Discussion on therapeutic relationship for nursing student

1. Prepared by:
Janet C. Gaddi, RMT, RN, RM, LPT, MAN

2. DEVELOPING A THERAPEUTIC
RELATIONSHIP
Therapeutic relationship is a dynamic interactive
process between professionally educated person, the
nurse, who helps another individual, the client to
seek and use help.

3. Goals of a Therapeutic Nurse-Client
relationship
 Help the client develop appropriate social and
verbal skills to test reality, and to solicit feedback
and support for new behaviors
 Help patients to reduce anxiety and body tension,
to develop a sense of competence, and to take risk
 Opportunity for a nurse to demonstrate ways of
handling situations or learn coping strategies

4. Reinforce self-worth
Enhance self-concepts and confidence
Examine relationship
Achieve growth
Solve problems
Extinguish (let go) of unwanted behavior

5. Essential characteristics of the Nurse
in a Therapeutic Relationship
 Empathy
- demonstrate sensitivity and caring.
- a pervasive phenomenon in the life experience of
all people.
- it allows people to feel the feelings of another
and respond to and understand that person’s
experience on his or her terms.

6.  Warmth
- the nurse should be aware of and accept the
client’s right to maintain distance.
- initially high levels of warmth can be
counter-productive for clients who have
received little warmth from others in their
lives or have been taken advantage of by
others.

7.  Genuineness
– refers to the ability to be real or honest with
another
- to be effective, it must be timed properly and
based on a solid relationship.
 Respect
– demonstrates that the nurse values the
integrity of the client and has faith in the
client’s ability to solve his or her problems,
given appropriate help.
 Concreteness – the quality of being concrete

8.  Immediacy
– responding to what is happening between the
client and the nurse in the here and now
- this dimension may involve the feelings of the
client toward the nurse, it can be one of the most
difficult to achieve
 Self-disclosure – act of revealing more about
ourselves

9. Nurse’s Self-Awareness
Self-awareness
is a process of increasing self-knowledge through
introspection, self-assessment and use of
feedback from significant people in the
environment regarding one’s behavior
- requires willingness to examine one’s own
perceptions, thoughts, beliefs, feelings, and
behaviors, and the responses of others toward
oneself in various circumstances

10. Self-concept
is the sum total of perceptions, feelings, and
beliefs about oneself
is a totality of a person’s attitudes, beliefs,
judgments, and values held in relation t one’s
behavior, abilities, and qualities.
is the way the person perceives his/her
abilities and worth.
reflects the integration of self, body, and moral
images, self-esteem and identity

11. The three components of self-concept and
development:
1. The actual responses of others toward the person
2. The person’s perception of these responses toward
himself/herself
3. The person’s acceptance and internalization of these
perceived responses, which then influence behavior.

12.  Methods to increase self-awareness
 Introspection
 Discussion
 Enlarging one’s experience
 Role-playing

13. Phases of a Therapeutic Relationship
a. Pre-interaction phase
begins before the nurse’s initial first contact with the
patient.
The nurse’s initial task is one of self-exploration. The most
important tool is the ability to communicate, empathize,
and solve problems.
 Common concerns of Psychiatric nursing students
Acutely self-conscious
Afraid of being rejected by the patients
Anxious because of the newness of the experience
Concerned about personally over identifying with
psychiatric patients
Doubtful of the effectiveness of skills or coping ability

14. Fearful of physical danger or violence
Insecure in therapeutic use of self
Suspicious of psychiatric patients stereotyped as
different
Threatened in nursing role identity
Uncertain about ability to make unique contribution
Uncomfortable about lack of physical tasks and
treatments
Vulnerable to emotionally painful experiences
Worried about hurting the patient psychologically

15. The self-analysis of the pre-interaction 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
constructive relationship with others and face reality
to help patients do likewise. If they are aware of and
in control of what they convey to their patients
verbally and nonverbally, nurses can function as role
models.

16. Other tasks of this phase include gathering data
about the patient if information is available and
planning for the first interaction with the patient.
The nursing assessment is begun, but most of the
work related to it is done with the patient in the
second phase of the relationship. Finally, nurses
review general goals of a therapeutic relationship
and consider what they have to offer patients.

17. Introductory or Orientation Phase
 It is during this phase that the nurse and patient
first meet. The nurse’s primary concerned is to
find out why the patient sought help and whether
it was voluntary. The basis of the nursing
assessment helps the nurse to focus on the
patient’s problem and to determine patient
motivation.

18. Formulating a contract. – the task in this phase is to
establish a climate of trusts, understanding,
acceptance, and open communication and formulate
a contract with the patient.

19. The following are elements of a nurse-patient
contract:
Names of individuals
Roles of nurse and patient
Responsibilities of nurse and patient
Expectations of nurse and patient
Purpose of the relationship
Meeting location and time
Conditions for termination
Confidentiality

20. The contract begins with the introduction of the
nurse and patient, exchange of names and
explanation of roles. An explanation of roles
includes the responsibilities and expectations of
the patient and nurse, with s description of what
the nurse can and cannot do. This is followed by
a discussion of the purpose of the relationship, in
which the nurse emphasizes that the focus of it
will be the patient and the patient’s life
experiences and areas of conflict.

21. Exploring feelings.
To explore the patient’s perceptions, thoughts,
feelings, and actions
To identify pertinent patient problems
To define mutual, specific goals with the patient

22. Patients also may display manipulative or testing
behavior during this phase as they explore the
nurse’s consistency and intent.
Level of continuum of care:
 Building trust
 Beginning assessment
 Management of emotions
 Providing support
 Providing structure

23.  Working Phase
 The nurse and 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 be integrated into the
individual’s life experiences.
 When patients are ready, the work toward behavioral
change can begin. Change may not be the goal for
some patients, especially the chronically ill. Instead,
stabilization with medications, reduction of symptoms,
and development of supportive relationships are valid
goals.

24. To test new behaviors:
1. Process of learning- changing behavior is difficult.
The following are steps for therapeutic relationship:
Observation is a prerequisite because without
awareness of the problem there is no motivation to
change. The nurse learns how well patients
understand their problems by asking for in-depth,
detailed descriptions of situations, thoughts, feelings
and behavior.

25.  Analysis is then necessary to encourage accuracy
in patients’ conclusions about their problems. It is
one thing for a patient to describe the type and
sequence of arguments

26.  Interpretation leads to a decision that change is
necessary and appropriate
 Planning step help patients solve their own
problems. The nurse encourages short-term,
realistic and achievable daily goals

27.  Testing-out step involves trying new behavior or
solutions in a safe environment first then in a real
situation
 Evaluation to assess the success of the new
behaviors or solutions to problems and to
determine whether modification or a different
approach is needed.

28. 2. In-depth data collection- nurse facilitate awareness,
analysis, and interpretation through in-depth
exploration of issues and by identifying priority issues.
3. Reality testing and cognitive restructuring. Reality
testing is an important strategy in the analysis,
interpretation, and planning steps. It helps patients to
see reality more clearly and objectively where there
may have been distortions or inaccuracies in the past.
The goal of reality testing is cognitive restructuring:
help patients cope with negative thoughts and beliefs
and see other viewpoints that will help them come to
more realistic conclusion.

29. 4. Writing/journaling – this is useful to have patients write
down their thought and feelings each day. This can be
the release for emotions and can facilitate a more
objective analysis of issues
5. Supportive confrontation is similar to reality testing but
has broader focus than specific perceptions,
interpretations, or feelings. It is aimed at
contradictions, discrepancies, responsibility,
accountability, independence, and behavioral change.
It combines support with encouragement fro
constructive, productive action. The support
acknowledges fears, pain, ambivalence, and difficult
process of change, while the confrontation includes
hope and confidence that an action is possible

30. 6. Promoting change
7. Teaching new skills. Common skills that patients
need to learn are relaxation, stress, conflict, and
anger management techniques, assertiveness,
problem-solving processes, symptom
management, coping skills, stress reduction and
communication, social and community living
skills

31. d. Termination phase is one of the most difficult
but most important phases of the therapeutic
nurse-patient relationship. During the
termination phase, learning is maximized for
both the patient and nurse. It is a time to
exchange feeling 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.

32. Strategies for termination:
Evaluation/summary of progress
Synthesizing what has occurred
Referrals
Discussion of termination

33. Criteria for Determining Patient
Readiness for Termination
1. The patient experiences relief from the
presenting problem
2. The patient functioning has improved
3. The patient has increased self-esteem and
a stronger sense of identity

34. 4. The patient uses more adaptive coping responses
5. The patient has achieved the planned treatment
outcome
6. An impasse has been reached in the nurse-patient
relationship that cannot be resolved

35. Reactions to Termination:
Patients react to termination indifferent ways. They
may deny the separation or deny the significance of
the relationship, perhaps causing the inexperienced
nurse to feel rejected by the patient. Patients may
express anger and hostility.
Nurse’s Task in Each Phase of the Relationship
Process

36. Phases
Preinteraction
Explore own feelings, fantasies, and fears
Analyze own professionals strengths and
limitations
Gather data about patient when possible
Plan for first meeting with patient
Introductory, or Determine why patient sought
help

37. Orientation
Establish trust, acceptance, and open
communication
Mutually formulate a contract
Explore patient’s thoughts, feelings, and actions
Identify patient’ s problem
Define goals with patient

38. Working
Explore relevant stressors
 Promote patient’s development of insight and use
of constructive coping mechanisms
 Overcome resistance behaviors

39. Termination
 Establish reality of separation
 Review progress of therapy and attainment of
goals
 Mutually explore feelings of rejection, loss,
sadness, and anger and related behaviors

40. Therapeutic
Communication
Communication Process
 Occurs as a sequence of events or a process. The
process is made up of seven parts that need to work
together to result in the transference and
understanding of meaning.

41. They are:
(1) the message
(2) a sender
(3) a receiver
(4) encoding
(5) a channel
(6) decoding
(7) a feedback loop

42. Message is an expression of the purpose of
communication. Without the message there can be
no communication
Sender is the person (or persons) conveying a
message
Receiver is the person (or persons) to whom the
message is directed and who its actual recipient is.

43. Act of encoding, which refers to the sender’s
conversion of the message into symbolic form.
This involves how the sender will translate the
message to the receiver. It can be accomplished
through verbal or nonverbal means.
Channel refers to the medium through which
the sender conveys the message. The channel
may be written, spoken, or nonverbal expression.

44. Decoding the receiver must translate the
message into an understandable form. Receiver’s
ability to decode the message is influenced by
their knowledge about the topic, skills in
reading, and listening, attitudes and
sociocultural values.
Feedback loop refers to the receiver indicating
that the message has been understood (decoded)
in the way that the sender intended (encoded). It
requires feedback from the receiver to the sender
serving as a check on the success of the
transference of meaning.

45. Three Elements of the communication Process:
Perception- occurs by activating the sensory end
organs of the receiver. The impulse is then
transmitted to the brain.
Evaluation- result in two responses: a cognitive
response related to the informational aspect of
the message and an affective responses related to
the relationship aspect of the message
Transmission takes place after the message
evaluation is complete

46. Goals of therapeutic communication:
1. Communications is the vehicle for establishing
therapeutic relationships
2. Communication is the means by which people
influence the behavior of another, leading to the
successful outcome of nursing intervention
3. Communication is the relationship itself because
without it, a therapeutic nurse-patient relationship is
impossible.

47. Two levels of communication:
1. Verbal communication
Occurs through words, spoken or written. It can
convey factual information accurately and
efficiently. It is less effective means of
communicating feelings or nuances of meaning, and
it represents only a small part of total human
communication

48. Denotative meaning – is actual or concrete meaning
Connotative – implied or suggested meaning
2. Non-Verbal communication includes everything
that dose not involve the spoken or written word,
including all of the five senses

49. Types of Nonverbal
Behavior
Vocal cues or paralinguistic cues include all the
nonverbal qualities of speech. Eg. Pitch, tone of
voice, quality of voice, loudness or intensity; rate
and rhythm of talking and unrelated nonverbal
sounds such as laughing, groaning, nervous
coughing and sounds of hesitation

50.  Action cues are body movements, sometimes
referred to kinetics. They include automatic
reflexes, posture, facial expression, gestures,
mannerisms and actions of any kind
 Object cues are the speaker’s intentional and
no intentional use of all objects. Dress,
furnishings, and possessions all communicate
something to the observer about the speaker’s
sense of self.
 Space – provides another clue to the nature of
the relationship between two people.

51. Four zones of space
Intimate space up to 18 inches this allows for
maximum interpersonal sensory stimulation
Personal space: 18 inches to 4 feet. This is used for
close relationships and touching distance. Visual
sensation is improved over the intimate range

52. Social-consultative space: 9 to 12 feet. This is less
personal and less dependent. Speech must be louder
Public space: 12 feet and more. This is used in speech
giving and other public occasions

53. e. Touch involves both personal space and action.
It is possibly the most personal of the nonverbal
messages.
Reasons why nurses use touch:
1. Establishing contact with the patient
2. Enhancing communication
3. Communicating caring, interest, and
recognition
4. Providing reassurance and comfort

54. • Double bind communication
A double bind is a dilemma in communication in which
a person receives two or more conflicting messages and
one message denies the other, a situation in which the
person will be put in the wrong however they respond,
and the person can't comment on the conflict, or resolve
it, or opt out of the situation. A double bind generally
includes different levels of abstraction in orders of
messages, and these messages can be stated or implicit
within the context of the situation, or conveyed by tone
of voice or body language. Further complications exist
when frequent double binds are part of an ongoing
relationship to which the person is committed.
Develop by GREGORY BATESON

55. • Proxemics the way people perceives and uses
environmental, social, and personal space in
interactions with others. Typically boundaries o
personal space for public and social communication
are more distant than those for intimate or
therapeutic communication

56. • Kinesics is the study of body movements. Body
language is the popular term that emphasizes the
meaning of facial expressions, eye movements,
gestures and mannerisms. Awareness of the cultural
meanings of nonverbal and verbal communication
facilitates a positive therapeutic alliance with
patients.

57. THERAPEUTIC COMMUNICATION
Offering self
Providing broad opening
Making an observation
Suggesting collaboration
Providing silence
Accepting messages
Providing general leads
Exploring

58. Focusing
Asking for clarification
Restating
Seeking consensual validation
Placing events in time or sequence

59. Non-therapeutic
Communication
 False reassurance
 Giving advise
 Rejecting
 Belittling
 Probing
 Overloading
 Under loading
 clichés

60. Therapeutic Impasses and their
solutions
Therapeutic impasses are blocks in the progress of
the nurse-patient relationship. They arise for a
variety of reasons, but they all create stalls I the
therapeutic relationship. Impasses provoke intense
feelings in both the nurse and the patient that may
range from anxiety and apprehension to frustration,
love, or intense anger.

61. a. Resistance is the patient’s reluctance or
avoidance of verbalizing or experiencing
troubling aspects of oneself. The term
resistance was initially introduced by Freud to
mean the patient’s unconscious opposition to
exploring or recognizing unconscious or even
preconscious material. Resistance is often
caused by the patient’s unwillingness to
change when the need for change is
recognized. Patients usually display resistance
behaviors during the working phase of the
relationship, because the greater part of the
problem-solving process occurs during this
phase

62. Resistance also may be a reaction by the patient to the
nurse who has moved too rapidly or too deeply into the
patient’s feelings or who has intentionally or
unintentionally communicated a lack of respect. It also
may simply be the result of a patient who is working with
a nurse who is an inappropriate role model for therapeutic
behavior
Secondary gain is another cause of resistance. Favorable
environmental, interpersonal and situational changes
occur, and material advantages may be obtained as a
result of the illness. Types of secondary gain include
financial compensation, avoiding unpleasant situations,
increased sympathy or attention, escape from work or
other responsibilities, attempted control of people, and
lessening of social pressures. Secondary gain can become a
powerful force in perpetuating an illness because it makes
the environment more comfortable.

63. Forms of Resistance Displayed
by Patients
Suppression and repression of pertinent information
Intensification of symptoms
Self-devaluation and a hopeless outlook on the
future
Forced flight into health where there is a sudden,
but short-lived recovery by the patient

64. Intellectual inhibitions, which may be evident when
the patient says she has “nothing on her mind” or
that she is unable to drink about her problems” or
when she breaks appointments, is late for sessions or
is forgetful, silent or sleepy
Acting out or irrational behavior
Superficial talk

65. Intellectual insight in which the patient
verbalizes self-understanding with correct use of
terminology yet continues destructive behavior
or uses the defense of intellectualization where
there is no insight
Contempt for normality, which is evident when
the patient has developed insight but refuses to
assume the responsibility for change on the
grounds that normality “isn’t so great”
Transference reactions

66. Transference is an unconscious response in which
the patient experiences feelings and attitudes toward
the nurse that were originally associated with other
significant figures in his or her life.

67. 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. Thus
the nurse may be viewed as authority figure from
the past, such as parent figure, or as lost loved
object, such as former spouse.

68. Two
Types of TransferenceA. Hostile transference –the patient internalizes
anger and hostility, this resistance may be
expressed as depression and discouragement. If
hostility is externalized, the patient may become
critical, defiant, and irritable and may express
doubts about the nurses training, experience, or
competence. The patient may compete with the
nurse by reading books on psychology and
debating intellectual issues rather than working
on real life problems.

69. B. Dependent reaction transference is characterized
by patient who are submissive, subordinate, and
ingratiating and who regard the nurse as a godlike
figure.

70. Countertransference – is a
therapeutic impass created by the
nurse’s specific emotional response to
the qualities of the patient.
Inappropriateness is the important
element as it is

71. Forms of
Countertransference
 Difficulty empathizing with the patient in
certain problem areas
 Feeling of depression during or after session
 Carelessness about implementing the contract
by being late, running overtime etc.
 Drowsiness during the session
 Feelings of anger or impatience because of the
patient’s unwillingness to change
 Encouragement of the patient’s dependency,
praise for affection

72. Three types of counter
transference
Reactions of intense love or caring
Reaction to intense disgust or hostility
Reactions to intense anxiety often in response to
resistance by the patient

73. Boundary Violations
These occur when a nurse goes outside the
boundaries of the therapeutic relationship and
establishes a social, economic or personal
relationship with a patient. As a general rule,
whenever the nurse is doing or thinking of doing
something special, different, or unusual for a patient,
often a boundary is involved.

74. A nurse should consider the possibility of a boundary
violation if he or she encounters the following:
Receives feedback that his or her behavior is
intrusive with patients or their families
Have difficulty setting limits with a patient
Relates to a patient like a friend or family member

75. Has a sexual feeling toward a patient
Feels that he or she is the only one who understands
the patient
Receives feedback that he or she is too involved with
a patient or family
Feels that other staff are to critical of a particular
patient
Believes that other staff members are jealous of his
or her relationship with a patient.

76. 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 son or daughter, for the
purpose of a social relationship

77. The nurse accepts free gifts from the patient’s
business
The nurse agrees to meet the patient for
treatment outside of the usual setting without
therapeutic justification
The nurse attends social functions of 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

78. Boundary Violations can be
Categories on the following:
 Role boundaries: These are related to the
psychiatric nurse’s role. They are reflected in
the question, Is this what a professional
psychiatric nurse does?
 Time boundaries: These relate to the time of
day that the nurse implements treatment. Odd
and unusual treatment hours that have no
therapeutic necessity must be evaluated as
potential boundary violation

79.  Place and Space boundaries: these are related
to where treatment takes place. An office or
hospital unit is the usual locale for most
treatment. Treatment out of the office usually
merits special scrutiny
 Money boundaries. These relate to evaluating
the compensation for treatment between the
nurse and patient. Bartering or seeing an
indigent patient for free should be carefully
reviewed for potential boundary violations

80.  Gifts and services boundaries
Divided into five types
 Gifts to reciprocate for care given
 Gifts intended to manipulate or change the quality
of care given or the nature of the nurse-patient
relationship
 Gifts given as perceived obligation by the patient
 Serendipitous gifts or gifts received by chance
 Gifts given to the organization to recognize
excellence of care received

81.  Clothing boundaries: these pertain to the nurse’s
need to dress in an appropriate therapeutic
manner.
 Language boundaries: this boundary raises
questions of when patients should be addressed
by their first or last names, the tone that the nurse
uses when talking with the patient, and the
nurse’s choice of words in implementing care.

82.  Self-disclosure boundaries: Inappropriately
timed self-disclosure by the nurse and the
nurse self-disclosure that lacks therapeutic
value are suspect for boundary violation
 Post discharge social boundaries: Post
discharge social contact with a patient by the
nurse always raises questions of boundary
violation.
 Physical contact boundaries: All physical
contact with a patient must be evaluated for
possible boundary violations.