Chapter 9

Therapeutic Relationships
Concepts of the Nurse-Patient
 Basis of all psychiatric nursing treatment approaches
 To establish that the nurse is
 Safe
 Confidential
 Reliable
 Consistent
 Relationship with clear boundaries
Goals and Functions
 Facilitate communication of distressing thoughts and
 Assist patient with problem solving
 Help patient examine self-defeating behaviors and test
 Promote self-care and independence
Social Relationships
 Initiated for the purpose of friendship or meeting a
 Mutual needs are met
 Communication to give advice, give or ask for help
 Content of communication superficial
Therapeutic Relationships
 Needs of patient identified and explored
 Clear boundaries established
 Problem-solving approaches taken
 New coping skills developed
 Behavioral change encouraged
Necessary Behaviors for Nurses
 Accountability
 Focus on patient’s needs
 Clinical competence
 Delaying judgment
 Supervision
Establishing Boundaries
 Physical boundaries
 The contract
 Personal space
Blurring of Boundaries
 When relationship slips into social context
 When nurse’s needs are met at expense of patient’s
Blurring of Roles
 Transference – patient unconsciously displaces onto
individual in current life emotions and behaviors from
childhood that originated in relationships with
significant others
 Transference intensified with person in authority in
current life
Blurring of Roles
 Countertransference – nurse displaces feelings related
to people in nurse’s past onto patient
 Patient’s transference to nurse often results in
countertransference in nurse
 Common sign of countertransference in nurse is
overidentification with the patient
Values, Beliefs, and
 Nurse’s values and beliefs
 Not right for everyone
 Reflect own culture/subculture
 Derived from range of choices
 Chosen from a variety of influences and role models
Peplau’s Model of Nurse-Patient
 Orientation phase
 Working phase
 Termination phase
Orientation Phase
• Establishing rapport
• Parameters of the relationship
• Formal or informal contract
• Confidentiality
• Assessing patient strengths and coping
• Identification of Nursing Diagnosis and
• Terms of termination
Working Phase
 Maintain relationship
 Gather further data
 Clarify expectations
 Develop plan of care
 Promote patient’s
 problem-solving skills
 self-esteem
Working Phase
 Facilitate behavioral change
 Overcome resistant behaviors
 Evaluate problems and goals
 Redefine them as necessary
 Promote practice and expression
of alternative adaptive behaviors
Termination Phase
 Summarize goals and objectives achieved
 Discuss ways for patient to incorporate new coping
strategies learned
 Review situations of relationship
 Exploring the need for referrals post-discharge
 Establish plans for long-term post discharge
Factors That Help Nurse-Patient
 Consistency
 Pacing
 Listening
 Encouraging active patient collaboration
 Initial impressions
Factors That Help Nurse-Patient
 Promoting patient comfort and balancing control
 Patient factors include
 trust and
 active participation
Factors That Encourage and
Promote Patient Growth
 Genuineness
 Empathy (not sympathy)
 Positive Regard
 attitudes and
 actions
Factors That Encourage and
Promote Patient Growth
 Attending
 Suspending value judgments
 Helping patients develop resources
A nurse seeks to establish a relationship
with a patient readmitted to the
hospital. The patient has bipolar
disorder, depressed type, and was
hospitalized the preceding month.
Which statement by the nurse would
contribute to establishing trust?
“Weren’t you complying with your medication
“It must be discouraging to be readmitted to the
hospital so soon.”
“Everyone with bipolar disorder ends up in the
hospital occasionally.”
“You must take your drugs as prescribed or you will
be rehospitalized.”
Communication and the Clinical Interview
The Communication Process
 Stimulus for information, comfort, or advice
 Sender – initiates contact
 Message – sent or expressed
 Variety of media – hearing, visual, touch, smell
 Feedback received
Factors That Affect Communication
 Personal factors
 Environmental factors
 Relationship factors
Nonverbal Communication
 Tone of voice
 Emphasis on certain words
 Physical appearance
 Facial expressions
 Body posture
 Amount of eye contact
 Hand gestures
Verbal Communication
 All words a person speaks
 Communicates
 Beliefs and values
 Perceptions and meaning
 Can convey
 Interest and understanding
 Insult and judgment
 Double or mixed messages
Therapeutic Communication
 Tools for enhancing communication
 Using silence
 Active listening
 Listening with empathy
Clarifying Techniques
 Paraphrasing
 Restating
 Reflecting
 Exploring
Asking Questions and Eliciting
Patient Responses
 Open-ended questions
 Closed-ended questions
Nontherapeutic Communication
 Excessive questioning
 Giving approval or disapproval
 Giving advice
 Asking “why” questions
Cultural Considerations
 Communication style
 Eye contact
 Touch
 Cultural filters – form of bias or prejudice
Preparing for the Interview
 Pace
 Setting
 Seating
 Introductions
 Initiating the interview
Attending Behaviors
 Foundation of the interview
 Eye contact
 Body language
 Vocal quality
 Verbal tracking
Process Recording
 Written record of a segment of the nurse-patient
session that reflects as closely as possible the verbal
and nonverbal behaviors of both patient and nurse
 Useful tool for identifying communication patterns