10 Developing Therapeutic Relationships - ohsu.edu

1 CHAPTER 10 Developing TherapeuticRelationshipsELIZABETH M. VARCAROLIS155 Visit the Evolve website at a pretest on the content in this studying this chapter, the reader will be able and compare the purpose, focus, communicationsstyles, and goals for (a) a social relationship , (b) an intimaterelationship, and (c) a Therapeutic and discuss the role of empathy, genuineness, andpositive regard on the part of the nurse in a nurse -client two attitudes and four actions that may reflect thenurse s positive regard for a what is meant by boundaries and the influence oftransference and countertransference on boundary and compare the three phases of the how you would address the four areas of concernduring your first interview with a aspects that foster a Therapeutic nurse -client rela-tionship and those that are inherent in a nontherapeuticnursing interactive process as identified in the research ofForchuk and associates (2000).

2 Four testing behaviors a client may demonstrateand discuss possible nursing interventions for each Therapeutic nurse -client relationship is the basis,the very core, of all psychiatric nursing treatment ap-proaches regardless of the specific aim. The very firstprocess between nurse and client is to establish an un-derstanding in the client that the nurse is entering intoa relationship with the client that essentially is safe,confidential, reliable, and consistent with appropriateand clear boundaries (LaRowe, 2004). It is true thatdisorders that have strong biochemical and geneticcomponents such as schizophrenia and major affectivedisorders cannot be healed through therapeuticmeans.

3 However, many of the accompanying emo-tional problems such as poor self-image and low self-esteem can be significantly improved through a thera-peutic nurse -client alliance or relationship (LaRowe,2004).Randomized clinical trials have repeatedly foundthat development of a positive alliance ( Therapeutic re-lationship) is one of the best predictors of outcomes intherapy (Kopta et al., 1999). The authors analyzed datafrom the large-scale National Institute of MentalHealth Treatment of Depression Collaborative Re-search Program that compared treatments for depres-sion. Analysis indicated that the development of atherapeutic alliance ( Therapeutic relationship ) was pre-dictive of treatment success for all a Therapeutic alliance or relationshipwith a client takes time.

4 Skills in this area gradually im-KEY TERMS and CONCEPTSThe key terms and concepts listed here appear incolor where they are defined or first discussed in , 165contract, 164countertransference, 159empathy, 157genuineness, 157intimate relationship , 156orientation phase, 164social relationship , 156termination phase, 167therapeutic encounter, 163therapeutic relationship , 156transference, 159values, 162values clarification, 162working phase, 165155-170_Varcarolis_Ch10 7/8/05 10:41 AM Page 155156 UNIT THREE Psychosocial Nursing Toolsprove with guidance from those with more skill and ex-perience. When clients do not engage in a Therapeutic al-liance, chances are that, no matter what plans of care orplanned interventions are made, nothing much will hap-pen except mutual frustration and mutual VERSUS OTHERTYPES OF RELATIONSHIPSThe nurse -client relationship is often loosely defined,but a Therapeutic relationship incorporating principlesof mental health nursing is more clearly defined and differs from other Relationships .

5 A therapeuticnurse-client relationship has specific goals and func-tions. Goals in a Therapeutic relationship include thefollowing:Facilitatingcommunication of distressing thoughtsand feelingsAssistingclients with problem solving to help facil-itate activities of daily livingHelpingclients examine self-defeating behaviorsand test alternativesPromotingself-care and independenceA relationship is an interpersonal process that in-volves two or more people. Throughout life, we meetpeople in a variety of settings and share a variety of ex-periences. With some individuals we develop long-term Relationships ; with others the relationship lastsonly a short time. Naturally, the kinds of relationshipswe enter into vary from person to person and from sit-uation to situation.

6 Generally, Relationships can be de-fined as (1) social, (2) intimate, or (3) RelationshipsAsocial relationshipcan be defined as a relationshipthat is primarily initiated for the purpose of friendship,socialization, enjoyment, or accomplishment of a needs are met during social interaction ( ,participants share ideas, feelings, and experiences).Communication skills used in social Relationships mayinclude giving advice and (sometimes) meeting basicdependency needs, such as lending money and helpingwith jobs. Often the content of the communication re-mains superficial. During social interactions, roles mayshift. Within a social relationship , there is little empha-sis on the evaluation of the RelationshipsAn intimate relationshipoccurs between two or moreindividuals who have an emotional commitment toeach other.

7 Those in an intimate relationship usuallyreact naturally to each other. Often the relationship isa partnership in which each member cares about theother s needs for growth and satisfaction. Within therelationship, mutual needs are met and intimate de-sires and fantasies are shared. Short- and long-rangegoals are usually mutual. Information shared betweenthese individuals may be personal and may want an intimate relationship for manyreasons, such as procreation, sexual and/or emotionalsatisfaction, economic security, social belonging, andreduced loneliness. Depending on the style, level ofmaturity, and awareness of both parties, evaluation ofthe interactions may or may not be RelationshipsThe Therapeutic relationshipbetween nurse and clientdiffers from both a social and an intimate relationshipin that the nurse maximizes his or her communicationskills, understanding of human behaviors, and per-sonal strengths to enhance the client s growth.

8 The fo-cus of the relationship is on the client s ideas, experi-ences, and feelings. Inherent in a Therapeutic (helping) relationship is the nurse s focus on significant personalissues introduced by the client during the clinical in-terview. The nurse and the client identify areas thatneed exploration and periodically evaluate the degreeof change in the client. Although the nurse may as-sume a variety of roles ( , teacher, counselor, social-izing agent, liaison), the relationship is consistentlyfocused on the client s problem and get their needs met outside the nurses begin to want the client to like them, do as they suggest, be nice to them, or give themrecognition, the needs of the client cannot be ade-quately met and the interaction could be detrimental(nontherapeutic) to the client.

9 Working under supervi-sion is an excellent way to keep the focus and bound-aries clear. Communication skills and knowledge ofthe stages of and phenomena occurring in a therapeu-tic relationship are crucial tools in the formation andmaintenance of that relationship . Within the context ofa helping relationship , the following occur: The needs of the client are identified and explored. Alternate problem-solving approaches are taken. New coping skills may develop. Behavioral change is nurses as well as students may struggle withrequests by clients to be my friend. In fact, studentsoften feel more comfortable being a friend because itis a more familiar role. However, when this occurs, thenurse or student needs to make it clear that the rela-tionship is a Therapeutic (helping) one.

10 This does notmean that the nurse is not friendly toward the client attimes. It does mean, however, that the nurse followsthe stated guidelines regarding a Therapeutic relation-ship; essentially, the focus is on the client, and therelationship is not designed to meet the nurse s client s problems and concerns are explored,potential solutions are discussed by both client andnurse, and solutions are implemented by the 7/8/05 10:41 AM Page 156 FACTORS THAT ENHANCEGROWTH IN OTHERSR ogers and Truax (1967) identified three personal char-acteristics that help promote change and growth inclients which are still valued today as vital componentsfor establishing a Therapeutic alliance or relationship .