• 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
• Self-realization, self –acceptance, and an increased
• 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
communication, responsive and action
dimensions, therapeutic impasses, and the
therapeutic outcome (Figure).
• Each of these 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
• 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
• 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
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
• 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 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
: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
: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
• 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
• 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,
• 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
• 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
• 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
: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
: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 occurs through
words, spoken written.
• 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,
• Object cues: are the speaker's
international and unintentional use of
all objects. Dress, furnishings, and
• Space: provides another clued to the
nature of the relationship between
• 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
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
• 1. Listening: listening is essential to
understanding the patient. Therefore the
first rule of a therapeutic relationship is to
lists to the patient.
• Real listening is difficult. It is an active,
not a passive, process.
• 2. Broad Openings: Broad openings,
such as "What are you thinking about?"
"Can you tell me more about that?" and
"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
• 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
• 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 what
• 8. Theme Identification: themes are underlying
issues or problems experienced by the patient
that emerge repeatedly during the course of the
• 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 ahs 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 and 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
• 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
• 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
• 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 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
• 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
• 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.
• 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
• 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.
• 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
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 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
• 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
• 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
• 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
• 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
• After experiencing role reversal, patients
may be more receptive to modifying their
• 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 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 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
• The first is the hostile transference. If the patient
internalizes anger and hostility, this resistance
may be expressed as depression and
• 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
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
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.