Mental Health Series

Therapeutic NursePatient Relationship

.By Sawiji, S.Kep. Ns., M.Sc
sawijiamani@gmail.com: Email
Phone: +6281-328-028-333
62877-1515-9222+

Nursing Basic Science Department

Muhammadiyah Gombong Health
Science Institute

 The therapeutic nurse-patient relationship

is a mutual learning experience and a
corrective emotional experience for the
patient.
It is based on the underlying humanity of
nurse and patient, with mutual respect and
acceptance of sociocultural differences.
In this relationship the nurse uses
personal attributes and clinical techniques
in working with the patient to bring about
insight and behavioral change.

:Characteristics of the relationship

The goals of a therapeutic relationship are directed toward
achieving the patient's optimal growth and include the
following dimensions:
Self-realization, self acceptance, and an increased
genuine self-respect.
A clear sense of personal identity and an improved level
of personal integration.
An ability to form intimate, interdependent, interpersonal
relationships with a capacity to give and receive love.
Improved functioning and increased ability to satisfy
needs and achieve realistic personal goals.

This chapter examines:

the personal qualities of the nurse as helper,
the phases of the relationship,
facilitative communication,
responsive and action dimensions,
therapeutic impasses,
and the therapeutic outcome (Figure).

Each of these
effectiveness.

factors

influences

the

nurse's

:I. Personal Qualities of the Nurse

The therapeutic tool of the psychiatric nurse
is the use of oneself. Thus self-analysis is
the first building block in providing quality
nursing care.
Research suggests that some essential
qualities are needed if one is to help others.

Awareness of Self. 1
The nurse must be able to examine
personal feelings, actions, and reactions.
A good understanding and acceptance of
self allow the nurse to acknowledge a
patient's differences and uniqueness.

Campbell (1980) has identified a holistic nursing model of selfawareness that consists of four interconnected components:
The psychological component includes knowledge of emotions, motivations,
self-concept, and personality. Being psychologically self-aware means being
sensitive to feelings and outside events that affect those feelings.
The physical component is the knowledge of personal and general
physiology, as well as of body sensations, body image, and physical potential.
The environmental component consists of the sociocultural environment,
relationship with others, and knowledge of the relationship between humans
and nature.
The philosophical component is the sense of life having meaning. A personal
philosophy of life and death may or may not include a spiritual being, but it
does take into account responsibility to the world and the ethics of behavior.
Together these components provide a model that can be used to promote the
self-awareness and self-growth of nurses and the patients for whom they care.

:Clarification of Values. 2
Nurses should be able to answer the question,
What is important to me? Awareness of one's
own values helps the nurse to be honest, to
better accept differences in others, and to avoid
the unethical use of patients to meet personal
needs.
One of the many challenges facing psychiatric
nurses today is the need to provide care for
patients from diverse backgrounds.

:Exploration of Feelings. 3
It is often assumed that helping others requires complete
objectivity and detachment. This is definitely not true.
Complete objectivity and detachment describe someone
who is unresponsive, false, unapproachable, impersonal,
and self-alienated-qualities that block the establishment
of a therapeutic relationship.
Rather, nurses should be open to, aware of, and In
control of their feelings so that they can be used to help
patients.
For example, despite the patient's statement that "things
are going real well", the nurse might perceive a strong
sense of despair or anger.

:Serving as Role Model. 4

Research has shown the power of role
models in molding socially adaptive, as
well as maladaptive, thus a nurse has an
obligation to model adaptive and growthproducing behavior.

:Altruism. 5
Altruism is concern for the welfare of others.
It does not mean that an altruistic person
should not expect adequate compensation
and recognition or must practice denial or
self-sacrifice.
Only if personal needs have been
appropriately met can the nurse expect to be
maximally therapeutic.

:Ethics and Responsibility. 6

The Code for Nurses reflects common
values regarding nurse-patient relationships
and responsibilities and serves as a frame
of reference for all nurses in their
judgments about patient welfare and social
responsibility.
Responsible ethical choice involves
accountability, risk, commitment, and
justice.

:Phases of the Relationship

It is important to distinguish between social
support and professional support.
The support requested and ultimately provided
should be within the domain of the nurse's role
as a professional caregiver.
Four phases of the nurse-patient relationship
have been identified: preinteraction,
introductory, or orientation, phase; working
phase; and termination phase.

:Preinteraction Phase. 1
The preinteraction phase begins before the
nurse's first contact with the patients. The nurse's
initial task is one of self-exploration.
The self-analysis of the preinteraction phase is a
necessary task.
To be effective, nurses should have a reasonably
stable self-concept and an adequate amount of
self-esteem. They should engage in positive
relationships with others and face reality to help
patients do the same.
Other tasks of this phase include gathering data
about the interaction with the patients.

:Introductory, or Orientation, Phase. 2

It is during the introductory phase that the nurse
and patient first meet. One of the nurse's
primary concerns is to find out why the patient
sought help
An additional task is to establish goal
consensus and collaboration.
Formulating a contract. The tasks in this phase
of the relationship are to establish a climate of
trust, understanding, acceptance, and open
communication and formulate a contract with the
patient. Box 2-4 lists the elements of a nursepatient contract.

The issue of confidentiality is an important one to discuss

with the patient at this time. Confidentiality involves the
disclosure of certain information only to another
specifically authorized person.
Other tasks of the nurse in the orientation phase of the
relationship are as follows:
To explore the patient's perceptions. Thoughts, feelings,
and actions.
To identify pertinent patient problems
To define mutual, specific goals with the patient.

:Working phase. 3
Most of therapeutic work is carried out during the working
phase. The nurse and the patient explore stressors and
promote the development of insight in the patient by
linking perceptions, thoughts, feelings, and actions.
These insights should be translated into action and a
change in behavior. They can then be integrated into the
individual's life experiences.
Patients often display resistance behaviors during this
phase because it involves the greater part of the problemsolving process.
As the relationship develops, the patient begins to feel
close to the nurse and respond by clinging to old defenses
and resisting the nurse's attempts to move forward.

:Termination phase. 4
Termination is one of the most difficult but most
important phases of the therapeutic nursepatient relationship.
Termination is a time to exchange feelings and
memories and to evaluate mutually the patient's
progress and goal attainment.
Levels of trust and intimacy are heightened,
reflecting the quality of the relationship and the
sense of loss experienced by both nurse and
patient

:II. Facilitative Communication

Communication, which takes place on two
levels (verbal and nonverbal), can either
facilitate the development of a therapeutic
relationship or serve as a barrier to it.

:Verbal Communication
Verbal communication occurs through
words, spoken written.

:Nonverbal Communication
Nonverbal communication includes all
relayed information that does not involve
the spoken or written word, including cues
from all five senses.
It has been estimated that about 7% of
meaning is transmitted by words, 38% is
transmitted by paralinguistic cues such as
voice, and 55% is transmitted by body
cues.

Types of Nonverbal Behaviors

Verbal cues: include all the nonverbal
qualities of speech.
Some examples include pitch; tone of
voice; quality of voice; loudness or
intensity; rate and rhythm of talking; and
unrelated nonverbal sounds, such as
laughing, groaning.

 Action cues: are body movements,

sometimes referred to as kinetics.
Reflexes, posture, facial expression,
gestures.

 Object cues: are the speaker's

intentional and unintentional use of all
objects. Dress, furnishings, and
possessions

 Space: provides another clued to the

nature of the relationship between
two people.

 Touch: involves both personal space

and action.
Therapeutic touch or the nurse's
laying hands on or close to the body
of an ill person for the purpose of
helping or healing.

:Therapeutic Communication Techniques

There are two requirements for therapeutic
communication:
1. All communication must preserve the self-respect
of both individuals.
2. One should communicate understanding before
giving any suggestions or advice.

Activities are carried out with the patient, not for the
patient.

 1. Listening: listening is essential to

understanding the patient.
Therefore the first rule of a therapeutic
relationship is to listen to the patient.
Real listening is difficult. It is an active,
not a passive, process.

Aids to Communication
Active listening
Expression of interest
Leaning forward
Nodding head
Verbalizations such as Uh-huh and Go
on
Frequent validation
Attempt to fully understand

 2. Broad Openings:
Broad openings, such as:
- "What are you thinking about?" "Can you
tell me more about that?
- "What shall we discuss today?"
encourage the patient to select topics to
discuss.

 3. Restating:
Restating is the nurse's repeating
of the main thought the patient
has expressed.

 4. Clarification:
Clarification occurs when the nurse
attempts to put into words vague ideas or
thoughts that are implicit or explicit in the
patient's talking.
Such as "I'm not sure what you mean. Are
you saying that ?"

 5. Reflection:
Reflection of content is also called validation,
which lets the patient know that the nurse has
heard what was said and understands the content.
It consists of repeating in fewer or different words
the essential ideas of the patient and resembles
paraphrasing. Sometimes it helps to repeat a
patient's statement, emphasizing a key word.
Reflection of feelings consists of responses to
the patient's feelings about the content.

 6. Focusing:
Focusing helps the patient
expand on a topic of importance.

 7. Sharing Perceptions:
Sharing perceptions involves asking the
patient to verify the nurse's understanding
of what the patient is thinking or feeling.
Perception checking is a way to explore
incongruent
or
double-blind
communication.
"You're smiling, but I sense that you're
really angry with what happened."

 8. Theme Identification:
themes are underlying issues or problems
experienced by the patient that emerge
repeatedly during the course of the nurse-patient
relationship.
They can relate to feelings (depression or
anxiety), behavior (rebelling against authority or
withdrawal), experiences (being loved or hurt),
or combinations of all three.

 9. Silence:
Silence on the part of the nurse has
varying effects depending on how the
patient perceives it.
To a vocal patient, silence on the part of
the nurse may be welcome, as long as the
patient knows the nurse is listening.
With a depressed or withdrawn patient,
the nurse's silence may convey support,
understanding, and acceptance.

 10. Humor:
Humor is a basic part of the personality
and has a place within the therapeutic
relationship.
As a part of interpersonal relationships, it
is a constructive coping behavior.
By learning to express humor, a patient
may be able to learn to express other
feelings.

 11. Informing:
informing or information giving, is an
essential nursing technique in which the
nurse shares simple facts or information
with the patient.

 12. Suggesting:
suggesting is the presentation of alternative
ideas, and is exploring alternative coping
mechanisms.
Suggesting or advice, also can be no
therapeutic, reinforces the patient's dependence.
The nurse's intent in using the suggesting
technique should be to provide feasible
alternatives and allow patients to explore their
values in their unique life situation.

III. RESPONSIVE DIMENSIONS

The nurse must possess certain skills or
qualities to establish and maintain a
therapeutic relationship.
Specific core conditions for facilitative
interpersonal relationships can be divided
into responsive dimensions and action
dimensions

 The responsive dimensions include

genuineness, respect, empathic
understanding, and concreteness.
The helping process can impede the
patient's growth rather than enhance it,
depending on the level of the nurse's
responsive and facilitative skills.

 The responsive dimensions are crucial in

a therapeutic relationship to establish trust
and open communication.
The nurse's goal is to understand the
patient and to help the patient gain self
understanding and insight.
These responsive conditions then
continue to be useful throughout the
working and termination phases.

Genuineness. 1
Genuineness means that the nurse is an
open, honest, sincere person who is
actively involved in the relationship.
Genuineness is the opposite of selfalienation, which occurs when many of an
individual's real, spontaneous reactions to
life are suppressed.

 Genuineness means that the nurse's

response is sincere, the nurse is not
thinking and feeling one thing and saying
something different.
It is an essential quality because nurses
cannot expect openness, self-acceptance,
and personal freedom in patients if they
lack these qualities themselves

 Whatever the nurse shows must be real

and not merely a 'professional' response
that has been learned and repeated.
In focusing on the patient, many of the
nurse's personal needs are put aside, as
well as some of the usual ways of relating
to others.

2. Respect
Respect is also called unconditional
positive regard.
It does not depend on the patient's
behavior.
Caring, liking, and valuing are other terms
for respect.
The patient is regarded as a person of
worth and is respected as such.

3. Empathy
Empathy is the ability to enter into the life of
another person, to accurately perceive the
person's current feelings and their meanings, and
to communicate this understanding to the patient.
Accurate empathy involves more than knowing
what the patient means. It also involves
sensitivity to the patient's current feelings and the
verbal ability to communicate this understanding
in a language attuned to the patient.

 Empathy can significantly promote

constructive learning and change.
First, it dissolves the patient's sense of
isolation by connecting the patient to
another person.
The patient can perceive that "I make
sense to another human being. .. so I must
not be so strange. and if I am in touch
with someone else, I am not so alone.

4. Concreteness
Concreteness involves using specific
terminology rather than abstractions when
discussing the patient's feelings,
experiences, and behavior.
It avoids vagueness and ambiguity and is
the opposite of generalizing, labeling, and
making assumptions about the patient's
experiences.

IV. ACTION DIMENSION

The action-oriented conditions for facilitative
interpersonal relationships are confrontation,
immediacy, therapist self-disclosure, catharsis,
and role playing.
With the action dimensions, the nurse moves the
therapeutic relationship upward and outward by
identifying obstacles to the patient's progress
and the need for specific behavior change.

Confrontation. 1
Confrontation often implies venting anger
and engaging in aggressive behavior.
However, confrontation as a therapeutic
action dimension is an assertive rather
than aggressive action.

Confrontation is an expression by the nurse of perceived

discrepancies in the patient's behavior. Three categories of
confrontation include the following:
discrepancies between the patient's expression of what he
is (self-concept) and what he wants to be (self-ideal)
discrepancies between the patient's verbal self-expression
and nonverbal behavior.
Discrepancies between the patient's expressed experience
of himself and the nurse's experience of him
Confrontation is an attempt by the nurse to make the patient
ware of incongruence in feelings, attitudes, beliefs and
behaviors.

 Confrontation also must be appropriately timed

to be effective (figure). In the orientation phase
of the relationship, the nurse should use
confrontation infrequently and pose it as an
observation of incongruent behavior.
A simple mirroring the discrepancy between a
patient's actions and words is the most
nonthreatening type of confrontation. The nurse
might say, "you seem to be saying two different
things. "this type of confrontation closely
resembles clarification at this time.

 Nurses also might identify discrepancies

between how they and patients are
experiencing their relationship, point out
unnoticed patient strengths or untapped
resources, or provide patients with
objective but perhaps different information
about their world.
Finally, to be effective, confrontation
requires high levels of empathy and
respect.

Immediacy. 2
Immediacy involves focusing on the current
interaction of the nurse and the patient in the
relationship. It is a significant dimension
because the patient's behavior and functioning
in the relationship are indicative of functioning in
other interpersonal relationships.
Immediacy involves sensitivity to the patient's
feelings and a willingness to deal with these
feelings rather than ignore them.

Nurse self-disclosure. 3
Self-disclosures are subjectively true, personal
statements about the self, intentionally revealed to
another person. The nurse may share experiences or
feelings that are similar to those of the patient and may
emphasize both the similarities and differences.
This kind of self-disclosure is an index of the closeness
of the relationship and involves a particular kind of
respect for the patient. It is an expression of
genuineness and honesty by the nurse and is an aspect
of empathy.
The research literature provides significant evidence that
therapist self-disclosure increases the likelihood of
patient self-disclosure. Patient self-disclosure is
necessary for a successful therapeutic outcome.

Emotional catharsis. 4
Catharsis occurs when the patient is encouraged
to talk about things that are most bothersome.
Catharsis brings fears, feelings, and experiences
out into the open so that they can be examined
and discussed with the nurse.
The expression of feelings can be very
therapeutic in itself; even if behavioral change
does not result

Role playing. 5
Role playing involves acting out a particular
situation. It increases the patient's insight into
human relations and can deepen the ability to
see the situation from another person's point of
view.
When role playing is used to facilitate attitude
change, one key element of the exercise is role
reversal. The patient may be asked to assume
the role of a certain person in a specific situation
or to play the role of someone with opposing
beliefs.

 After experiencing role reversal, patients

may be more receptive to modifying their
own attitudes.
Used as a method of promoting selfawareness and conflict resolution, role
playing may help the patient "experience"
a situation, which can be more helpful
than just talking about it.

 One of the ways in which role playing can be

used to resolve conflicts and increase selfawareness is through a dialogue that requires
the patient to take turns speaking for each
person or each side of a problem.
If the conflict is internal, the dialogue occurs in
the present tense and alternates between the
patient's conflicting selves until one part of the
conflict outweighs the other.
If the conflict involves a second person, the
patient is instructed to "imagine that the other
person is sitting in the chair across from you."

V. Therapeutic impasses
Therapeutic impasses are blocks in the progress of the
nurse-patient relationship.
They come about for a variety of reasons, but all
impasses create stalls in the therapeutic relationship.
Impasses provoke intense feelings in both the nurse and
the patient, which may range from anxiety and
apprehension to frustration, love, or intense anger.
Four specific therapeutic impasses and ways to
overcome them are discussed here: resistance,
transference, counter-transference, and boundary
violations.

Resistance. 1
Resistance is the patient's reluctance or
avoidance of verbalizing or experiencing
troubling aspects of oneself.
Resistance is often caused by the
patient's unwillingness to change when
the need for change is recognized.

Transference. 2
Transference is an unconscious response in
which patients experience feelings and attitudes
toward the nurse that were originally associated
with other significant figures in their life.
Transference reduces self-awareness by
allowing the patient to maintain an inaccurate
view of the world in which all people are seen in
similar terms.
The first is the hostile transference. If the patient
internalizes anger and hostility, this resistance
may be expressed as depression and
discouragement.

 A second difficult type of transference is

the dependent reaction transference.
This resistance is characterized by
patients who are submissive, subordinate,
and ingratiating and who regard the nurse
as a godlike figure.

Counter transference. 3
Counter transference is a therapeutic impasse
created by the nurse's specific emotional
response to the qualities of the patient.
Counter transference reactions are usually of the
following three types:
1. Reactions of intense love or caring
2. Reactions of intense disgust or hostility
3. Reactions of intense anxiety, often in response
to resistance by the patient.

Boundary violations. 4
Which occur when a nurse goes outside
the boundaries of the therapeutic
relationship and establishes a social,
economic, or personal relationship with a
patient.

Possible boundary violations related to psychiatric nurses

The patient takes the nurse out to lunch or dinner.
The professional relationship turns into a social relationship.
The nurse attends a party at a patient's invitation.
The nurse regularly reveals personal information to the patient.
The patient introduces the nurse to family members, such as a son
or daughter, for the purpose of social relationship.
The nurse accepts free gifts from the patient's business.
The nurse agrees to meet the patient for treatment outside the usual
setting without therapeutic justification.
The nurse attends social functions that include the patient
The patient gives the nurse an expensive gift.
The nurse routinely hugs or has physical contact with the patient
The nurse does business with or purchases services from the patient.

VI. Therapeutic outcome