity(Bordin, 1994; Hanson, 2005; Hewitt & Coffey,2005; Perraud et al., 2006; Shattell, Starr, &Thomas, 2007).

Components of therapeutic alliance, such asevolutionary and time-dependent characteristics,have been studied primarily in long-term mentalhealth nursing relationships. For example, inresearch with nurses collaborating in long-termtherapy relationships with individuals who havechronic mental illness, components such as trustand rapport building, mutual relating, and knowingthe patient are significant components in therapeu-tic alliance (Dearing, 2004; Hedelin & Jonsson,2003; O'Brien, 2001; Turkel, 2001). However,factors such as limited psychotherapy funding(Peake et al., 1997), shorter inpatient stays(McGihon, 1999), and increasing communitymental health service referrals have resulted in thewidespread use of brief therapy with relativelylimited time for interaction.

Building Alliance in Brief Therapy in Nursing

The central phenomenon in brief therapy, and thefactor that largely determines its effectiveness, isthe therapeutic alliance (Levenson et al., 2002). Themanagement of time is key to differentiatingbetween therapeutic alliance in traditional therapyand in brief therapy. In brief therapy, timing isparamount and requires multidimensional control(Eckert, 1993, p. 245), which goes beyond thelinear concept of time limitation in treatment. Thissuggests that the relationship is not dependent onthe progression of time so much as on how time ismanaged with each client (Hagerty & Patusky,2003). This may explain why early positive allianceformation is a stronger predictor of treatmentoutcome than alliance in later stages of treatmentis (Bachelor & Horvath, 1999; Despland et al.,2009; Horvath & Bedi, 2002).

Hagerty and Patusky (2003) challenged thenecessity of factors such as evolutionary trustbuilding and multiple stages in a time-dependentcontext as a prerequisite to the achievement of theclient's health goals. This is a controversial claim innursing, where much of the research on nurse–client relationships emphasizes the importanceof evolution of trust over time in a largelynondirectional relationship and a lengthy periodof engagement (Bowles et al., 2001; O'Brien, 2000;Spiers, 2002).

The therapeutic alliance has been more widelystudied outside of nursing practice despite theemergence of brief therapy as the most typicalmode of mental health treatment in communitymental health clinics and other nonhospital settingswhere nurses provide treatment. Early researchindicates that brief therapy methods and strategiesare harmonious with nursing values (Bowles et al.,2001). However, the result is that nursing still lackswithin the context of community-based brieftherapy, theoretically based knowledge with whichto assess, foster, and maintain effective therapeuticrelationships with clients. The essential question ishow the interactional competencies nurses use tocreate and enhance perceptions of connectednessand disconnectedness in long-term alliances, suchas sense of belonging, reciprocity (Morse, 1991),mutuality (McCann & Baker, 2001), and synchrony(Hagerty & Patusky, 2003; McCann &Baker, 2001;Spiers, 2002), relate to brief therapy situations.Unfortunately, there is a paucity of empiricalresearch explicating the strategic communicationchoices both nurses and patients make during thecourse of the interaction and how these choicescontribute to the nature of brief “essential relation-ships” found in community mental health nursing(Dearing, 2004). There is a need to explicate hownurses are adapting principles and methods for thesenew brief therapy contexts.

RESEARCH METHOD

The research method used in this study was aqualitative focused ethnography. This is a time-limited method that explores a specific topic for itsmeaning among a specific group of people and wasthe best way to obtain nurses' insider perceptionsand accounts of the therapeutic alliance in brieftherapy (Morse & Richards, 2002). As is commonin qualitative research, the conceptual frameworkguiding the study was based on assumptions aboutthe centrality of the nurse–patient relationship as avehicle to provide nursing care. Both nurses andtheir clients intentionally use specific interactionstrategies to work toward mutually establishedinteractional and therapeutic goals (Spiers, 1998,2002). Articulation of the researchers' beginningassumptions was also necessary to qualitativeinquiry (Morse & Richards, 2002). The researchteam consisted of a community mental health nurseand expert qualitative methodologist experienced ininteraction-based research. Constant collaboration

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in interpreting data, coding, and analytic themingprovided opportunities to raise awareness of beliefsand assumptions influencing the data analysis.Focus group interviews were the primary sourceof data collected because of the potential to create acumulative, free exchange of ideas in a synergisticfashion that may produce serendipitous resultswhich can be explored within the group (Krueger,1997; Streubert & Carpenter, 1999). This proved tobe important when exploring therapeutic alliancewithin a small, close group, with members open toexpressing their views. The study was reviewed andapproved by the appropriate institutional andclinical ethical and administrative agencies.

Sample and Setting

The study was conducted in a community mentalhealth clinic system of a larger regional mentalhealth program in Western Canada. For this study,brief therapy was defined as 10 sessions or less.This included brief crisis intervention, solution-focused single sessions, consultation and referrals,and diverse brief psychotherapies with adult andgeriatric populations.

Convenience sampling based on poster distribu-tion in the community clinics in the region initiallyidentified participants who had a minimum of (a)3 years of experience in community nursing, (b)primarily provided brief therapy or consultationservices, and (c) had previous experience in long-term therapy. Later in the study, theoreticalsampling was used to explore themes emerging inthe data analysis. For example, we sought infor-mants with consultant experience only and whocould provide long-term treatment with clients withchronic mental illness.

The sample consisted of 11 participants(10 women and 1 man) ranging in age from 43 to66 years (M = 52.7 years), with a range of 22–44 years in nursing (M = 31.2 years) and a range of5–29 years in community mental health nursing(M = 19.5 years). Six participants had a bachelor ofscience in nursing degree, and 5 participants held anursing diploma.

The 10 participants were interviewed in threedifferent focus groups, with one individual inter-view and a verification interview to engageparticipants in discussion of the emerging results.All groups had heterogeneity of nurses in briefpsychotherapy and those in consulting roles. All thenurses knew each other. Focus groups were held

during working hours at the main mental healthclinic site. All participants signed informed consentforms and agreed to maintain confidentiality. Focusgroup discussions began with reflections on arecent initial interview with a new client in whichthey had experienced a sense of alliance formationby the end of the session. Subsequent questionsexplored experiences, perceptions, and outcomes ofactions that successfully or unsuccessfully resultedin therapeutic alliance (Table 1). Groups weremoderated by the second author and an observerwho was an experienced mental health nurse.

Data Analysis

Focus group data were transcribed verbatim andanalyzed using thematic content analysis (Burnard,1991). Data were sorted by topic coding, using bothdescriptive open and interpretive codes (Morse &Richards, 2002). The transcripts were initially readseveral times to gain an overall sense of the contentand reveal any overarching concepts. As can beseen in Table 2, topic and analytic, descriptive, andinterpretive codes were used to construct categoriesand to explore the relationships between the themes(Morse & Richards, 2002).

Pseudonyms, including some androgynous ones,were assigned to further assure confidentiality byavoiding gender attribution that might identify aparticular informant. A methodological journal waskept from the outset of the interviews, anddescriptive and analytical memoing was used totrack the progression of understanding and synthe-sizing the data (Morse & Field, 1995). Data analysisand emerging categories and themes were discussedin analysis meetings between the two authors andtwo extra clinical resource nurse experts. Differ-ences in interpretations were discussed, andconsensus in analysis was obtained.

As qualitative research is iterative rather thanlinear, it was appropriate to use verificationstrategies to continuously and incrementally iden-tify and correct errors throughout the research. Inthis approach, the researcher moves back and forthbetween design and implementation to systemati-cally check data and explore the fit between dataand the conceptual analysis to ensure methodolog-ical coherence, sampling sufficiency, researcherneutrality, and theoretical development (Morse,Barrett, Mayan, Olson, & Spiers, 2002). Theprocess ensured accurate interpretation of datacollected from appropriate informants, resulting in

377BUILDING ALLIANCE IN BRIEF THERAPY

credible findings with potential for applicabilityoutside the immediate context (DePoy & Gitlin,1998; Morse & Richards, 2002).

RESULTS

Participant nurses experienced the therapeuticalliance as an intuitively perceived sense of themoment of connection occurring when the clientrecognized that the nurse was fully attuned andaligned with them as they connected to their ownmost pressing issues in a positive way. Building atherapeutic alliance in brief therapy consisted ofnonlinear overlapping phases in which specificbehavioral and communication strategies were usedby the nurse to achieve the aims of establishingmutuality, finding the fit between nurse and client,and activating the clients' power to achieve theirgoals. Alliance formation resulted in a sense ofenergy alignment toward accomplishment of treat-ment goals. The nurse perceived the client behav-ioral indicator to be the moment when the clientopened up at a different level and revealed their realfeelings and concerns to the nurse.

Phase 1: Establishing Mutuality

“Establishing mutuality” involves helping clientsunderstand what to expect in therapy and theirrespective roles in treatment and obtaining theirwilling consent and participation in the process.“Establishing mutuality” is achieved by “equalizingpower” and “setting the stage.”

“Equalizing power” refers to the ways nurses tryto foster a mutual equal footing at the beginningof therapy.

It's almost giving them the one-upmanship position becausewhen they come in and sit down, I ask them what they wantand particularly when you get people who have not beenreferred by themselves, they've been referred by others andthey very quickly say that my doctor made this appoint-ment, and I say that that's okay but I need to know fromyou (Meg).

Alliance formation could be negatively impactedwhen the client has not purposefully soughttreatment. Community mental health clients areoften referred or self-refer at the insistence ofanother party. Nurses strive to overcome any senseof coercion by offering clients the choice toparticipate, thereby obtaining their consent in aprocess of respectful negotiation.

Nurses also sought to equalize power byacknowledging that their expertise and effort as anurse needed to be matched with their client'savailable knowledge and energy. This was achievedby inviting the client to meet them halfway.

Within the first 15 minutes, I say that this is about choice,that this is voluntary, and that I don't have the answersnecessarily, but together we're going to….So I think thatrather than being done to or done for, I am including themin the process and saying I don't have the answers you'regoing to have to meet me halfway here (Dina).

Equalizing Power required that nurses deal withspecific legal constraints which provided bound-aries that could be both reassuring and potentiallycoercive. Nurses needed to tell the client about thelimits of confidentiality, for example, that childwelfare legislation covered mandatory protection ofchildren and that when there were threats of harm toself or others, the nurses would obtain servicesirrespective of client preference.

“Setting the stage” refers to the work nursesengage in during the first session to help ensure thatclients understand what to expect—the rationale forthe assessment, the respective roles of client andnurse, goal setting, expectations for keepingappointments and timeliness, guidelines for disclo-sure, and client's choice to leave some mattersundisclosed. This essentially involves educationabout the mental health services, negotiation, andthe nurse–client contract.

Specific nursing communication strategies such asaffirmation, validation, and normalization, which arewoven throughout the alliance-building process, arefundamental in “setting the stage” to create a safeclimate for disclosure. These strategies work byaffirming the presence of unvoiced feelings. Nurseshelp control the pace of disclosure when the client isunable todo so. In this study, nurses affirmed feelings,goals, self-help activities, and reciprocal actions of theclients; showed respect for their capacities; providedvalidation that they were on the right track; andnormalized their fears and experiences:

She said right after the session about how much better shefelt just realizing that her thinking isn't all crazy. So I thinkthat sort of thing—just validating, providing information,providing factual information to them can sometimes reallyhelp them sometimes to say, “Gee I'm not wrong” (Lisa).

In the phase of “establishing mutuality”,assessment needed to be client led to better

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understand the core issues as understood by theclient, rather than the perceptions of others. All thenurses weighed the importance of gatheringassessment data systematically to complete bu-reaucratic needs “to fill all the boxes” versusfollowing with the client's need or cues. Assess-ment was most effective when the nurses turnedthe lead over to the client and used their ownclinical experience to extract much of the neededinformation in context:

Sometimes people just want to tell their stories, andallowing them, giving them the time to tell the story, istherapeutic in itself; for some people, it is the best therapythey ever had, ever been given before, even if it is quiteexhausting sometimes, but you need to be flexible and youneed to think, “this is the client, it's not about me” (Mary).

Nurses set the stage for mutual learning byformulating the clients' assessment information andinviting their feedback. When the client identifiedoverwhelming issues, nurses helped the clientprioritize key concerns and establish a plan forworking through them. During a first interview, thenurses providing brief therapy to younger adultsstated that they would introduce some flavor ofpsychotherapy to help clients decide if this was apreferred treatment option. Nurses emphasized that,in this mutual working arrangement, the clientscould learn to use their own strengths to make themfeel better.

I think that that's part of the therapeutic alliance—that thisis the agreement, that this isn't about us curing them. Thatthis is a working relationship and that they need to set theirgoals and own—have ownership of them. And I get somepeople like that guy who said, “you didn't make me feelbetter.” And then I had to spend a couple of minutesexplaining, well this is an assessment, but treatmentisn't about a therapist making a client feel better, it is aprocess of people learning how to make themselves feelbetter (Des).

“Reflective listening” and “being present” wereboth critical to establishing a mutual workingarrangement because these facilitate the nurse'sand client's ability to work together to uncover thereal issues. “Valuing uniqueness” of the client is astrategy closely related to “reflective listening.”Agreement to work in mutuality does not assumethat the client complies with the nurse's viewpointsor that this situation would be similar to any othercontext. For example, Pat articulated the impor-tance of accepting differences: “valuing their

uniqueness and also valuing their beliefs andvalues, although they may be different fromyours.” Nurses were cognizant of the risk ofassuming the trajectory of the client situationwhen they recognized emerging pattern similarities.They were conscious not to lose sight of theindividual within the accumulation of similarstories in their experience:

We read the assessment, and we think this is a story thatwe've heard one or two hundred times before, you knowthat when you get in there, it is not the same as everybodyelse, that their story is just a little bit different andindividual, that how they are feeling is not the same aseveryone else and validate them for that (Des).

Phase 2: Finding the Fit inReciprocal Exchange

“Finding the fit” refers to the mutual work involvedin determining the best level and way of commu-nicating and working together. This is a reciprocalprocess in which the nurse learns about the clientand how best to tailor his or her approaches todevelop a strong connection with the client. Theclients, in turn, were perceived as assessing thenurse and finding their fit in the relationship forthemselves. “Finding the rhythm” represents hownurses “search for a hook” in the engagementprocess. This includes being congruent with clientaffect, as well as matching language, speechpatterns, and functional level.

Nurses stated that showing their “human-ness”was an important aspect of finding the rhythmthrough hooking the client into engagement: “thatyou're not just a machine that sits there and makesno judgments, that sits there and goes mhm” (Dina).They described activating a disclosure of personaland professional self that matched the intellectual,emotional, or functional level of the client.Balancing professional and personal disclosurewas influenced by the perceived need to showwarmth to the client and to “be ordinary,” a conceptdrawn from other research in this subject area(Barker, Jackson, & Stevenson, 1999). An “ordi-nary” stance is regarded as important in briefinterventions where it can take more effort toconvince the client to accept treatment and is lessimportant with clients who show obvious accep-tance of entering a long-term treatment relationship.This strategy is also influenced by individualpersonal ethics and beliefs about being genuine.

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In other words, whether or not the nursesintentionally projected more warmth than theyreally felt could be viewed as a positive manipula-tion of the client or a skilled application oftherapeutic self in keeping with the client's clinicalpresentation and issues.

A controversial strategy is the use of humor inalliance formation. Most nurses providing psycho-dynamically informed brief psychotherapy withyounger adults avoid the use of humor as they havefound that the risk of alliance rupture through clientmisinterpretation can be too great. However, thoseworking with older clients or with chronic mentalillness indicated that judicious use of humorseemed to promote positive energy flow and wasfound to be a helpful gauge of alliance formation:

…and I guess with that you suddenly see a smile or a laugh,and I guess that's what I respond to, it's taking the wholesituation and turning it around (mhm), so you are getting adifferent response from the client (Kelly).

Phase 3: Activating the Power of the Client

This phase represents the work involved in findingand activating the strengths of the clients to movefrom a sense of helplessness to being an activetreatment participant. In this phase, no one singleapproach was used, and a variety of models andstrategies were employed (Hazlett-Stevens &Craske, 2002). Solution-focused and Gestalt tech-niques were used to facilitate clients' understandingof their own capacities. Reframing, in which thenurse transforms negative experiences into positiveones, is a technique used to intentionally highlightstrengths or to promote change through a newperspective. Fostering hope is also an intentionalalliance-building action. Nurses project a confidentpersona of certainty and capability to reassure theclient that they are in safe hands. They may alsointervene pragmatically to effect immediate changeand hope for less capable clients, such as by writingadvocacy letters for assured income. The nurses'essential role in “activating the power” of the clientis to signal that change is occurring even within thefirst meeting:

I think the other thing is that on the first interview…youneed to provide something, you need to actually havesomething happen….There has to be something besideswhat we've been told over the years, that first time you seethem it's “an assessment,” you have to find out what'swrong with them (Kelly).

Clients were encouraged to do their own work inmutual interaction with the nurse, to draw on thepower of the relationship to act on the solutions thatthey identified. This recognized that in regard totreatment, the client is in “the driver's seat” and thenurse alongside. The power of the relationship isused to augment the personal power within theclient to act on his or her own decisions.

Well, I think that the client always has to be in the positionof power and they, my job is to empower them to do whatthey need to do, not to do it for them, and then be with themwhile they do it and support them but support it in a waythat they have control, not that they're coming in and beingtold, “Go do A, B, C and D and then come back and reportto me how you did” (Meg).

Tailoring Brief Alliance for Clients WithChronic and Acute Illness

The responsiveness of the client is a significantfactor in building a therapeutic alliance. Theseverity and chronicity of presenting symptomsare immediate factors that can inhibit or increasealliance formation. Other elements includedquality of object relations and personalitystyle, ego strengths, and coping styles (Gallop &O'Brien, 2003).

Nurses acknowledged that there is a risk ofgiving more effort and caring to likeable, attractiveclients with interesting stories. Some participants,as a way to counteract this tendency, felt theyworked harder to connect with clients they did notlike. Nurses recognized particular types of clientsfrom clinical histories and anticipated dislikingworking with those people. These types of clientsincluded sexual offenders or those with aggressionand anger problems. Nurses also reported moredifficulty with clients, such as those who wereevasive and secretive, who demanded and con-veyed entitlement, who were unwilling to partici-pate equally in the treatment process, and whowanted to be fixed and then “yes-but-ted” anyoffered solutions.

Dina identified that a positive factor in allianceformation is the intuitive capacity of the client tounderstand the nurse—to recognize the energylevel and attentiveness of the nurse or to respond tothe nonverbal cues the nurse is using to convey hisor her commitment to the client. It is clear that forthe participants in this study, clients more suited tobrief therapy alliance formation were seen as

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healthier, with stronger boundaries, more sociallyadept, able to accept observations or interpretationsabout their issues, and had the ability to integratethe nurse's formulations and develop and try theirown strategies.

The ones that you have rapport with, they question you,they may not agree with a word, but they do it in a way thatis more like a dialogue than sort of attacking (Des).

The Role of Time in Brief Therapy

Time was a major influence in developing atherapeutic alliance in brief therapy. Nursespurposefully paid attention to time structure toassure that the essential phases of alliance wereachieved in a mutual process. They used strategiessuch as having flexible time limits to a session,matching a client's expressed or demonstratedneed to shorten or at times lengthen a session, andnegotiating time to ensure that the client feltvalued and unrushed. They validated the impor-tance of client issues by setting limits on theclient's pacing and disclosure if it meant that therewas insufficient time to adequately address issuesraised by the client.

Nurses indicated that they used time differentlyin brief therapy compared with traditional relation-ships. They moved more quickly from assessmentto “getting to the work” in the same sessionbecause clients “were more equipped to follow usalong in the goal” (Lisa). Similarly, nurses inconsulting work scheduled longer visits knowingit might be a single session to accommodate datacollection through therapeutic interviewing, aswell as goal and plan establishment. Nursesworking with caseload assignments that includedclients with more severe chronic mental illnessfocused more on rapport building, knowing that itwas essential to build on that relationship firstbefore “fostering out” the client to other partners inthe treatment network, such as day programs orvocational services.

Factors Influencing the Nurse's Ability toBuild an Alliance

A range of environmental factors influenced boththe nurse's ability to form a therapeutic allianceand their willingness to do so with particularclients. For example, some factors, such asmaintaining energy and being able to clear one'smind between clients, were severely influenced by

the nurses' workload, scheduling, driving, andweather conditions. Nurses described the impor-tance of “tuning in” and “turning off” internaldistractions and influences.

Sometimes we get so pressured with the amount of workthat we have to do…and you really have to take the time, ifyou're cognizant, to still yourself and be with that person atthe time (Kari).

All of the informants acknowledged theirresponses and the risk for potentially destructiveemotional reactions (O'Kelly, 2001) to clientswhose features or situations were very dystonicto the nurse's values or history or which resonatedtoo closely:

I can certainly say that there are clients whose situationrings all the bells in my own family history and I have to be,well I am aware, I don't have to work at it, I'm aware….I'vesorted out some of that stuff in my own therapy so that ifsomething comes up in a client situation that rings bellsthat…in my own personal therapy, and that's been veryuseful, so I know how to use the radar thing to theadvantage of the client mostly (Sara).

A significant influence on alliance formationfor most participants was the acquisition ofexperience, strengthened by past formal clinicalsupervision. Most nurses described the importanceof intuition, shaped by experience, which helpedthem maintain “presence” in the face of the client'sturmoil, even in situations that, on the surface,appeared threatening.

Nurses' Perceptions of Client ActionsToward Alliance Formation

The nurses' perceptions of what their clients werecontributing to build the alliance related to clientparticipation in the treatment tasks, as well as toaffirmation and direction of the actions of the nurseto meet client needs. Nurses described clients asdemonstrating trust by progressing through levelsof information sharing from the surface-level socialniceties and biographical facts to asking questionsand deeper self-disclosure that revealed their fears,uncertainties, and vulnerabilities. They demonstrat-ed motivation and psychological mindedness bymoving to an active stance as coparticipant, beinggoal oriented and action minded in willingness tofollow through, being responsible with appoint-ments and homework, and in one instance using thesame “psychotherapy language” as the nurse.Clients demonstrated their interest in mutual

381BUILDING ALLIANCE IN BRIEF THERAPY

understanding by questioning, indicating what didnot fit for them, and affirming when the nurse hadbeen helpful.

The assessment process was reciprocal withthe client finding out about the nurse. Somenurses thought their clients assessed their caringand “human” credentials by asking for personaldetails about marital status and family. Othershad clients comment on their perceived moodand energy levels. Clients might also subtlyindicate a preferred relational style, such as byusing humor. Some nurses said clients wouldexplicitly state the behaviors that demonstratedcaring from their nurse, such as divulging pasttreatment failures and the actions of the healthprofessional that undermined their trust; make apoint of identifying off-limit topics to signalproblems with openness and trust; or seekreassurance about their acceptability to thenurse despite their “badness.”

Choosing Not to Pursue aTherapeutic Alliance

We asked the participants about situations wherealliance formation was not achieved. Nursesdescribed this occurring with clients who werehighly defensive or dishonest, demanding andnoncollaborative, expecting the nurse to “fix”them, and with extreme behaviors, such as historiesof being physically or sexually abusive, especiallyto children.

Nurses asserted the importance of acknowledg-ing and accepting their self-limitations, recogniz-ing that they would not be able give energy to thealliance or to respond to certain clients from apositive, wellness orientation. They emphasizedthe need to do no harm despite strong negativefeelings or indifference toward the client. Nursesreported assuming their most professional stanceto explain their “no go” with the client and helpingthe client find an alternate source of help, usuallyelsewhere than the agency. Lisa's descriptionwas characteristic:

I look at myself, and I think this person is not going to workwith me, and I need to find something else, or I'm not goingto work with this person, whichever it is, so I have to findsomething for their best interest. Sometimes I've actuallysaid to them, I don't think there's anything we can do foryou. Or, when will you fire me? When will I be the nexttherapist to be fired because I didn't fix you? I willsometimes be very straight with them, but some of them I

will recognize that maybe their weak point is actuallymy weak point, and maybe I should get them some morehelp (Lisa).

DISCUSSION

Nurses in this study used a range of intentionalactions in nonlinear, interactive phases, typicallyoccurring in the first session, to build a therapeuticalliance in brief therapy. The intentional actionsreflect social relatedness competencies to engageclients and foster and maintain helpful relationshipsbetween nurse and client: mutuality, reciprocity,synchronicity, and a sense of belonging (Dear-ing, 2004; Hagerty, Lynch-Sauer, Patusky, &Bouwsema, 1993; Hewitt & Coffey, 2005).

Clients with acute and chronic mental illnessimprove more rapidly with well-planned, specificnursing interventions. Although case managementis a predominant approach in community mentalhealth nursing (O'Brien, Kennedy, & Ballard,2008), increasing client loads and a reduction intime to spend with individual clients mean thatnurses are developing new ways in which to workwith clients toward mutually defined goals forrecovery, community integration, and improvedquality of life. However, although many funda-mental nursing texts still regard long-term relation-ships in which to care for individuals, allianceformation within brief therapy contexts allowsnurses to use time as a strategy with which tococonstruct interventions that have effects farbeyond an individual session, interaction, or briefrelationship (Hagerty & Patusky, 2003; Levensonet al., 2002).

The core principles of psychiatric rehabilitationfocus on collaborative partnership, recovery, andenhanced quality of life based on the assumptionthat all people have the capacity to change and learnand accordingly should be treated with respectand dignity (U.S. Psychiatric Rehabilitation Asso-ciation, 2007). Alliance formation in brief therapyas described in this study demonstrated how thecommunity mental health nurses made consciousand consistent efforts to build on the strengths ofeach partner in the interaction and to individualizethe care to address the unique needs of eachindividual. Drawing upon their clinical experienceand knowledge, which provided generalizedknowledge about symptom patterns, they usedspecific interaction strategies to build personalized

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professional alliances that were based on mutualtrust, rapport, and partnership.

Thus, time management, rather than elapsedtime, is more relevant to alliance formation(Levenson et al., 2002). Limitations on time weremade to “work for” the nurse and client byinfluencing the level of engagement and thestructure of the session and by prioritizing treatmentissues and plans (Eckert, 1993; Shattell et al.,2007). Focused activity in brief therapy involvedskillful management of time to work together toidentify and then initiate a change process that theclients would continue to work through after theirrelationship with the nurses had ended.

The mutuality of action or work within thetherapeutic alliance in brief therapy is particularlyimportant in this study. The coordination of suchaction is supported through emotional engagementand may be formed within the first session(Sexton et al., 1996). As in traditional therapeuticalliances, these nurses worked on establishingcollaborative tasks that have been mutuallyunderstood; goals that are mutually derived,based on client readiness; and bonds that encom-pass a sense of compatibility, trust, respect, andcaring, which vary according to the nature of theactivity (Bordin, 1994; Hanson, 2005; Hewitt &Coffey, 2005; Perraud et al., 2006; Shattell et al.,2007). These are fundamental concepts in theprovision of nursing care (Spiers, 2002).

The outcomes of therapeutic alliance are influ-enced by the nurses' capacity to identify and matchinterventions to the clients' functioning style(Dearing, 2004; Despland et al., 2009). In thisstudy, there was mutual work and reciprocalexchange during which both nurse and clientdetermined the potential fit of the relationship andtailored their own responses (Spiers, 2002). “Find-ing the rhythm” involved nursing actions in patternidentification and alignment with the client. Inaddition to matching language (Lotzkar & Bottorff,2001), nurses were congruent in actions, affect, andinteractional style—a process called “tuning in”(McCann & Baker, 2001) or “getting it, together”(Dearing, 2004). Some nurses increased clientcomfort by starting at the client's point of concernwith the topic that they valued (Tryon &Winograd,2002). Matching styles and approaches to clientattributes is fundamental to alliance formationwhether in short- or long-term alliances and hasbeen shown to improve outcomes (Bachelor &

Horvath, 1999; Beutler, Harwood, Alimohammed,& Malik, 2002; Hanson, 2005; Hewitt & Coffey,2005; Meyer & Pilkonis, 2002).

Individuals typically approach a mental healthtreatment service when they become unable toachieve well-being. Through the mutuality of goalsetting and treatment contracting in the brief therapycontext, conditions are created for the activation ofpower within the client. The more participation inmutual goal setting and mutual determination of themeans to achieve those goals, the more likely clientsare to use power to achieve those goals (Dearing,2004; Hokanson Hawks, 1991). Mutuality meansenhancing the clients' own ability to heal, ratherthan having the nurse do it for them. Power isharnessed as a relational process (Shearer & Reed,2004) to magnify the clients' personal agency andself-healing capacities through the supportivestructure of the relationship (Hewitt & Coffey,2005; Shattell et al., 2007; Tallman & Bohart,1999). Thus, the therapeutic alliance is experiencedas transformational energy (Chinn, 1995).

The emphasis on equalization of power appearsto be a distinctive activity in this study incomparison with existing research on allianceformation. Reciprocity, the sense of an equitable,balanced, give-and-take exchange (Hagerty et al.,1993; Hagerty & Patusky, 2003), was evident in thenurses' efforts to promote equity in the relationshipand to give clients the early lead in the dialogueduring assessment and in communication strategiesthat affirmed the client and their contributions. Inthe early phase of alliance building, nurses workedto establish a more equitable power balance wherenurse and client had equal but different roles(Shattell et al., 2007; Spiers, 2002; Street &Downey, 1996).

Community mental health nurses hold severalsources of power in the context of client care:expert, informational, legitimate, referent, associa-tive, and coercive power (Benton, 1999; VanBreeSneed, 2001). There may be a sense of coercionwhen someone other than the client initiates therequest for treatment intervention, which must beovercome if the alliance is to be successful(Howgego et al., 2003). The nurses in this studydid not ignore clients' sense of resistance. Instead,nurses strove to work through these issues withinthe first phase of alliance formation so that a mutualworking partnership could be established (Hewitt &Coffey, 2005; Tallman & Bohart, 1999).

383BUILDING ALLIANCE IN BRIEF THERAPY

There are close links between activation of powerand fostering of hope. Hope is related to thecapacity for people to see a direction to theachievement of their goals and to feel that theycan move in that direction. The nurses' emphasis onmutuality in goal setting and the treatment process,with the client as coparticipant, was critical to beingable to foster hope and thus ensure effectiveoutcomes (Dearing, 2004; Tryon & Winograd,2002). Nurses felt that this was occurring as early asthe first interview (Tallman & Bohart, 1999).

Some components of alliance formationremained the same in essence, whether or not thecontext was brief therapy or longer term therapy.For example, sense of belonging, as well as the needto feel valued and to fit in (Hagerty et al., 1993;Hagerty & Patusky, 2003), emerged as a relatednesscompetency that closely parallels the actions ofnurses to tailor their approaches to alliance forma-tion (Dearing, 2004; Hewitt & Coffey, 2005). Thebond aspect of the alliance is an important focus fornurses in both brief and long-term therapy, with therecognition that it was a longer process in long-termalliance formation (Dearing, 2004; Hayne&Yonge,1997; Hedelin & Jonsson, 2003; O'Brien, 2001;Turkel 2001). The reasons for brief therapytreatment dropout are multifaceted (Levenson etal., 2002; Tallman & Bohart, 1999), but failure toestablish a strong therapeutic alliance is probablyone of them (Howgego et al., 2003). Therefore,increased intentionality in brief therapeutic allianceformation using relatedness competencies mighthelp more clients complete treatment.

A critical distinction in alliance formation in brieftherapy in comparison with long-term therapy wasthe perception that the focus was more on thepresenting symptoms and problems in a healthierindividual who usually had an adequate supportsystem. This attention to wellness within illnessappears intended to emphasize sameness and we-ness, the common ground, rather than the differencescreated by the symptoms and behaviors arising fromsevere and persistent mental illness (Hagerty,Lynch-Sauer, Patusky, Bouwsema, & Collier,1992). Brief therapy appears to be an effective wayfor nurses to positively engage clients and empowerthem to resolve their problems (Bowles et al., 2001).This research illustrates the congruence betweencommunity nurses' current approaches and practiceand the theoretical frameworks of brief therapy.Using specific approaches such as solution-focused

brief therapy to educate nurses can enhancecommunication skills, client engagement, andempowerment (Bowles et al., 2001).

There are several limitations to this study. Noclients were interviewed, and to gain a more holisticunderstanding of the alliance from multiple per-spectives, there is a need for research that exploresthe client's perspective and that explores theinteraction as it occurs from a third-person stance(Martin et al., 2000; Spiers, 2002). The studysample was limited to experienced nurses, of whomthe majority was educated beyond the diplomalevel, and their perspectives were based on recall ofa recent positive alliance experience, which mayhave put an ideal light on the phenomenon.

CONCLUSION

Although therapeutic alliance is consistently relatedto positive client outcomes in general mental healthrelationships (Despland et al., 2009), nursing hasbeen slow to articulate the process and character-istics of alliance, particularly in the context of brieftherapy. This qualitative focused ethnography hascontributed to the empirical understanding ofalliance-building actions of nurses in brief therapy.It has revealed a description of the intentional actionsthat contribute to therapeutic alliance formation in anonlinear phased process that is comparable with thesocial relatedness competencies of mutuality, reci-procity, synchrony, and sense of belonging identi-fied by Hagerty et al. (1993). Furthermore, theconvergence of informants' ideas with the psycho-therapy literature suggests that these experiencednurses have successfully adapted their practice toapply highly developed knowledge and skills tobuild alliances within the context of brief therapy.

ACKNOWLEDGMENT

The authors thank Daniel S. Scott, RN, MN, forhis help in the preparation of this article.

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APPENDIX ATable 1. Guiding Questions for Focus Groups

Think about a first session that you had with a new client recently, in whichyou had a sense of an established therapeutic alliance by the end of it.Think about what you were experiencing and doing, and what the clientwas doing.

1. What does therapeutic alliance mean to you in the context ofbrief therapy in nursing?

2. What gave you a sense that you had a therapeutic alliance?3. What did you do intentionally to foster quick connections

with the client, knowing it was a brief therapy/consultationrelationship?

4. What do you do to foster that alliance, regardless of thenature of the encounter?

5. What contributes to the establishment of the therapeuticalliance?

6. Are there differences in the nature of the therapeutic alliancein brief therapy compared with long-term therapy? If so,what are they?

7. What factors make it easier to connect in a therapeuticalliance?

8. How does time influence the therapeutic alliance in brieftherapy?

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9. Can you think of a situation where you think you “messed up”in establishing a therapeutic alliance? What do you thinkcontributed to that occurrence or made it more difficult?

10. Are there ever times in which you do things purposefully tolimit engagement in a therapeutic alliance? Why? What doyou do?

11. To sum up, if you were talking with a nurse new to your area,what would you tell him or her about the most importantfactors to think about in establishing a therapeutic alliance inbrief therapy/consultation relationships?

APPENDIX BTable 2. Nurses' Descriptions of the Therapeutic Alliance

Descriptor Category Participant Quotes

Intuition Meg: And you also know at a gutlevel, at an intuitive level—I can'tdescribe it any other way…yousimply know when that connectionhas been made and when it hasn't,and for me, there is no in-between.Nine times out of 10, it occurs in theinitial assessment.Dina: To me, it comes as a sense ofintuition. Sometimes, the person willsay to me—you understand what I'mtalking about….But it's like theyfinally realize that you understandwhere they're coming from, thatyou've had the patience and takenthe time despite their stumblingaround…trying to explain themselves.Kari: You know what I think that is?It's when a person is forthcomingabout giving you information, likethey're not guarded, they're not hesitant,and that they reflect themselves to givethat information…like it just feels right…and you just know.

Visceral knowing as anindicator of intuition

Sara: I get a sensation right here[points] in my chest and my solarplexus…where I experience myconnection…and when that varies,I go with the variation of that intuition.

Lisa: It's just, you know, you've hitit on the head, you know, and they'reright there with you….I think it's areal physical turning toward you…when we hit that moment is whenthey really start to tell us what reallyis going on inside, what they're reallyfeeling… before that, they just answerquestions.

Energy exchangeas process

Mary: Sometimes it is beyond ourcontrol; sometimes there is somethingwe are not aware of, somesubconscious ways of communicatingwith people and…nonverbalcommunication is very important…sounds very unscientific, but there arethings we don't know, maybe thereare certain ions, atoms matching,it's a matching.

Energy exchangeas outcome

Pat: I find that if the client is able tohave some self-disclosure atthat affective level which is cathartic,and I'm able to have assisted themin identifying it, then they are ableto sort of get this “ah-ha”!Kelly: When I first saw him, it wasokay, so you've seen all these otherpeople, all this stuff has been done,what can we do different to changewhat's happening. And so it wasswitching the focus…and him sortof going “ah-ha” and being enthused.Des: And they're comfortable withhow much they gave, they arecomfortable when they leave withhow much they said and gave, and…the speed was all right…and youjust know.Angie: Well, I guess there is aconnection created, the person is lessdefensive, more willing to open up,talks more, so that picks up theenergy. Um—it's almost like a littlebit of joy, a little bit of hopefulnesshappening there.

Table 2 (continued)

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