Therapeutic Relationship

Ms. Rica A. Santos, RN

Objectives

Differentiate between therapeutic nurse-client relationship and a social relationship

Give emotional support using the nursing process according to mental health principles and incorporating transactional analysis concepts.

Effectively use the communicator role in the therapeutic nurse relationship.

Objectives

Use nursing presence and anticipatory guidance in all stages of the nurse-client relationship, facilitating the client’s psychosocial adjustment to life changes.

Describe the caregiver role in creating a therapeutic environment to help the client move towards health.

As according to LaRowe (2004) the very first process between the nurse and

the client is to establish an understanding in the client that the nurse is entering into a relationship

with the client that essentially is safe, confidential, reliable, and consistent

with appropriate and clear boundaries (Varcarolis, et.al.)

Types of Relationship

Social relationship Intimate relationship Therapeutic relationship

Interpersonal Relations in Nursing (1952)

Helping Relationship

Definition

Interpersonal relationship Therapeutic relationship Therapeutic alliance Is an intellectual and emotional bond between the nurse

and the client and is focused on the client. Respects client confidentiality Focuses on the client’s well being Is based on mutual trust, respect and acceptance

Definition

Respects the client as an individual, including Maximizing the client’s abilities to participate in

decision making and treatments Considering ethnic and cultural aspects Considering family relationships and values

The nurse and the client identify areas that need exploration and periodically evaluate the degree of change in the client

Helping is a growth-facilitating process that strives to achieve two basic goals (Egan, 1998) Help the clients manage their problems in living more

effectively and develop unused or underused opportunities more fully.

Help clients become better at helping themselves in their everyday lives

Keys to the helping relationship Development of trust between the nurse and the

client Underlying belief that the nurse cares about and

wants to help the client.

Mental Health Principles

An individual’s reality is based on his/her subjective experiences.

People make the best choices they can for themselves at any given moment.

The meaning of communication is the response the communication elicits

Because a person cannot NOT respond, nearly everything one does be influences

All behavior is useful in some context

Mental Health Principles

It is better to have some choice than no choice The more flexible, the more control that person has in

the system Individuals possess the psychological resources they

need to make the changes they want. Anything one can pretend, one can master There are no mistakes, only outcomes

Goals in a therapeutic relationship

Facilitating communication of distressing thoughts and feelings

Assisting clients with problem solving to help facilitate activities of daily living (ADL)

Helping clients examine self-defeating behaviors and test alternatives

Promoting self-care and independence

The goals of the nurse is to help the client

Feel understood Identify and explore problems relating to others Discover health ways of meeting emotional needs Experience satisfying interpersonal relationship

The goals of the nurse is to help the client

Establish and maintain a therapeutic alliance in which the client will feel safe and hopeful that positive change is possible

Once specific needs and problems have been identified, the nurse can work with the client on increasing problem-solving skills, learning new coping behaviors and experiencing more appropriate and satisfying ways of relating to others

Nurses must get their needs met outside the relationship.

Factors that enhance growth in others

Genuineness Empathy vs. Sympathy Positive regard

Attending Suspending value judgments Helping clients develop resources

Principles in therapeutic relationship

Help the client feel comfortable in talking about himself Refrain from doing too much talking Listen carefully – to the whole, the parts, what precedes

and follows Note that the initial topic may not be the most crucial Attend to the communication cycle and be sure that what

is said is what is heard; encoding, decoding, potential for breakdown

Principles in therapeutic relationship

Observe vigilantly and constantly initial contact use of space communication choices how the story unfolds

What is the client’s dress? Timing Evaluate progress and validate

Establishing Boundaries

Overhelping Controlling

Projection Transference Countertransference

What do you sense -- specifically -- in your body as you look at him/her?

Where do you tense, relax, become warm, cold, feel bigger, smaller, etc.?

Does your breathing change? How? What do you feel emotionally as you look at him/her? Does your body want to move as you look at him/her?

How?

What happens if you follow the movement? What fantasies or other pictures come to mind as you

look at him/her? If this person was an animal, what animal would he/she

be? What animal would you be interacting with this person's

animal?

What do you like about him/her? What don't you like? What does he/she like about you? Not like? How is he/she like you? Different? Who does he/she remind you most of? How are they

alike? Different?

What have you learned about your relationship to your therapist? What would be worthwhile, or necessary to share with your therapist?

Nursing Boundary Index Self-Check

1. Have you ever received feedback about your behavior being overly intrusive with patients and their families?

2. Do you ever have difficulty setting limits with patients?

3. Do you ever arrive early or stay late to be with your patient for a longer period?

4. Do you ever find yourself relating to patients or peers as you might to a family member?

Nursing Boundary Index Self-Check

5. Have you acted on sexual feelings you have for a patient?

6. Do you feel that you are the only one who understands the patient?

7. Have you received feedback that you get “too involved” with patients or families?

8. Do you derive conscious satisfaction from patients’ praise, appreciation, or affection?

Nursing Boundary Index Self-Check

9. Do you ever feel that other staff members are too critical of “your” patient?

10. Do you ever feel that other staff members are jealous of your relationship with your patient?

11. Have you ever tried to “match-make” a patient with one of your friends?

12. Do you find it difficult to handle patients’ unreasonable requests for assistance, verbal abuse, or sexual language?

Understanding self and others

Values Values clarification

Prizing one’s beliefs and behaviors (emotional)

Choosing one’s beliefs and behaviors (cognitive)

Acting on one’s beliefs (Behavioral)

Accountability Focus on client’s needs Clinical competence Supervision

Phases

Pre-interaction/ Pre-orientation Introductory/ Orientation Working Termination

Interacting with Clients with Various Emotional

State

When Interacting with an Anxious Client

Provide the client with simple, organized information in a structured format

Explain who you are and your role and purpose Ask simple, concise questions. Avoid becoming anxious like the client. Do not hurry and decrease external stimuli.

When Interacting with an Angry Client

Approach the client in a calm, reassuring, in-control manner.

Allow him to ventilate feelings. However, if the client is out of control, do not argue with or touch the client.

Obtain help from other health care professionals as needed.

Avoid arguing and facilitate personal space so the client does not feel threatened or cornered.

When Interacting with a Depressed Client

Express interest in and understanding of the client and respond in a neutral manner.

Do not try to communicate in an upbeat encouraging manner. This will not help a depressed client.

When interacting with a Manipulative Client

Provide structure and set limits. Differentiate between manipulation and a reasonable

request. If you are not sure whether you are being manipulated,

obtain an objective opinion from other nursing colleagues.

When Interacting with a Seductive Client

Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors.

Encourage client to use more appropriate methods of coping in relating to others.

When Discussing Sensitive Issues

First be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client’s health and may need to be discussed with someone.

Ask simple questions in non-judgmental manner. Allow time for ventilation of client’s feelings as needed. If you do not feel comfortable or competent discussing

personal, sensitive topics, you may make referrals as appropriate, for example, to a pastoral counselor for spiritual concerns or other specialist as needed.

Transactional Analysis

Transactional analysis, commonly known as TA to its adherents, is an integrative approach to the theory of psychology and psychotherapy. Integrative because it has elements of psychoanalytic, humanist and cognitive approaches. It was developed by Canadian-born US psychiatrist Eric Berne during the late 1950s.

TA emphasizes a pragmatic approach, that is, it seeks to find "what works" in treating patients, and, where applicable, develop models to assist understanding of why certain treatments work. Thus, TA continually evolves.

The Ego-State(or Parent-Adult-Child, PAC) Model

At any given time, a person experiences and manifests their personality through a mixture of behaviours, thoughts and feelings. Typically, according to TA, there are three ego-states that people consistently use:

Parent ("exteropsyche")

a state in which people behave, feel, and think in response to an unconscious mimicking of how their parents (or other parental figures) acted, or how they interpreted their parent's actions.

For example, a person may shout at someone out of frustration because they learned from an influential figure in childhood the lesson that this seemed to be a way of relating that worked.

Characteristics

Sets limits Gives advice Disciplines Guides Protects Makes rules Teaches “how to” Nurtures Judges; criticizes

Adult ("neopsyche")

a state of the ego which is most like a computer processing information and making predictions absent of major emotions that cloud its operation. Learning to strengthen the Adult is a goal of TA.

While a person is in the Adult ego state, he/she is directed towards an objective appraisal of reality.

Assertive

Characteristics

Logical thought – decision making process Reacts with autonomy, objectivity Processes reality data Helps us deal with the outside world safely Regulates and mediates between the

demands of the internal parent and child Autonomous Reality Oriented Objective

Child ("archaeopsyche")

a state in which people behave, feel and think similarly to how they did in childhood.

For example, a person who receives a poor evaluation at work may respond by looking at the floor, and crying or pouting, as they used to when scolded as a child. Conversely, a person who receives a good evaluation may respond with a broad smile and a joyful gesture of thanks. The Child is the source of emotions, creation, recreation, spontaneity and intimacy.

Characteristics

Angry, rebellious Frightened Conforming (pleasing parent) OR Loving, spontaneous, trusting, joyful,

adventurous

Transaction

The interaction between people and their respective selves within. 

Reciprocal or Complementary Transactions

A: "Have you been able to write the report?" B: "Yes - I'm about to email it to you." ----

(This exchange was Adult to Adult) A: "Would you like to skip this meeting and go watch a

film with me instead?" B: "I'd love to - I don't want to work anymore, what should we go and see?"

(Child to Child) A: "You should have your room tidy by now!" (Parent to

Child) B: "Will you stop hassling me? I'll do it eventually!" (Child to Parent)

Crossed Transaction

A: "Have you been able to write that report?" (Adult to Adult) B: "Will you stop hassling me? I'll do it eventually!" (Child to Parent) A: "If you don't change your attitude, you'll get fired."

A: "Is your room tidy yet?" (Parent to Child) B: "I'm just going to do it, actually." (Adult to Adult)

A: "I can never trust you to do things!" (Parent to Child) B: "Why don't you believe anything I say?" (Adult to Adult)

Duplex or Covert Transactions

A: "I need you to stay late at the office with me." (Adult words) body language indicates sexual intent (flirtatious Child)

B: "Of course." (Adult response to Adult statement). winking or grinning (Child accepts the hidden motive).

Remember

You are all three ego states (person). All 3 are important and desirable. It is best that the adult be functioning all the time to be

aware of the influences of the child, parent, and adult. The adult chooses the most appropriate ego state.

Milieu Therapy

A form of psychotherapy that involves the use of therapeutic communities.

Patients join a group of around 30, for between 9 and 18 months.

During their stay, patients are encouraged to take responsibility for themselves and the others within the unit. Milieu therapy is thought to be of value in treating personality disorders and behavioral problems.

Milieu Therapy is a planned treatment environment in which everyday events and interactions are therapeutically designed for the purpose of enhancing social skills and building confidence.  Academics are woven into the daily routine using an integrative and interactive approach that incorporates learning styles and areas of interest. 

The milieu, or "life space," provides a safe environment that is rich with social opportunities and immediate feedback from caring staff.  The milieu is not static but it is flexible and features normalizing and developmental perspectives that use common structures familiar to all children, such as daily routines, consistent rules and activities. 

Seven Basic Assumptions in Milieu Therapy

The health in each individual is to be realized and encouraged to grow.

Every transaction is an opportunity for therapeutic intervention.

The patient owns his own environment including the unit structure, its management, and its activities.

Each patient owns his behavior. Peer pressure is a useful and a powerful tool. Inappropriate behaviors are dealt with as they occur. Restrictions and punishment are to be avoided

Therapeutic milieu cannot occur unless interpersonal skills are developed among staff. This

means much more than didactic education. Staff must be

empowered so that they can “empower” patients.

Quiz

1. A patient who has anorexia nervosa says to the nurse, “I feel so fat and ugly.” Which of the following response would be most therapeutic?

A. “Don’t be so hard on yourself.”

B. “It sounds as if you’re feeling bad about your body.”

C. “You look fine to me.”

D. “I’d love to be your size.”

2. If a client fails to follow the information or teaching provided, how should the nurse respond?

A. Give up, as the client doesn’t want to change

B. Develop a tough approach

C. Re-teach the information, as the nurse is the expert

D. Reassess the client’s importance given to the behavior and readiness to change it.

3. When clients need to express feelings, enhance their self-esteem or clarify values, the need for therapeutic use of self arises. Certain skills must be developed to be effective. As a health care provider you must…..

A. Develop self-awareness and acceptance

B. Use facilitative communication techniques and good interpersonal skills

C. Develop health care provider-client relationship D. All of the above

4. A man who is a declared agnostic is extremely depressed after losing his home, his wife, and his children in a fire. His nursing diagnosis is Spiritual Distress: Spiritual Pain related to inability to find meaning and purpose in his current condition. The most important nursing intervention to plan is:

A. Ask the patient which spiritual adviser he would like you to call

B. Recommend that the patient read spiritual biographies or religious books

C. Explore with the patient what, in addition to his family, has given his life meaning and purpose in the past.

D. Introduce the belief that God is a loving and personal God.

5. While the nurse is conducting an interview to a client with eating disorder, she said “I cannot anymore stand the way I look right now.” Which among the following responses by nurse would be most therapeutic for the client?

A. “It’s ok, you are not the only one who is experiencing that.”

B. “There’s nothing to worry, you’ll regain your usual shape pretty soon for as long as you’ll cooperate with us.”

C. “I don’t think you look bad.”

D. “Tell me more about your feelings.”

6. A nurse notices the mother of a hospitalized one-month-old boy sitting and talking on the telephone while the infant lies in the crib crying. Which of the following statements would the nurse be most appropriate?

A. “Your baby is crying and needs your attention now.”

B. “Let’s check your baby together to see what he needs”

C. “Why do you think your baby is crying at this time?”

D. “When did you last feed your baby?”

7. A client who is doing a return demonstration of how to change a wound dressing to the leg contaminates the dressing after appropriately cleansing the wound. The best nursing response is to:

A. Say, "You have done this all wrong! Let me show you again."

B. Remove the dressing, cleanse the wound again, and apply a new dressing

C. Say and do nothing to avoid upsetting the client

D. Say, "You did a good job of cleansing the wound. Let's look at ways to best put the dressing on."

8. The nurse enters the room of a patient with cancer. He is crying and states, “I feel so alone.” Of the following statements, which is the most therapeutic? T469

A. The nurse stands at the patient’s bedside and states, “I understand how you feel. My mother said the same thing when she was ill.”

B. The nurse stands in the patient’s room and asks, “Why do you feel so alone? Your wife has been here everyday.”

C. The nurse holds the patient’s hand and asks, “What makes you feel so alone?”

D. None of the above

9. Mr. Ying is scheduled for surgery. He says to you, “I am so frightened - what if I don’t wake up?” What would be your best response?

A. “You have a wonderful doctor.”

B. “Let’s talk about how you are feeling.”

C. “Everyone wakes up from surgery.”

D. “Don’t worry, you will be just fine.”

10. The patient is scheduled for proctosigmoidoscopy. She says she is nervous. What would be the most appropriate response of the nurse?

A. “You need not to worry! You have the best doctor in the hospital.”

B. “I don’t blame you for feeling that way. If I were in your position, I would feel the same manner.”

C. “Why do you feel that way? Don’t you trust God?

D. “You sound really upset. Would you like to sit and talk about it?