copyright © 2014 wolters kluwer health | lippincott williams & wilkins chapter 5 therapeutic...

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 5

Therapeutic Relationships

Chapter 5

Therapeutic Relationships


Therapeutic RelationshipTherapeutic Relationship

• One of the most important skills a nurse can develop

• Crucial to success of interventions with clients requiring psychiatric care


Components of Therapeutic RelationshipComponents of Therapeutic Relationship

• Trust – Behaviors such as caring, interest, understanding,

consistency, honesty, promise keeping, listening (see Box 5.1)

– Congruence is essential.

• Genuine interest – Self-comfort, self-awareness of strengths and

limitations, clear focus


Components of Therapeutic Relationship (cont.)Components of Therapeutic Relationship (cont.)

• Empathy– Putting oneself in client’s shoes

• Client and nurse giving “gift of self”

– Different from sympathy (feelings of concern or compassion; focus shifting to nurse’s feelings)

• Acceptance (no judgments; set boundaries)

• Positive regard (unconditional nonjudgmental attitude)


Self-AwarenessSelf-Awareness

• Know self– Values (sense of right and wrong, code of conduct for

living)• Values clarification

• Choosing• Prizing• Acting

– Beliefs– Attitudes (see Boxes 5.2 and 5.3)


QuestionQuestion

• Is the following statement true or false?

• A nurse displays empathy by showing feelings of concern and compassion.


AnswerAnswer

• False

• Rationale: Empathy is putting oneself into the client’s shoes.

– Sympathy is showing feelings of concern and compassion.


Therapeutic Use of SelfTherapeutic Use of Self

• Use of aspects of personality, experience, values, feelings, intelligence, needs, coping skills, perceptions to establish relationships beneficial to clients

– Concept developed by H. Peplau


Therapeutic Use of Self (cont.)Therapeutic Use of Self (cont.)

• Johari window: tool to learn about oneself

– 4 quadrants: open/public self; blind/unaware self; hidden/private self; unknown

– Goal: move qualities from quadrants 2, 3, 4 into quadrant 1


Therapeutic Use of Self (cont.)Therapeutic Use of Self (cont.)


Patterns of KnowingPatterns of Knowing

• Ways of observing, understanding client interactions

• Four patterns (Carper, 1978; see Table 5.1)– Empirical (derived from nursing science)

– Personal (from life experiences)

– Ethical (from moral nursing knowledge)

– Aesthetic (from art of nursing)


Patterns of Knowing (cont.)Patterns of Knowing (cont.)

• Fifth pattern : unknowing (Munhall, 1993)

– Nurse admits lack of knowledge of client or understanding of client’s subjective world


Types of RelationshipsTypes of Relationships

• Social– Purpose of friendship, socialization, companionship,

or task accomplishment– Superficial communication; shifting roles; outcomes

rarely assessed

• Intimate– Emotional commitment of two persons– Individual needs met; assistance with helping each

other meet needs


Types of Relationships (cont.)Types of Relationships (cont.)

• Therapeutic

– Focus on needs, experiences, feelings, ideas of client only

– Use of communication skills, personal strengths, understanding of human behavior by nurse

– Joint agreement on areas to work on; outcome evaluation


QuestionQuestion

• Is the following statement true or false?

• A social relationship involves superficial communication for the purposes of friendship or task accomplishment.


AnswerAnswer

• True

• Rationale: A social relationship occurs for friendship, socialization, companionship or task achievement. It involves superficial communication with shifting roles.


Establishing a Therapeutic RelationshipEstablishing a Therapeutic Relationship

• Peplau’s model of three phases

– Orientation

– Working

– Termination (see Table 5.3)

• Overlapping, interlocking of phases


Establishing a Therapeutic Relationship: Orientation PhaseEstablishing a Therapeutic Relationship: Orientation Phase• Meeting nurse, client

• Establishment of roles

• Discussion of purposes, parameters of future meetings

• Clarification of expectations

• Identification of client’s problems

• Nurse–client contracts/confidentiality, duty to warn/self-disclosure


Establishing a Therapeutic Relationship: Working PhaseEstablishing a Therapeutic Relationship: Working Phase

• Problem identification: issues or concerns identified by client; examination of client’s feelings and responses

• Exploitation: examination of feelings and responses; development of better coping skills, more positive self-image, behavior change, independence

• Possible transference/countertransference


Establishing a Therapeutic Relationship: Termination PhaseEstablishing a Therapeutic Relationship: Termination Phase

• Begins when client’s problems are resolved

• Ends when relationship is ended

• Deals with feelings of anger or abandonment that may occur; client may feel termination as impending loss


Behaviors Diminishing Therapeutic RelationshipsBehaviors Diminishing Therapeutic Relationships

• Inappropriate boundaries (relationship becomes social or intimate)

• Feelings of sympathy, encouraging client dependency

• Nonacceptance of client, avoidance (see Box 5.4)


QuestionQuestion

• During the working phase of a nurse–client relationship, which of the following would occur?

– A. Expectations are clarified.

– B. Nurse–client contracts are established.

– C. Feelings of loss are addressed.

– D. Client feelings are examined.


AnswerAnswer

• D. Client’s feelings are examined.

• Rationale: During the working phase, the client identifies issues or concerns, and his or her feelings and responses are examined.

– Expectations are clarified, and contracts are established during the orientation phase. Feelings of loss are addressed during the termination phase.


Therapeutic Roles of the Nurse in a RelationshipTherapeutic Roles of the Nurse in a Relationship

• Teacher (coping, problem solving, medication regimen, community resources)

• Caregiver (therapeutic relationship, physical care)

• Advocate (ensuring privacy and dignity, informed consent, access to services, safety from abuse and exploitation)

• Parent surrogate (see Box 5.5)


Self-Awareness IssuesSelf-Awareness Issues

• Nurse’s self-awareness: crucial to developing therapeutic relationships

• Helpful activities: values clarification, journaling, group discussions, reading

• Development of self-awareness: continual, ongoing process

copyright © 2014 wolters kluwer health | lippincott williams & wilkins chapter 5 therapeutic...

Documents

needs slide

phases slide

peplau slide

art of nursing slide

clear focus slide

therapeutic relationships

warnself disclosure

psychiatric care slide