mental health

1. The Nurse-Patient
Relationship:
Developing the Therapeutic
Relationship
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2. Developing Therapeutic Relationships
At the completion of this session students will:
 Formulate a list of therapeutic techniques
 Have reviewed the phases of a therapeutic one-to-
one relationship
 Compare and contrast social and therapeutic
relationships
 Be aware of the potential boundary violations that
may occur during a therapeutic relationship
 Define self-awareness and describe a strategy for
developing self-awareness
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3. Exercise
Discuss within groups these following
questions:
 What is a relationship?
 What does it mean to be therapeutic?
 How does the therapeutic relationship differ
from other relationships?
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4. The Therapeutic relationship is a
concept that is fundamental to the
identity of mental health nurses
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5. Characteristics of a therapeutic
relationship
 Nurse takes responsibility for the conduct of the
relationship
 Relationship has a specific purpose and a health
related goal
 Relationship terminates when the identified goal is met
 Focus of the relationship is on the client
 Relationship is entered through necessity
 Choice of whom to be in the relationship is not
available to either the nurse or the client
 Self-disclosure is limited for the nurse but encouraged
for the client
 Understanding should always be put into words
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6. The Mental Health Nurse role within
the relationship
 Route to understanding
 Finding meaning to the experience
 Creating opportunities for change to occur
 Problem solving
 Health promotion
 Being a resource for clients
 education
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7. Peplau’s six nursing roles
 Stranger role
 Resource role
 Teaching role
 Counselling role
 Surrogate role
 Active leadership role
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8. Enhancing growth in others
 Genuineness
– Congruence
 Empathy
– Understanding ideas expressed and feelings present in
the other
 Positive regard
– Some actions manifest an attitude of respect
(attending, suspending value judgments)
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9. Enhancing growth in others
 Helping Clients Develop Resources
– Awareness, encouragement
 Self disclosure
– Appropriate (feelings, attitudes and beliefs)
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10. Exercise: Recognising role
limitations in self-disclosure
1. Make a list of phrases that describe your
own personality, such as:
 I am shy
 I get angry when criticised
 I find conflicts hard to handle
 I am sexy
2. Mark each descriptive phase with one of
the following:
A. Too embarrassing or intimate to discuss in a group
B. Could discuss in a group of peers
C. This behaviour characteristic might affect my ability to
function in a therapeutic manner if disclosed 10

11. Exercise cont’d
Discuss in groups:
1. What criteria were used to determine the
appropriateness of self-disclosure?
2. How much variation is there in what each of you
would share with others in a group or clinical
setting?
3. Were there any behaviours commonly agreed on
that would never be shared with a client?
4. What interpersonal factors about the client would
facilitate or impede self-disclosure by the nurse?
5. What have you learnt from this exercise that
could be useful in future encounters with clients?
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12. Phases of the Nurse-Client
relationship
 Preorientation
– Planning for the first interaction with client
– Identifying nurse concerns
 Orientation
– Compressed due to short hospitalisations;
longer in community-based care
– Issues: trust, parameters of relationship,
contract, confidentiality, termination
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13. Phases of the Nurse-Client
relationship
 Working – Tasks:
– Maintain relationship
– Gather further information
– Promote client problem-solving skills, self-esteem and
communication
– Facilitate behavioural change
– Overcome resistance behaviours
– Evaluate problems and goals and redefine them as
necessary
– Practice and express alternative adaptive behaviours
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14. Phases of the Nurse-Client
relationship
 Termination
– Deal with intense feelings regarding the
experience
– Summarise goals and objectives
– Review client plans for the future
– Finalise termination
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15. Boundary Blurring
 Relationship slips into a social context
 Nurse behaviour meets personal needs at
expense of client
 Under helping
 Over helping
 Controlling
 Narcissism
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16. Boundary Blurring
 Transference
– the unconscious emotional reaction patients
have in a current situation that is really based
on previous relationships and experiences
– Main Issue – the wish to be taken care of and to
have needs met
– Forms may be severe or subtle
– Can be positive and negative
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17. Boundary Blurring
 Counter- Transference
– Reactions based on the nurses past experience
– May lead the nurse to have inappropriate
responses to a patients action
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18. Boundary Blurring
 Transference – Interventions
– Recognise the transference or counter-
transference
– Examine gently but directly
– Limit setting
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19. Factors beneficial to relationships
 Consistent regular and private interactions with
client
– Consistency in assigned nurse
– Regular routine of activities
 Being honest and congruent
 Letting client set the pace
 Listening to client concerns
 Positive initial attitudes and preconceptions
 Promoting client comfort and balancing control
 Client demonstrating trust and actively
participating in relationship
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20. Factors hampering relationship
 Lack of nurse availability
 Lack of nurse self-awareness
 Nurse negative feelings about client
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21. Self-awareness
 Recognising the nature of ones own
attitude, emotions and behaviour
 a keen sense of self awareness acts as a
barometer of the relationship process
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22. Exercise – Developing self-
awareness
An effective way of raising self-awareness is
the use of questioning.
 In order to raise your awareness of some
important issues ask yourself the following
questions then discuss your responses in
small groups
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23. 1. What kinds of values do I hold as a important framework
for living?
2. Where do these values come from?
3. How do they inform my understanding of what it is to be
a person in this world?
4. How has my family of origin influenced how I view the
world?
5. What values did my family hold as important?
6. What do I see as important in family life?
7. What do I know about why I choose to be a nurse?
8. What are the pervading social attitudes towards people
in mental distress?
9. What are my beliefs about people in mental distress or
with mental illness?
10. What experiences have I had that influence how I feel
about people with mental illness?
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