Home | | Psychiatric Mental Health Nursing | Establishing the Therapeutic Relationship

Chapter: Psychiatric Mental Health Nursing : Therapeutic Relationships

Establishing the Therapeutic Relationship

The nurse who has self-confidence rooted in self- awareness is ready to establish appropriate therapeutic relationships with clients.



The nurse who has self-confidence rooted in self- awareness is ready to establish appropriate therapeutic relationships with clients. Because personal growth is ongoing over one’s lifetime, the nurse cannot expect to have complete self-knowledge. Awareness of his or her strengths and limita-tions at any particular moment, however, is a good start.



Peplau studied and wrote about the interpersonal pro-cesses and the phases of the nurse–client relationship for 35 years. Her work provides the nursing profession with a model that can be used to understand and document prog-ress with interpersonal interactions. Peplau’s model (1952) has three phases: orientation, working, and resolution or termination (Table 5.2). In real life, these phases are not that clear-cut; they overlap and interlock.



The orientation phase begins when the nurse and client meet and ends when the client begins to identify problems to examine. During the orientation phase, the nurse estab-lishes roles, the purpose of meeting, and the parameters of subsequent meetings; identifies the client’s problems; and clarifies expectations.


Before meeting the client, the nurse has important work to do. The nurse reads background materials available on the client, becomes familiar with any medications the cli-ent is taking, gathers necessary paperwork, and arranges for a quiet, private, and comfortable setting. This is the time for self-assessment. The nurse should consider his or her personal strengths and limitations in working with this client. Are there any areas that might signal difficulty because of past experiences? For example, if this client is a spouse batterer and the nurse’s father was also one, the nurse needs to consider the situation: How does it make him or her feel? What memories does it prompt, and can he or she work with the client without these memories interfering? The nurse must examine preconceptions about the client and ensure that he or she can put them aside and get to know the real person. The nurse must come to each client without preconceptions or prejudices. It may be useful for the nurse to discuss all potential prob-lem areas with the instructor.

During the orientation phase, the nurse begins to build trust with the client. It is the nurse’s responsibility to establish a therapeutic environment that fosters trust and understanding (Table 5.3). The nurse should share appropriate information about himself or herself at this time, including name, reason for being on the unit, and level of schooling: For example, “Hello, James. My name is Miss Ames and I will be your nurse for the next six Tuesdays. I am a senior nursing student at the University of Mississippi.”

The nurse needs to listen closely to the client’s history, perceptions, and misconceptions. He or she needs to con-vey empathy and understanding. If the relationship gets off to a positive start, it is more likely to succeed and to meet established goals.


At the first meeting, the client may be distrustful if pre-vious relationships with nurses have been unsatisfactory. The client may use rambling speech, act out, or exaggerate episodes as ploys to avoid discussing the real problems. It may take several sessions until the client believes that he or she can trust the nurse.


Nurse–Client Contracts. Although many clients have had prior experiences in the mental health system, the nurse

must once again outline the responsibilities of the nurse and the client. At the outset, both nurse and client should agree on these responsibilities in an informal or verbal contract. In some instances, a formal or written contract may be appropriate; examples include if a written contract has been necessary in the past with the client or if the cli-ent “forgets” the agreed-on verbal contract.


The contract should state the following:


·    Time, place, and length of sessions


·    When sessions will terminate


·    Who will be involved in the treatment plan (family members or health team members)

·    Client responsibilities (arrive on time and end on time)


·    Nurse’s responsibilities (arrive on time, end on time, maintain confidentiality at all times, evaluate progress with client, and document sessions).


Confidentiality. Confidentiality means respecting the client’s right to keep private any information about his or her mental and physical health and related care. It means allowing only those dealing with the client’s care to have access to the information that the client divulges. Only under precisely defined conditions can third parties have access to this information; for example, in many states the law requires that staff report suspected child and elder abuse.


Adult clients can decide which family members, if any, may be involved in treatment and may have access to clinical information. Ideally, the people close to the client and responsible for his or her care are involved. The cli-ent must decide, however, who will be included. For the client to feel safe, boundaries must be clear. The nurse must clearly state information about who will have access to client assessment data and progress evaluations. He or she should tell the client that members of the mental health team share appropriate information among them-selves to provide consistent care and that only with the client’s permission will they include a family member. If the client has an appointed guardian, that person can review client information and make treatment decisions that are in the client’s best interest. For a child, the parent or appointed guardian is allowed access to information and can make treatment decisions as outlined by the health-care team.


The nurse must be alert if a client asks him or her to keep a secret because this information may relate to the client’s harming himself or herself or others. The nurse must avoid any promises to keep secrets. If the nurse has promised not to tell before hearing the message, he or she could be jeopardizing the client’s trust. In most cases, even when the nurse refuses to agree to keep information secret, the client continues to relate issues anyway. The following is an example of a good response to a client who is suicidal but requests secrecy:


Client: “I am going to jump off the 14th floor of my apartment building tonight, but please don’t tell anyone.”


Nurse: “I cannot keep such a promise, espe-cially if it involves your safety. I sense you arefeeling frightened. The staff and I will help you stay safe.”


The Tarasoff vs. Regents of the University of California (1976) decision releases professionals from privileged communication with their clients should a client make a homicidal threat. The decision requires the nurse to notify intended victims and police of such a threat. In this cir-cumstance, the nurse must report the homicidal threat tothe nursing supervisor and attending physician so that both the police and the intended victim can be notified. This is called a duty to warn.


The nurse documents the client’s problems with planned interventions. The client must understand that the nurse will collect data about him or her that helps in making a diagnosis, planning health care (including medications), and protecting the client’s civil rights. The client needs to know the limits of confidentiality in nurse–client interac-tions and how the nurse will use and share this informa-tion with professionals involved in client care.


Self-Disclosure. Self-disclosure means revealing per-sonal information such as biographical information and personal ideas, thoughts, and feelings about oneself to cli-ents. Traditionally, conventional wisdom held that nurses should share only their name and give a general idea about their residence, such as “I live in Ocean County.” Now, however, it is believed that some purposeful, well-planned, self-disclosure can improve rapport between the nurse and the client. The nurse can use self-disclosure to convey support, educate clients, and demonstrate that a client’s anxiety is normal and that many people deal with stress and problems in their lives.


Self-disclosure may help the client feel more comfort-able and more willing to share thoughts and feelings, or help the client gain insight into his or her situation. When using self-disclosure, the nurse must also consider cultural factors. Some clients may deem self-disclosure inappropriate or too personal, causing the client discom-fort. Disclosing personal information to a client can be harmful and inappropriate, so it must be planned and considered thoughtfully in advance. Spontaneously self-disclosing personal information can have negative results. For example, when working with a client whose parents are getting a divorce, the nurse says, “My parents got a divorce when I was 12 and it was a horrible time for me.” The nurse has shifted the focus away from the client and has given the client the idea that this experience will be horrible for the client. Although the nurse may have meant to communicate empathy, the result can be quite the opposite.





The working phase of the nurse–client relationship is usually divided into two subphases: During problem identification, the client identifies the issues or concerns causing problems. During exploitation, the nurse guides the client to examine feelings and responses and to develop better coping skills and a more positive self-image; this encourages behavior change and develops independence. (Note that Peplau’s use of the word exploi-tation had a very different meaning than current usage, which involves unfairly using or taking advantage of a person or situation. For that reason, this phase is betterconceptualized as intense exploration and elaboration on earlier themes that the client discussed.) The trust estab-lished between nurse and client at this point allows them to examine the problems and to work on them within the security of the relationship. The client must believe that the nurse will not turn away or be upset when the client reveals experiences, issues, behaviors, and problems. Sometimes the client will use outrageous stories or act-ing-out behaviors to test the nurse. Testing behavior chal-lenges the nurse to stay focused and not to react or to be distracted. Often when the client becomes uncomfortable because he or she is getting too close to the truth, he or she will use testing behaviors to avoid the subject. The nurse may respond by saying, “It seems as if we have hit an uncomfortable spot for you. Would you like to let it go for now?” This statement focuses on the issue at hand and diverts attention from the testing behavior.


The nurse must remember that it is the client who examines and explores problem situations and relation-ships. The nurse must be nonjudgmental and refrain from giving advice; the nurse should allow the client to analyze situations. The nurse can guide the client to observe pat-terns of behavior and whether or not the expected response occurs. For example, a client who suffers from depression complains to the nurse about the lack of concern her chil-dren show her. With the assistance and guidance of the nurse, the client can explore how she communicates with her children and may discover that her communication involves complaining and criticizing. The nurse can then help the client explore more effective ways of communi-cating in the future. The specific tasks of the working phase include the following:


·    Maintaining the relationship


·    Gathering more data


·    Exploring perceptions of reality


·    Developing positive coping mechanisms


·    Promoting a positive self-concept


·    Encouraging verbalization of feelings


·    Facilitating behavior change


·    Working through resistance


·    Evaluating progress and redefining goals as appropriate


·    Providing opportunities for the client to practice new behaviors


·    Promoting independence.


As the nurse and client work together, it is common for the client unconsciously to transfer to the nurse feelings he or she has for significant others. This is called transfer-ence. For example, if the client has had negative experi-ences with authority figures, such as a parent or teachers or principals, he or she may display similar reactions of negativity and resistance to the nurse, who also is viewed as an authority. A similar process can occur when the nurse responds to the client based on personal unconscious needs and conflicts; this is called countertransference. For example, if the nurse is the youngest in her family and often felt as if no one listened to her when she was a child, she may respond with anger to a client who does not listen or resists her help. Again, self-awareness is important so that the nurse can identify when transference and counter-transference might occur. By being aware of such “hot spots,” the nurse has a better chance of responding appro-priately rather than letting old unresolved conflicts inter-fere with the relationship.




The termination or resolution phase is the final stage in the nurse–client relationship. It begins when the prob-lems are resolved, and it ends when the relationship is ended. Both nurse and client usually have feelings about ending the relationship; the client especially may feel the termination as an impending loss. Often clients try to avoid termination by acting angry or as if the problem has not been resolved. The nurse can acknowledge the client’s angry feelings and assure the client that this response is normal to ending a relationship. If the client tries to reopen and discuss old resolved issues, the nurse must avoid feeling as if the sessions were unsuccessful; instead, he or she should identify the client’s stalling maneuvers and refocus the client on newly learned behaviors and skills to handle the problem. It is appropriate to tell the client that the nurse enjoyed the time spent with the cli-ent and will remember him or her, but it is inappropriate for the nurse to agree to see the client outside the thera-peutic relationship.

Study Material, Lecturing Notes, Assignment, Reference, Wiki description explanation, brief detail
Psychiatric Mental Health Nursing : Therapeutic Relationships : Establishing the Therapeutic Relationship |

Privacy Policy, Terms and Conditions, DMCA Policy and Compliant

Copyright © 2018-2024 BrainKart.com; All Rights Reserved. Developed by Therithal info, Chennai.