Chapter 5 Therapeutic Relationships

Therapeutic Relationships
Vidbeck pg144-155
Learning Outcomes
• Describe necessary components in the nursepatient relationship.
• Explain the importance of values, beliefs, and
attitudes in the development of the nurse-patient
• Describe the importance of self-awareness and
therapeutic use of self in the nurse-patient
Learning Outcomes
• Describe the differences between social and
therapeutic relationships.
• Describe and implement the phases of the
nurse-patient relationship.
• Explain the negative behaviors that can diminish
the nurse-patient relationship.
Therapeutic Relationships
• The ability to establish therapeutic relationships
with patients is one of the most important skills
a nurse can develop.
• Social Relation- (ex: family, friends) info
unlimited, more emotionally invested. Can give
• Therapeutic Relation- (ex: pt/nurse) Info
exchange limited, less emotionally invested.
Cannot give advice.
– Nurses carries the whole load.
Therapeutic nurse-patient
• Purposeful and goal-directed
• Has defined boundaries
• Is structured to meet the patient’s needs
– In Social relationship its give and take, but in an
Nurse-Patient relationship its all about the pt.
• Is safe, confidential, reliable, and consistent
– Applies Physically and Mentally
Therapeutic Relationships (cont’d)
• Components include:
– Trust
– Genuine interest
– Empathy (not sympathy)
• Sympathy implies a feeling of recognition of
another's suffering
– Sympathy makes pt more dependant
• Empathy is often characterized as the ability to "put
oneself into another's shoes".
– Acceptance of person, not necessarily his or her
– Unconditional positive regard
– Self-awareness and therapeutic use of self
Self-Awareness and
Therapeutic Use of Self
Understanding how we present ourselves and
how we are seen by others
• Self-awareness: process of understanding
one’s own values, beliefs, thoughts, feelings,
attitudes, motivations, strengths, and
limitations and how one’s thoughts and
behaviors affect others
– Self Disclosure- when your’e telling things to a pt
that they don’t need to know. Info the pt doesn’t
need to know unless its therapeutic
• Ex: Where you live
Therapeutic Use of Self
Use yourself as a tool to help pt grow/heal
• Therapeutic use of self: the nurse uses
aspects of his or her personality, experience,
values, feelings, intelligence, needs, coping
skills, and perceptions to establish relationships
with clients that are beneficial to clients
Establishing the
Therapeutic Relationship
• Therapeutic relationships are focused on the
needs, experiences, feelings, and ideas of the
patient, not the nurse
• The therapeutic relationship
consists of three phases:
1) Orientation
2) Working
3) Termination
Establishing the Therapeutic
Relationship (cont’d)
• In the orientation phase:
– Information gathering, to use in interventions
and to problem solve
– The nurse and patient meet
– Roles are established
– Purposes and parameters of future meetings
are discussed
– Expectations are clarified
– Patient’s problems are identified
– Keep pt involved throughout
Establishing the Therapeutic
Relationship (cont’d)
• The working phase involves:
– Problem identification
• The patient identifies the issues or concerns
causing problems (Caution: pt may not see
what their “real” problem is)
• Examination of the patient’s feelings and
• Exploitation:
– Development of better coping skills and a
more positive self-image, behavior change,
and independence
Establishing the Therapeutic
Relationship (cont’d)
• In the working phase, the nurse must be
acutely aware of 2 common elements can
– Transference: when patients
unconsciously transfer feelings they have
for significant persons in their life onto the
– Countertransference: when the nurse
responds to the patient based on his or
her own unconscious needs and conflicts
Establishing the Therapeutic
Relationship (cont’d)
• The termination aka resolution phase:
– Begins when the patient’s problems are resolved
– Ends when the relationship is ended
– Deals with feelings of anger or abandonment that
may occur
• Anxiety (from readiness to be released) can lead to
anger or nervousness
Remind then that their time there has been a benefit
– Happens when problems subside
– For closure, tell them “goodbye”
Behaviors That Diminish
Therapeutic Relationships
• Inappropriate boundaries (relationship becomes social or
– Feelings of sympathy and encouraging dependency
(Nurse should show empathy and not sympathy)
– Nonacceptance of the patient as a person because of his
or her behaviors, leading to avoidance of the client
Nurse self-awareness is the way to avoid
such problems (Keep boundaries and set
Therapeutic Roles of the
Nurse in a Relationship
• Teacher
Expressing their feeling
Finding social support
Coping skills
• Caregiver
• Advocate
– Act on their behave and make sure that they’re not
being taken advantage of
– Make sure they are safe
• Parent surrogate
– Not love/hug, but remind them of bathing, hygiene,
wash hands, eat vegetables, etc.
Self-Awareness Issues
• Self-awareness on the nurse’s part is crucial to
developing therapeutic relationships
– As a nurse, know your role. Keep treatment non-biased.
• Values clarification, journaling, group discussions,
and reading will assist with this process
• Developing self-awareness is a continual, ongoing
process; the nurse needs to plan for self-growth
Learning Outcomes
• Describe the goals of therapeutic
• Identify therapeutic and nontherapeutic verbal
communication skills.
• Discuss boundaries in therapeutic
• The process people use to exchange information:
– Verbal
• Speech
– Context
• the set of facts or circumstances that surround a
situation or event
– Nonverbal
• Eyes, Facial expression, Tone of voice
– Congruency
• The quality of agreeing; being suitable and appropriate
– Incongruency
• out of place, absurd behavior
Communication (cont’d)
• Interpersonal interactions between the nurse and
the patient
• It focuses on the patient’s specific needs and is
used to:
Establish the therapeutic relationship
Identify the patient’s most important concerns
Assess the patient’s perceptions
Facilitate the patient’s expression of emotions
Teach the patient and family necessary self-care skills
Recognize the patient’s needs
Implement interventions designed to address the patient’s needs
Guide the patient toward satisfactory and acceptable solutions
Essential Components of
Therapeutic Communication
• Privacy and respect for boundaries
– Therapeutic communication is most comfortable at 3 to 6 feet;
should not be less than 18 inches
• Touching
– Touch may be comforting and supportive
– Touch also is an invasion of intimate and
personal space (Telegraph when you’re about to touch the pt)
– Nurse must evaluate whether the patient perceives touch as
positive or threatening and unwanted; never assume that touching
a patient is acceptable
Essential Components of
Therapeutic Communication (cont’d)
• Active listening- means refraining from other
internal mental activities and concentrating
exclusively on what the patient says
• Active observation- means watching the speaker’s
nonverbal actions as he or she communicates
Verbal Communication Skills
• Use concrete messages
– Use words that are clear and concise
– Concrete messages are specific and clear
– Concrete messages elicit more accurate
Verbal Communication Skills (cont’d)
– Therapeutic communication techniques facilitate
interaction and enhance communication between
patient and nurse
– Techniques that encourage the patient to discuss
his or her feelings or concerns in more depth
• Exploring- delving further into the subject
• Focusing- concentrate ?’s on a certain point
• Restating- clarification, repeating
• Reflecting- good to help pt “open up”
• Ask broad open-ended ?’s, make observations
(NOTE: Refer to p. 107-111,table 6.1)
Verbal Communication Skills (cont’d)
• Nontherapeutic communication includes:
– Advising- Don’t give advice
– Agreeing- Don’t agree w/ delusions or
hallucinations- things that pt sees, hears,
smells (but, don’t argue either)
• “I know you see that giant Penguin, but I don’t.”
– Reassuring- Don’t give them false
• Can lead to pt no longer trusting you
Nonverbal Communication Skills
• Facial expression
• Body language
– Gestures, posture
• Vocal cues
– Tone of voice
• Eye contact
– Some pts will not make eye contact
– Can be a tale to their emotions
– Don’t look in eyes all the time, b/c they
think u can see what they are thinking
• Silence
– They may be processing info
– Are they gathering their thoughts?
Understanding the Meaning of
• Messages often contain more meaning than
just the spoken words
• The nurse must try to discover all the
meaning in the patient’s communication, not
only the literal meaning of the words
Understanding Context
• Understanding the context of a situation
gives the nurse more information and
reduces the risk of assumptions
• To clarify context, the nurse must gather
information from verbal and nonverbal
sources and validate findings with the
Understanding Spirituality
• Spirituality is a patient’s belief about life, illness,
death, and one’s relationship to the health, universe
• The nurse must first assess his or her own spiritual
beliefs (self-awareness, remain unbiased)
• The nurse must remain objective and nonjudgmental
• The nurse must assess the patient’s spiritual needs
Cultural Considerations
• The nurse must be aware of cultural differences in:
– Speech patterns and habits
– Styles of speech and expression
– Eye contact
– Touch
– Concept of time
– Health and health care
– Be sensitive to their culture
Goals of a Therapeutic
Communication Session
• Establishing rapport (get along)
• Identifying issues of concern
• Being empathetic, genuine, caring, and
unconditionally accepting of the person
• Understanding the patient’s perception
• Exploring the patient’s thoughts and feelings
• Developing problem-solving skills
• Promoting the patient’s evaluation of solutions
• Make sure it is all pt oriented
Beginning Therapeutic
• Introduce and establish a contract
– “I’m the nurse. I will… And I expect you to…”
• Find patient-centered goals
– Everyone is different. Depends on what the pt’s needs are.
-Use directive or nondirective role appropriately,
based on patient behaviors
Beginning Therapeutic
Communication (cont’d)
• Phrase questions appropriately
– Ask for clarification
– Manage patient’s avoidance of the anxietyproducing topic
• Change subject for a minute
– Avoid asking why
• Guide the patient in problem-solving and empower
the patient to change
– Help them realize they can solve problems
• Alert for inappropriate responses by nurse
– Ex: Judging, arguing
Community-Based Care
• Nurses are increasingly caring for patients in the
family unit and in communities
• Nurses need increased self-awareness and
knowledge about cultural differences
• Nurses need self-awareness and sensitivity to the
beliefs, behaviors, and feelings of others
• Nurses must collaborate with the patient and family
as well as other healthcare providers
Self-Awareness Issues
• Nonverbal communication is as important as verbal
• Ask colleagues for feedback
– “Am I getting the info that I need?”
• Examine your communication skills
Response to Illness
Learning Outcomes
• Discuss individual characteristics and factors
that influence a patient’s response to illness.
• Explain the nurse’s role working with patients of
different cultural backgrounds.
• Describe cultural factors important in assessing
and working with patients of different cultures.
Individual Factors
• Age, stage of growth and development
• Genetics and biologic factors
– Just because your mom is psycho, doesn’t
mean you’re going to be…
• Physical health and health practices
• Response to drugs
– Not everyone reacts to meds the same
– Elderly: slower metabolism, med stays in their system
Individual Factors (cont’d)
• Pts have different coping skills:
– Self-efficacy
• His/her perception of illness
– Hardiness- ability to survive, resist illness
– Resilience and resourcefulness- how u bounce back
– Spirituality- being punished
– Ask to self: how quick can pt bounce back? Or
how do they respond to illness.
– How we respond has to do w/ how hardy and
resilient we are.
Interpersonal Factors
• Sense of belonging
– If pt feels valued or that they fit
in, they will do much better in
• Social networks and social
– Fitting in family, job, friends
• Family support
Cultural Factors
• Beliefs about causes of illness
• Factors in cultural assessment:
– Communication
– Physical space or distance
– Social organization
– Time orientation
– Environmental control
– Biologic variations
• Socioeconomic status and social class
Cultural Patterns and Differences
• Knowledge of expected cultural patterns
provides a starting place for the nurse to begin
to relate to persons from different ethnic
– May see a mix of cultures
– Look at the person/Indv.
Cultural Patterns and Differences
• No Q’s specifically about diff cultures; but
understand that they exist.
• African Americans
– Usually family-oriented, but client makes
own decisions
– Conversation animated
– Handshakes and direct eye contact convey
interest and respect
– View mental illness as a spiritual imbalance
or punishment for sin
Cultural Patterns and Differences
• Filipinos
– Greet others with smiles rather than
– Facial expressions animated
– Direct eye contact impolite, especially with
authority figures
– Mental illness viewed as having religious and
mystical causes
Cultural Patterns and Differences
• Mexican Americans
– Touching prevalent among family, but not
necessarily welcome from strangers
– Direct eye contact with authority figures avoided
– Silence denotes disagreement
– Illness comes from imbalance between person
and environment
Nurse’s Role in Working With Clients
From Various Cultures
• Nurse must learn about the client’s cultural values,
beliefs, and health practices
– Best source of information is the client:
• “How would you like to be cared for?”
• “What do you expect (or want) me to do for
Self-Awareness Issues
• Maintain a genuine, caring attitude
• Ask how you can promote or assist with spiritual,
religious, and health practices
• Recognize your own feelings and possible
• Remember that the patient’s response to illness is
complex and unique
Learning Outcomes
• Identify the factors that influence the assessing
of a mental health patient.
• Describe how to conduct a interview with a
patient on a mental health unit.
• Explain the components used to gather
information in the psychosocial assessment of a
mental health patient.
• Identify other sources of data used in patient
Purposes of Psychosocial
• To construct picture of patient’s current emotional
state, mental capacity, and behavioral function
• To form basis for plan of care
• To establish clinical baseline to evaluate
effectiveness of treatment and interventions
Factors Influencing Assessment
• More of a nursing observation on a psych floor.
• Patient’s participation/feedback
– Answers may show signs of impaired thinking
• Patient’s health status
– Pain may hamper response/feedback
• Patient’s previous experiences/misconceptions
about health care
– Consider possible previous abuse or forced admission
• Patient’s ability to understand
– Patient may be unable to read or have language barrier
• Nurse’s attitude and approach
– Safety 1st, for pt and for yourself
How to Conduct the Interview
• Provide a comfortable, private, safe environment
• Obtain input from family and friends (with patient’s
• Ask questions that are open-ended or closed-ended
as needed (avoid “Yes or No” type Q’s)
– “How can we help?”
– Very important to obtain “accurate” input
Content of the Assessment
• History- very important
• General appearance and motor behavior (Slide 62)
– Observe: Grooming habits, style
• Mood and affect* (Next slide)
• Thought process and content* (Slide 55)
– Does he know the time and place?
– Is pt oriented or in touch w/ reality?
• Sensorium and intellectual processes
– Ability to problem solve
• Judgment and insight
• Self-concept
– Many clients don’t think they need to be there
• Roles and relationships
– Have they severed relationships?
• Physiologic and self-care concerns
– Are they misinterpreting pain or physical problems?
Mood and Affect Assessment
Helps w/ diagnosis
Mood- is pervasive and sustained quality of
person’s emotional tone: described as euphoric,
dysphoric, euthymic, or labile (rapidly changing)
Affect- outward expression of emotion: described
as blunted, flat, inappropriate/incongruent to
verbal, appropriate, hyper-reactive, or
Thought Processes and Content
Thought process- how patient thinks
Thought content- what patient actually says
Common terms in assessing :
Delusions- false fixed ideas. Ex: someone is out to get them
(persecutory, paranoid, grandiose, somatic)
Hallucinations- something heard (#1), smelled, or seen (#2)
Ideas of reference- interpretation of external events having reference
to one's self (thoughts directed towards him)
Loose associations- jump from one subject to another (random
Tangential thinking- talking to them and their mind just wanders off
Abstract thinking- understand the glass house thing
Thought Process and Content (cont’d)
when talking to them, make sure to give them time to answer
Thought blocking- stopping abruptly when thinking (for some reason pt
can’t think right now)
Thought broadcasting- others can hear your thoughts
Thought insertion- others are putting thoughts in head, controlling them
Thought withdrawal- others are taking thoughts from head
Word salad- putting words together that have no meaning/ connection/
Concrete thinking- form logical thought
Phobic- fearful of item/ situation/ environment
Reality oriented-
Data Analysis
After completing the assessment the nurse
analyzes all the data to help in forming the
patient’s plan of care
Other data may be gathered from the following
• Psychosocial assessment
• Psychological tests
• Psychiatric diagnoses
• Mental status exam
Psychological Tests
• Psychological tests are another source of data to
use in planning care
– Intelligence tests assess cognitive abilities and
intellectual functioning
– Personality tests evaluate self-concept,
impulse control, reality testing, and major
defense mechanisms
Psychiatric Diagnoses
• Based on the DSM-IV-TR multiaxial system:
– Axis I: clinical disorders
– Axis II: personality disorders, mental retardation
– Axis III: general medical conditions
– Axis IV: psychosocial and environmental
– Axis V: global assessment of functioning (GAF)
Mental Status Exam
Focuses on the patient’s cognitive abilities:
• Orientation to person, time, place, date,
season, day of the week
• Ability to interpret proverbs
• Ability to perform math calculations
• Memorization and short-term recall
• Naming common objects in the
• Ability to follow multi-step commands
• Ability to write or copy a simple drawing
Self-Awareness Issues
• Judgments are not part of the assessment process
• Be open, clear, and direct when asking about
personal or uncomfortable topics
• Examining one’s own beliefs and gaining selfawareness is a growth-producing experience
• The nurse must not allow personal beliefs to
interfere with the nurse–patient relationship and the
assessment process
Appearance/Motor behavior
Cont. from slide 53
• Neologism- invented words; a word coined
by a psychotic or delirious patient that is
meaningful only to the patient.
• Psychomotor retardation- overall slowed
• Waxy flexibility- maintain of posture even if
uncomfortable or awkward
• Automatism- repeated purposeful behavior
– Tapping/clicking related to anxiety