Australian and New Zealand Journal of Mental Health Nursing (2001) 10, 176–186

INTRODUCTION

The organization of mental health services hasbeen structured around the assignment of indi-vidual client care to an individual professional.This concept, often referred to as case manage-ment, has been accorded a pivotal place in thecare of people with mental illness and has beenassigned to a variety of disciplines including com-munity psychiatric nurses. While some servicesfocus on the organizational aspects of the role,others, including most Australian services, focuson direct service provision and incorporate atherapeutic relationship. Few studies have

addressed issues related to the therapeutic rela-tionship or how the client perceives their relationship with the case manager.

The aim of this study was to develop an under-standing of the experience of the relationshipbetween community psychiatric nurses andclients with severe and persistent mental illness.

The aim of this paper is to present the findingsrelated to clients’ understandings of the rela-tionship and to discuss the implications of this forboth nursing and mental health services. Thenurses’ experiences of the relationship are discussed in an earlier paper (O’Brien, 2000).

BACKGROUND

Case management models and psychotherapeutic relationshipsRepper and Peacham (1991) argue that the ‘realmeasure of success in community care provision

FEATURE ARTICLE

The relationship between communitypsychiatric nurses and clients with severeand persistent mental illness: The client’sexperience

Correspondence: Louise O’Brien, University of WesternSydney, Nepean, School of Health and Nursing, ParramattaCampus, PO Box 10 Kingswood, NSW 2747, Australia.Email: l.obrien@uws.edu.au

Louise O’Brien, PhD, RPN, RGN.Accepted October 2000.

Louise O’BrienUniversity of Western Sydney, Nepean, and Wentworth Area Health Service, Sydney, Australia

ABSTRACT: The aim of this phenomenological study was to construct an inter-pretation of the experience of nurse–patient relationships, in the context of com-munity psychiatric nursing. The purpose of this paper is to focus on the experienceof the relationship from the perspective of the clients. Themes of ‘having someonelooking out for me’, ‘working in collaboration’, and ‘being understood and gainingunderstanding’ were identified. This thematic structure was used to understand themeaning of the relationship for the clients. Implications for practice, education,clinical supervision and mental health services are discussed.

KEY WORDS: collaboration, community psychiatric nursing, mental illness,nurse–patient relationships, phenomenology, psychotherapy, trust.

is the extent to which the needs of people withserious, long-term psychiatric difficulties arecatered for’ (p. 62). They described the corefunctions of case management as assessment,development of a comprehensive care plan,ensuring access to services, monitoring andadvocacy, and long-term flexible support. Theyalso supported the need for a therapeutic rela-tionship to:

help the client develop a more stable sense ofidentity to integrate their cognitive and problemsolving abilities, to consider the range of alter-native possibilities and to avoid impulsiveactions’ (pp. 64–65).

The value of the relationship between the casemanager and the client was given scant recogni-tion in early publications on case management,notable exceptions being Adler, Drake and Stern(1984) and Lamb (1980). Lamb (1980) warnedagainst a case manager system that was ‘an imper-sonal bureaucracy itself.’ He suggested that:

it is…important to understand the psychody-namics of the patient’s illness, have…informa-tion about his early life, and, …understand whatkinds of real life situations interact with hispersonal dynamics to cause psychotic episodes,interfere with growth, or deprive him of grati-fication with life…Someone needs to knowabout the current significant events in thepatient’s life and how he is reacting to them…Itis difficult to possess this knowledge outside thecontext of a therapeutic relationship (p. 762).

The early 1990s saw greater recognition of therelationship between the client and the casemanager (see Bachrach, 1992; Goering, Wasy-lenki, Farkas, Lancee & Ballantyne, 1988; HumanRights and Equal Opportunity Commission 1993;Maurin, 1990; McGorry, 1992; Repper, Ford &Cooke, 1994; Repper & Peacham, 1991). Thisinterest was followed by an increase in interest inspecific models and outcomes (Kuno, Rothbard& Sands, 1999; Stanard, 1999). However, it shouldbe noted that although these studies do not focuson a therapeutic relationship they do acknowl-edge the importance of psychotherapeutic rela-tionships in case management (Rapp, 1998).Carey (1998) and Williams and Schwartz (1998)

identified the similarities between case manage-ment and psychotherapy and suggested thattherapeutic constructs from the psychodynamictradition can be applied productively to enhancethe effectiveness of case management.

Psychotherapeutic relationships have beencited as important in all phases of recovery frompsychotic illness. The continuity of a psycho-therapeutic relationship in the recovery phase isneeded to help patients cope with the experienceof the illness and its treatment. The relationshipcan make the difference between managing theillness and falling into a chronic sense of despair(Corrigan, Liberman & Engel, 1990; McGorry,1992).

A study of outcome for 82 patients assigned tocase managers noted that ‘the relationshipbetween the case manager and the patient maybe the most potent therapeutic factor within theprogramme [and that]…patients reported greatsatisfaction with this type of continuous relation-ship six months after entering the program’(Goering et al., 1988; p. 275). A review of pro-grammes for people with serious mental illnessliving in the community identified that thecommon factor of success was ‘the presence of atleast one individual who can provide tangible aswell as intangible assistance, someone to clarifythe expectations as well as to provide the affec-tive encouragement to meet these expectations’(Crosby, 1987; p. 35).

The establishment of psychotherapeuticrelationships has been linked with the enhance-ment of hope in people with serious mentalillness (Kirkpatrick, Landeen, Byrne, Woodside,Pawlick & Bernardo, 1995) as a ‘type of internal“glue” that helped to maintain emotional equilib-rium’ (Pollack, 1989; p. 315) and helped toprovide the coherence for a fragmented self. Thiscoherence and the experience of being under-stood may be essential for the ‘life or deathstruggle’ for the survival of the self (p. 319). Thenurturing of a sense of self within the supportivepsychotherapeutic relationship may provide ameans of developing strengths with which tocope with severe mental illness (Davidson, 1992;Josephs, 1988; Kane & McGlashan, 1995; Rock-land, 1993).

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Clients perceptions of psychotherapeuticrelationshipsIndividuals suffering mental illness haveexpressed the importance of having a psycho-therapeutic relationship. In a survey of 200clients of community mental health services byCoursey (1989), 90% reported that individualpsychotherapy was helpful. Psychotherapy wasseen to supply support, understanding andacceptance and a person who was not afraid tobe with them in their most troubled times.

Self-reports of the experience of mental illnessreflected the struggle of the person with theillness (Lally, 1989; Leete, 1987, 1989) and theimportance of psychotherapeutic relationship asan ongoing part of treatment (Ruocchio, 1999).In a study of clients’ perceptions of the expe-rience of mental illness, themes of ‘stigmatiza-tion and resulting alienation, loss, distress, andacceptance’ were identified (Vellenga & Christen-son, 1994; p. 360). The clients experienced a per-vasive sense of distress; they were often anxious,fearful and despairing, feeling totally alone andburdened by symptoms. Important aspects ofcoming to terms with the illness were self-acceptance and acceptance of others. InOuschan’s (1998) Australian qualitative study ofthe experience of mental illness, clients identi-fied the impact of mental illness as loss of senseof self, and loss of dignity and credibility. Theyidentified the need for ‘someone who understoodand validated their pain, fear and sense of loss’(p. 68).

In a series of interviews conducted withpatients with severe psychiatric disorders whohad been hospitalized Davidson (1992) revealedthat the patients’ struggle to improve ‘involvedsignificant changes in the meaning that (they)attributed to their illness and in their sense of selfover time’ (p. 7). Important to re-establishing asense of self was understanding the illness andhaving someone who believed in them and theirpotential.

Mental health services and psychotherapeutic aspects of careDespite the evidence that a psychotherapeuticrelationship may be important to recovery, much

of the emphasis on the care of the severelymentally ill in the community has centred onmedication and rehabilitative systems (Bataille,1990; Coursey, 1989; Wasylenki, 1992; Zahniser,Coursey & Hershberger, 1991). These authorsexpressed concern about the failure to recognizethe psychotherapeutic skills required to provideeffective case management, community supportand rehabilitation.

Nursing, case management and psychotherapeutic aspects of careResearch related to community psychiatricnursing has paid little attention to the psycho-therapeutic aspects of care. Much of the earlierliterature emphasizes role function and goals (seeBarratt, 1989; Carr, Butterworth & Hodges,1980; Griffith, & Mangen, 1980) rather thanpractice and interventions. The psychotherapeu-tic relationship has been identified as central topsychiatric nursing (Anthony, 1999) and advo-cated due to nurses ability to attend to ‘thepatient’s subjective experience’ and to fosterhope (Czuchta & Johnson, 1998; p. 35).Thelander (1997) advocated the use of psy-chotherapy, informed by Peplau, in long-termrelationships with patients with severe mentalillness. No studies were identified whichexamined the client’s experience within a nurse–client relationship in the context of communitymental health services.

METHODOLOGY

The methodological framework selected for thisstudy was hermeneutic phenomenology, basedon the writing of Heidegger (1962). Hermeneuticphenomenology can be used to understand theexperiences of nurses and patients in a variety ofcontexts, and to explore the value of particularways of being in nursing.

The philosophical constructs, which under-pinned the framework, included an understand-ing of persons as self-interpreting beings who areinvolved in their worlds in meaningful ways, anda definition of language as a means of identify-ing, describing and achieving shared meaning. Inaddition, the implications of the methodology

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include a commitment by the researcher tounderstand the experience as a whole and acceptance that participants can reflect upon andarticulate their experiences. The conversationalprocess between the researcher and the partici-pants provides an arena where shared meaningcan be established (Kvale, 1996; van Manen,1990). Transcriptions reflect as nearly as possiblethe experience of the conversation (Sandelowski,1993). The preunderstandings of the researcherare explicated and the interpretive process isborne out of the text and the researcher’s pre-understandings. Writing is a creative process thatreaches beyond narrative description to revealmeaning and understanding (Barritt, Beekman,Bleeker & Mulderij, 1985; O’Brien, 2000).

METHOD

The participants and the settingI came to the study with experience of being acommunity psychiatric nurse in which I devel-oped long-term relationships with clients. Myunderstanding of the nurse–patient relationship,in this setting, was that it appeared to be valuable;that clients appreciated the relationship and thatit was influential in maintaining the well-being ofthe client.

The selection of clients was purposeful. Theclients, with pseudonyms of Monica, Rebecca,Dorothy, Rachel and Shirley, lived in the com-munity and met the criterion of having a seriousand persistent mental illness. Their mentalillness, diagnosed according to the Diagnosticand Statistical Manual of Mental Disorders(American Psychiatric Association, 1994), was ofat least 2 years’ duration. All of the clients werefemale, with ages ranging from 33 to 67 years andliving in public housing. They had formed a rela-tionship with a community nurse, and wereinvited to participate. For discussion of thenurses in the study see O’Brien, 2000.

Ethical issuesAppropriate university and healthcare ethicscommittees approved the study. All participantswere provided with an information sheet and a

consent form which indicated that consent couldbe withdrawn at any time. Clients who wereinvited to participate were considered by thenurses to be unlikely to suffer through the processof the conversations about the relationship. Therewere no ethical problems identified in the courseof the study. The clients expressed the value theyfound in the experience of talking about andexploring the meaning of the relationship.

Data collection, management andanalysisIndividual, audio taped interviews, lastingbetween 1 and 11/2 hours were conducted.Interviews were conversational in nature andopened with an invitation to ‘Tell me about yourrelationship with…’. All participants were inter-viewed three times (except one client, who wasinterviewed twice). Gaps between interviewswere no more than 1 week. Interviews withclients occurred, at their request, in their homes.The clients all related in detail about their illness,its onset and process, the treatment they hadreceived, and past therapists, as well as abouttheir relationship with the current communitynurse. My input involved maintaining a conver-sational stance, requesting further informationand asking for concrete examples.

Journal notes, made immediately followingeach conversation, described the participant, thesetting, non-verbal communication, and personalreflection. Transcription of all verbal communi-cation occurred before the next conversation, toallow for identification of areas that needed clar-ification. Journal notes were appended to thetranscription. Data analysis involved reading andre-reading of the comprehensive transcripts inentirety and in sections. Sub-themes that illumi-nated meaning were identified and named andsubsequently collapsed into themes thatreflected the meaning of the relationship.

RESULTS

The clients’ experience of the relationshipThe conversations with the clients centredaround three themes that reflected their expe-rience of the relationship: having someone

NURSE–PATIENT RELATIONSHIPS 179

looking out for me, working in collaboration, andbeing understood and gaining understanding.While there was some overlap, the themes rep-resent different aspects of the relationship andrepresent how all the clients viewed the rela-tionship. The themes, and the associated sub-themes are discussed below.

Having someone looking out for me meanthaving someone there, surviving, and having asane haven.

Having someone there

‘Having someone there’ meant that the clientshad someone to contact and knew that someonewas monitoring their mental health. Dorothysummed up the importance of having someonethere:

If I do get sick I know Michael (client’s son) cancontact Laurence. He…makes sure I haveenough support…checks that I am thinkingstraight. It is useful to have someone keeping aneye on me.

Rebecca discussed a recent crisis wherehaving someone there was important:

When Dad died she was there – she knew howmuch it upset me – she understood – and whenI started to worry about the TV and the mannext door she helped me see what was reality. Irealized when she talked to me that it was theillness.

Shirley said that in the past she was not awarethat she could contact anyone if she needed helpand did not really know that her suffering in isolation could be alleviated:

I wasn’t aware I could…I went to out-patientsbefore. The doctor would say, ‘How are you?’but he wanted to know about the symptoms.

Surviving

‘Having someone looking out for me’ meant sur-viving. Surviving meant being able to live withthe illness. Suicide was seen as an alternative andthis was stated implicitly or explicitly. Rachelstated, ‘I couldn’t survive without Sophia – orsomebody like that.’ Shirley was quite explicit:

If it wasn’t for her being around…I wouldn’t behere…I would have suicided…even if Jane is

off duty I know that the rest of the team arethere.

All of the clients commented that the relation-ship was influential in them not being readmit-ted to hospital. Monica felt that the relationshipwould provide a safety net even when she nolonger needed to be seen on a regular basis: ‘if Ihad a problem in the future – after we terminate– I can contact him’.

Having a sane haven

‘Having someone looking out for me’, meanthaving a sane haven. All clients alluded to thisand Rachel coined the term:

Having a sane haven – having that contact andthat sanity between schizophrenia and reality…she provides reality – she reassures me – helpsme see what is real – it gets pretty confusing inthe schizophrenic world but I trust her to tellme what is real – I can’t trust many people – I get suspicious.

The clients used the sane haven to discuss con-cerns about day-to-day living. They were oftenunsure whether the way they experienced lifeevents was similar to others. They often did notfeel safe discussing their concerns with others incase what they said was not understood. They usedthe relationship to test out their perceptions safely.

Working in collaborationThis theme reflected the consistent reference tothe close working bond that the clients felt theyhad with the nurse. This was commented uponwith a sense of pride, and they felt that the effortof working through issues and difficulties was ajoint one. Shirley commented: ‘we’ve come a longway…we’ve worked on a lot of things’. Shedescribed her work with Jane as a process of‘becoming a person’. Monica talked of workingwith Gareth to make meaning out of her experi-ence of mental illness ‘If I had not worked withGareth on finding some meaning in the experi-ence I would have continued to see my admis-sion to hospital in a totally negative light’.Working in collaboration involved: having an ally,being supported, sharing power and havingoptions, being respected, and being able todiscuss the relationship.

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Having an ally

Working in collaboration meant having an allywho would see things from their point of view.Rebecca commented that:

She looked at the situation at home and recog-nized how difficult it was…No one had…triedto see it from my point of view. Thathelped…Finally there was someone in therebatting for me.

Despite Monica previously having lookedupon mental health professionals with a greatdeal of suspicion she noted ‘I connected withhim…I took to him straight away – I can’t tell youwhy’. Shirley described her experience of alliancewith Jane as ‘not feeling so desolate’.

Being supported

Working in collaboration meant having someonewho was willing to provide support and practicalassistance in order for them to live in the world.Rebecca talked about the fact that Ursula imme-diately recognized that she had very few posses-sions ‘no-one else…had done that. My family saidI didn’t need anything because I was only stayingthere temporarily’.

Working in collaboration meant being sup-ported to stand up for rights. Rebecca com-mented:

I didn’t value myself…I felt like a failure…Sheencouraged me to stand up for my rights as theboys’ mother…I was pretty unsure of myselfbefore I saw Ursula, about how much of amother I could still be. I thought…because youhave this…maybe you can’t (be a mother).

Being supported meant having someone tohelp sort out the problems:

It’s having someone to suggest the next step…Ithought ‘What am I going to do?’ This is such abig mess – She encouraged me to sort it out alittle bit at a time…She’d encourage me to findthe answers…

Being respected

The clients felt respected in the relationship‘Sophia never gives the impression that she thinksyou a looney’ Rebecca noted that even when shewas confused and her speech incoherent, she was

treated with respect ‘I am talking to somebodyand I am not making sense but she is taking it inand doesn’t seem to think I am stupid or crazy’.

Sharing power and having options

Working in collaboration meant sharing powerand exercising choice in the relationship.Rebecca talked of the education that Ursulaprovided but that she could choose what shewanted to know at a particular time: ‘if she wastelling me more than I wanted to know I’d let herknow’. Monica appreciated that Gareth left thefrequency of their contact, which had initiallybeen legally imposed, up to her: ‘he’d say, “youtell me when you want me to visit”…I didn’t feellike he was forcing anything on me’.

The clients’ experience of being mentally illwas such that they often felt that they did not havechoices:

My self-confidence took a real battering in thatplace [hospital]. Gareth said I had choices butI couldn’t believe him – I didn’t think he wouldlie to me, I just thought he had it mixed up – Ittook me six months to realize I can do thingsand no-one is going to check me back in therefor not obeying orders.

Rachel felt that Sophia took her ideas seri-ously: ‘Sophia doesn’t enforce things and she willtalk things over…your choices are important’.Rebecca appreciated that Ursula did not tell herwhat to do but encouraged her to explore her ownideas ‘She would listen to what was important tome and what I think should happen…’.

Being able to discuss the relationship

Working in collaboration meant being able todiscuss the relationship. Clients described therelationship as ‘a friend – but different…not likeother friends’. All of the clients said that they haddiscussed the relationship with their nurse andwere aware of the difference. Monica stressedthat she understood their relationship and thattransference issues had been discussed:

I am very aware that he is my nurse. We did talkabout that – that the relationship is one of himbeing a therapist/nurse or whatever – and I don’tget that mixed up with any other relationship –I have a lot of respect for him and he for me.

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We talked about the transference – he said thatmy feeling dependent on him was normal andwe had to work through it and not ignore it –and we have.

Being understood and gaining understandingBeing understood was ‘having someone reallypresent, trusting’, and ‘not being judged’.Gaining understanding included learning aboutthe illness, being able to make sense of theirexperiences, developing the ability to knowthemselves and how they related to the world and finding ways to deal with the stigma of mentalillness.

Being understood

The most common comment about the relation-ship was ‘I feel understood’. The clients felt thatthe nurses made an effort to understand themand this process was seen as important as beingunderstood. Rebecca felt from the beginning thatUrsula understood her distress. She talked withpride about the fact that Ursula said ‘it would behard for anyone to cope with what you cope with’.Monica felt that Gareth’s empathy was importantand believed that knowing something of Gareth’sbackground gave his understanding credibility.

Having someone really present

The clients felt that the nurses attended to them,took time to talk and tried to see things from their perspective. They often compared thisexperience to other experiences with health professionals:

It’s as if they are not even taking in what you aresaying…Ursula will help you pinpoint what isbothering you and help you find a way you canwork on the problems.

Having someone to talk to about the day-to-day issues was important. Dorothy commentedthat she needed to talk about the concerns ofliving a life with a mental illness, considerablephysical problems and having a son with schizo-phrenia.

Well,…he is someone you can talk to – I haven’thad someone to talk to about things – I feel Ihave someone for me…he is there for me.

The clients talked of the nurses really payingattention and being interested in their life expe-riences. They knew the nurses would make andkeep appointments and would spend an hourwith them.

Not being judged

Not being judged was important to the clients’feelings of being understood. Monica felt thatGareth did not stand in judgement:

He really doesn’t judge me…There have beenthings that I have done that I am not proud ofbut he doesn’t change. He doesn’t condone whatI do but he doesn’t reject me.

Rachel commented:

I think it is because Sophia doesn’t condemn youfor doing the wrong thing – I never feel badabout myself with Sophia – that I am wicked ornot good for anything…That is very importantbecause – you can feel so bad about yourself –so condemned for having a mental illness.

Trusting

Trust was an important aspect of being under-stood. Shirley commented that she had nottrusted anyone in the way she trusted Jane. Herdeprived past and mental illness had left herunsure about people. It took a long time for trustto develop and she was grateful that Jane per-sisted with her. The clients were confident thatthe nurses knew them as people and knew howtheir illness affected them. The clients alsotrusted the nurses’ knowledge about mentalillness and its treatment. Despite the fact thathaving choices, being respected and sharingpower were very important aspects of therelationship, the clients trusted that if the nursesneeded to make decisions for their safety and thedecisions would be the right ones.

Gaining understanding

Gaining understanding meant learning aboutliving with the illness. The clients talked aboutbeing aware of the early signs of recurrence oftheir illness and felt comfortable in makingcontact with the nurse if they were concerned.The clients commented that the nurse had spenttime explaining the illness and its treatment but

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they had not wanted to know about their illnessall at once. They said that they liked to read aboutthe illness, in pamphlets or books, then discusswith the nurse how it related to them specifically.All the clients rejected group education pro-grammes ‘I have control over how much I wantto know at a particular time by talking withUrsula’. Monica felt she would not have acceptededucation about her illness had Gareth not spenttime developing the relationship.

I didn’t want to know about it but he said if Iwanted to be in charge of it I needed to know.He taught me about the illness – and I need toknow what – and how much it affects me withoutthe medication…Gareth has talked to me aboutrecognizing the early warning signs of illness.He also taught the kids about my illness. Mydaughter sometimes says, ‘Mum – you aregetting high again’. I try to control it…Garethhas taught me some relaxation exercises to slowmy mind down when it starts to race.

Gaining understanding also meant being ableto understand their experiences. Rebecca talkedabout learning to accept the limitations of her relatives’ support. ‘Ursula taught me only toexpect what she [mother] could give me and tounderstand her perspective. I think she found itvery hard to cope with me being sick’.

Gaining understanding meant developing theability to know themselves and how they relatedto the world. Shirley talked of learning to recog-nize her feelings. She said that she had felt likean ‘it.’ An ‘it’ was like being a thing that reactedto the environment but that had no centre, ‘noreal me’. Working with Jane had allowed her todevelop into ‘a person who had a right to feelings’.

Monica talked of gaining understanding of herdestructive relationships by examining the rela-tionships of her childhood. She now understoodthat those relationships influenced the choicesshe made. Rebecca felt much clearer about hervalue as a person. She felt supported to continuein her role as mother and to make claims to betreated by her relatives with respect.

In summary, the relationship was experiencedby the clients as one in which they had someoneto look out for them, in which they worked collabo-ratively on the problem of being-in-the-world as

a person with a mental illness, and experiencedbeing understood and gaining understanding.

DISCUSSION

The meaning of the relationship for theclientsThe clients were able to describe a professionalrelationship, in which they worked with the nurseto look at the problems of living a life with amental illness. The clients stressed the impor-tance of being understood as a person and havingchoices and came back to these points manytimes. The clients re-established a sense of selfin the relationship and in so doing they were ableto go on to examine what possibilities that selfmight have in the world.

The five clients described the relationship aslife-sustaining and suggested that their survivalin the community depended upon it. They suggested that the relationship had reduced hospitalization, increased self-esteem, provideda safety net, and helped them understand them-selves and what was going on around them. Theysaw the nurses as concerned about the day-to-day problems that they encountered in living alife with a mental illness. Knowing that the nursewas going to be there at an appointed time andthat it was sufficient time to be able to talk abouttheir concerns was important.

The importance of the relationship to theclients resonated with the self-accounts of mentalillness and treatment. It was important to beacknowledged as a person, to have at least oneperson in the world who took a genuine interestin the day-to-day issues that concerned them, hadhope for them, believed in them, and saw themas important enough to work with collaboratively.The clients’ perceptions confirm the evidencefrom the literature that a psychotherapeutic relationship is important to the ability of clientswith severe and persistent mental illness to livein the community.

The meaning related to nursing practice,education, and clinical supervisionThe uncovering of the structure of the relation-ship highlights its importance to clients with

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mental illness. Psychiatric nurses need theknowledge and skills to be able to enter into relationships with these clients. Nurses need toknow about mental illness and its treatment,understand how it affects the client’s ability to livea life, and understand how that ability is affectedby the social and cultural context. In addition,nurses need knowledge of psychotherapeuticconcepts and dynamics and the interpersonalskills, self-awareness and maturity to be able touse them. These issues need to be addressed ineducation and clinical supervision.

The meaning related to the structure ofmental health servicesThe structure of mental health services needs toconsider the time and resources that nursesrequire in order to provide for nursing care basedon long-term relationships for clients with seriousand persistent mental illness. Despite thegrowing evidence from the professional litera-ture and from personal accounts of people withmental illness that psychotherapeutic supportiverelationships are humane, useful and efficacious,their provision for people with serious and per-sistent mental illness is seldom factored into thetime it takes to provide care. Whether clientsactually are assigned to a health professional whocan provide good supportive psychotherapyoften depends less on any assessment of need ofthe client and more on the chance of assignment.

The value and limitations of the studyThis study emphasizes the importance of thenurse–patient relationship in care of people withlong-term mental illness. It provides an articula-tion of those activities undertaken by communitypsychiatric nurses that are often dismissedwithout acknowledgement of their value toclient-care and well-being.

While this methodology limits the number ofparticipants it maximizes the richness and depthof data collected. The methodology provided away of exploring what is important to people withmental illness and what they find useful inreducing their suffering and sustaining them asthey struggle to live in the community.

The participants in the study were all female.While the nurses did indicate that they had developed therapeutic relationships with maleclients, episodes of illness and unwillingness toparticipate precluded involvement in this study.Further research needs to identify whether maleclients perceive this relationship in the same way.

ACKNOWLEDGEMENTS

This PhD study was undertaken at University ofTechnology, Sydney, Australia and supervised byDr Cheryl Waters and Dr Michael Carey.

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