Therapeutic study

1. Therapeutic relationship

2.  Therapeutic relationship – is a relationship that is established
between a health care professional and a client for the purpose of
assisting the client to solve his problems.

3. Components of a Therapeutic Relationship
• One of the most important skills of a nurse is developing the
ability to establish a therapeutic relationship with clients.
• For interventions to be successful with clients in a psychiatric
facility and in all nursing specialties it is crucial to build a
therapeutic relationship.
• Crucial components are involved in establishing a therapeutic
nurse-patient relationship and the communication within it
which serves as the underpinning for treatment and success.
• It is essential for a nurse to know and understand these
components as it explores the task that should be accomplish
in a nurse-client relationship and the techniques that a nurse
can utilize to do so.

4. TRUST
 Without trust a nurse-client relationship would not be
established and interventions won’t be successful.
 For a client to develop trust, the nurse should exhibit the
following behaviors:
Friendliness
• Caring
• Interest
• Understanding
• Consistency
• Treating the client as human being
• Suggesting without telling
• Approachability
• Listening
• Keeping promises
• Providing schedules of activities
• Honesty

5. GENUINE INTEREST
 Another essential factor to build a therapeutic nurse-client
relationship is showing a genuine interest to the client.
 For the nurse to do this, he or she should be open, honest and
display a congruent behavior. Congruence only occurs when the
nurse’s words matches with her actions.
EMPATHY
 For a nurse to be successful in dealing with clients it is very
essential that she empathize with the client. Empathy is the nurse’s
ability to perceive the meanings and feelings of the client and
communicate that understanding to the client.

6. ACCEPTANCE
• Clients are unpredictable. There are times that they outburst with
anger or act out their inappropriate desires. A nurse, who does
not judge the client or person no matter what his or her behavior,
is showing acceptance. Acceptance does not mean accepting all
the inappropriate behavior but rather acceptance of the person as
worthy.

7. POSITIVE REGARD
 Positive regard is an unconditional and nonjudgmental attitude
where the nurse appreciates the client as a unique worthwhile
human being that shows respect for the client regardless of his
or her behavior background and lifestyle. The following ways
are example of how to promote respect and positive regard to a
client:
Calling the client by name
• Spending time with the client
• Listening to the client
• Responding to the client openly
• Considering the client’s ideas and preferences when planning
care

8. POSITIVE REGARD
• Positive regard is an unconditional and nonjudgmental attitude
where the nurse appreciates the client as a unique worthwhile
human being that shows respect for the client regardless of his or
her behavior background and lifestyle.
SELF-AWARENESS
• Self-awareness is the process of understanding one’s own values,
beliefs, thoughts, feelings, attitudes, motivations, prejudices,
strengths and limitations.
THERAPEUTIC USE OF SELF
• A nurse can only use his or her personality, experiences, values,
feelings, intelligence, needs, coping skills and perceptions to build
a relationship with clients (therapeutic use of self) when he or she
has developed self-awareness and self-understanding.

9. Therapeutic Technique
1. Offering Self
making self-available and showing interest and concern.
• “I will walk with you”
2. Active listening
paying close attention to what the patient is saying by observing both
verbal and non-verbal cues.
• Maintaining eye contact and making verbal remarks to clarify and
encourage further communication.
3. Exploring
“Tell me more about your son”
4. Giving broad openings
What do you want to talk about today?

10. 5. Silence
Planned absence of verbal remarks to allow patient and nurse to think over
what is being discussed and to say more.
6. Stating the observed
verbalizing what is observed in the patient to, for validation and to encourage
discussion
• “You sound angry”
7. Encouraging comparisons
· asking to describe similarities and differences among feelings, behaviors, and
events.
• · “Can you tell me what makes you more comfortable, working by yourself
or working as a member of a team?”
8. Identifying themes
asking to identify recurring thoughts, feelings, and behaviors.
• “When do you always feel the need to check the locks and doors?”

11. 9. Summarizing
reviewing the main points of discussions and making appropriate conclusions.
• “During this meeting, we discussed about what you will do when you feel
the urge to hurt your self again and this include…”
10. Placing the event in time or sequence
asking for relationship among events.
• “When do you begin to experience this ticks? Before or after you entered
grade school?”
11. Voicing doubt
voicing uncertainty about the reality of patient’s statements, perceptions and
conclusions.
• “I find it hard to believe…”
12. Encouraging descriptions of perceptions
asking the patients to describe feelings, perceptions and views of their
situations.
• “What are these voices telling you to do?”

12. 13. Presenting reality or confronting
stating what is real and what is not without arguing with the patient.
• “I know you hear these voices but I do not hear them”.
• “I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.
14. Seeking clarification
asking patient to restate, elaborate, or give examples of ideas or feelings to seek
clarification of what is unclear.
• “I am not familiar with your work, can you describe it further for me”.
• “I don’t think I understand what you are saying”.
15. Verbalizing the implied
rephrasing patient’s words to highlight an underlying message to clarify statements.
• Patient: I wont be bothering you anymore soon.
• Nurse: Are you thinking of killing yourself?
16. Reflecting
throwing back the patient’s statement in a form of question helps the patient identify
feelings.
• Patient: I think I should leave now.
• Nurse: Do you think you should leave now?

13. 18. General leads
using neutral expressions to encourage patients to continue talking.
• “Go on…”
• “You were saying…”
19. Asking question
using open-ended questions to achieve relevance and depth in discussion.
• “How did you feel when the doctor told you that you are ready for discharge
soon?”
20. Empathy
recognizing and acknowledging patient’s feelings.
• “It’s hard to begin to live alone when you have been married for more than thirty
years”.
21. Focusing
pursuing a topic until its meaning or importance is clear.
• “Let us talk more about your best friend in college”
• “You were saying…”
22. Interpreting
providing a view of the meaning or importance of something.
• Patient: I always take this towel wherever I go.
• Nurse: That towel must always be with you.

14. 23. Encouraging evaluation
asking for patients views of the meaning or importance of something.
• “What do you think led the court to commit you here?”
• “Can you tell me the reasons you don’t want to be discharged?
24. Suggesting collaboration
offering to help patients solve problems.
• “Perhaps you can discuss this with your children so they will know how you feel
and what you want”.
25. Encouraging goal setting
asking patient to decide on the type of change needed.
• “What do you think about the things you have to change in your self?”
26. Encouraging formulation of a plan of action
probing for step by step actions that will be needed.
• “If you decide to leave home when your husband beat you again what will you
do next?”
27. Encouraging decisions
asking patients to make a choice among options.
• “Given all these choices, what would you prefer to do.

15. 28. Encouraging consideration of options
asking patients to consider the pros and cons of possible options.
• “Have you thought of the possible effects of your decision to you and your family?”
29. Giving information
providing information that will help patients make better choices.
• “Nobody deserves to be beaten and there are people who can help and places to go
when you do not feel safe at home anymore”.
30. Limit setting
discouraging nonproductive feelings and behaviors, and encouraging productive ones.
• “Please stop now. If you don’t, I will ask you to leave the group and go to your
room.
31. Supportive confrontation
acknowledging the difficulty in changing, but pushing for action.
• “I understand. You feel rejected when your children sent you here but if you look at
this way…”
32. Role playing
practicing behaviors for specific situations, both the nurse and patient play particular
role.
• “I’ll play your mother, tell me exactly what would you say when we meet on
Sunday”.

16. 33. Rehearsing
asking the patient for a verbal description of what will be said or done in a particular
situation.
• “Supposing you meet these people again, how would you respond to them when
they ask you to join them for a drink?”.
34. Feedback
pointing out specific behaviors and giving impressions of reactions.
• “I see you combed your hair today”.
35. Encouraging evaluation
asking patients to evaluate their actions and their outcomes.
• “What did you feel after participating in the group therapy?”.
36. Reinforcement
giving feedback on positive behaviors.
• “Everyone was able to give their options when we talked one by one and each of
waited patiently for our turn to speak”.

17. Anti – therapeutic Relationship
1. Overloading
talking rapidly, changing subjects too often, and asking for more information than
can be absorbed at one time.
• “What’s your name? I see you like sports. Where do you live?”
2. Value Judgments
giving one’s own opinion, evaluating, moralizing or implying one’s values by using
words such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”.
• “You shouldn’t do that, its wrong”.
3. Incongruence
sending verbal and non-verbal messages that contradict one another.
• The nurse tells the patient “I’d like to spend time with you” and then walks
away.
4. Underloading
remaining silent and unresponsive, not picking up cues, and failing to give
feedback.
• The patient ask the nurse, simply walks away.
5. False reassurance/ agreement
Using cliché to reassure client.
• “It’s going to be alright”.

18. 6. Invalidation
Ignoring or denying another’s presence, thought’s or feelings.
• Client: How are you?
• Nurse responds: I can’t talk now. I’m too busy.
7. Focusing on self
responding in a way that focuses attention to the nurse instead of the client.
• “This sunshine is good for my roses. I have beautiful rose garden”.
8. Changing the subject
introducing new topic
• inappropriately, a pattern that may indicate anxiety.
• The client is crying, when the nurse asks “How many children do you have?”
9. Giving advice
telling the client what to do, giving opinions or making decisions for the client,
implies client cannot handle his or her own life decisions and that the nurse is
accepting responsibility.
• “If I were you… Or it would be better if you do it this way…”
10. Internal validation
making an assumption about the meaning of someone else’s behavior that is not
validated by the other person (jumping into conclusion).
• The nurse sees a suicidal clients smiling and tells another nurse the patient is in
good mood.