BY: FIROZ QURESHIDEPT. PSYCHIATRIC NURSING

INTRODUCTION The term therapeutic impasse may be used to

describe a number of situations that can arise inpsychotherapy. Impasses can occur as a result ofdisagreement between the therapist and client,unacknowledged issues within therapy, or stagnationin therapy. When an impasse first occurs, therapystops making progress. A client may previously havebeen feeling better or exploring previouslyunexplored issues, but an impasse makes furtherexploration difficult. It can also cause a therapist toquestion his or her competence.

DEFINITION Therapeutic impasses are blocks in the progress of the

nurse-patient relationship. They come about for a

variety of reasons, but all impasses create stalls in the

therapeutic relationship.

TYPES Resistance

Transference

Counter transference

Gift giving

Boundary violation

RESISTANCE Resistance is the patient’s attempt to remain unaware of

anxiety producing aspects within himself.

It’s a natural learned reluctance to avoidance of

verbalizing or even experiencing troubled aspects of self.

TYPES OF RESISTANCE

Primary: Often caused by patient’s unwillingness to

change when the need for change is recognized.

It may be also a reaction by the patient to the nurse

who has moved too rapidly & too deeply into patient’s

feeling.

Cont… Secondary: secondary gain favourable environment,

interpersonal & situational changes occur. Material

advantage as a result of illness.

It includes financial compensation, avoiding

unpleasant situations, increased sympathy or attention,

escape from responsibility, lessening of social pressure.

Forms of resistance displayed by patient

Suppression and repression of pertinent information.

Intensification of symptoms.

Self-devaluation and a hopeless outlook on the future.

Forced flight into health in which a sudden but short-lived

recovery is experienced by the patient.

Acting-out or irrational behaviour.

Superficial talk.

MANAGEMENT

Active listening

Clarification – Give for focused idea of what is happening.

Reflexion – Helps the patient to become aware of what has

been going in his mind.

Explore behaviour to find possible reason.

Maintain open communication with supervisor.

Cont…

TRANSFERENCE It is an unconscious response of the patient in which

he experiences feeling & attitudes towards the nurse

that were originally associated with significant figures

in his early life.

Such response utilizes the defence mechanism of

displacement.

Transference reactions are harmful to the therapeutic

process only if they remain ignored & unexamined.

TYPES OF TRANSFERANCE Hostile transference: If the patient internalizes anger

and hostility, this resistance may be expressed as

depression and discouragement. If the hostility is

externalized, the patient may become critical, defiant,

and irritable and may express doubts about the nurses

training, experience, or competence.

Dependent reaction: the resistance is characterized

by patient who are submissive, sub ordinate, and

ingratiating and who regard the nurse as a godlike

figure.

Cont…MANAGEMENT

No need to terminate relationship unless poses a serious barrier to therapy or safety.

Nurse should work with patient in sorting out past from the present.

Assist patient in identifying the transference & reassign a new & more appropriate meaning to the current nurse patient relationship.

the goal is to guide the patient to independence by teaching them assume responsibility for their own behaviours, feeling & thoughts & to assign the correct meaning to the relationship based on the present circumstances instead of past.

COUNTER TRANSFARANCE

It’s a therapeutic impasse created by the nurse.

It refers to nurse’s specific emotional response generated

by the qualities of the patient.

In this case the nurse identifies the patient with

individuals from her past & personal needs will interfere

with therapeutic effectiveness.

The nurse’s unresolved conflicts about authority, sex,

assertiveness & independence ten to create problems

rather than solve them.

TYPES Reaction of intense love or caring

Reaction of intense disgust hostility

Reaction of intense anxiety, often in response to

resistance by the patient.

FORMS OF

COUNTERTRANSFERANCE Inability to empathize with patient in certain problem

areas.

Depressed feeling during or after the sessions.

Carelessness about implementing the contract by being

late, running overtime etc.

Drowsiness during sessions.

Feeling of anger or impatience because of patient’s

unwillingness to change.

Encouragement of patients dependent behaviour, praise

affection.

Cont… Pushing the patient before he is ready or arguing.

Trying to help the patient in matters not related to the

identified nursing goals.

Dreaming or preoccupation with the patient.

Sexual or aggressive fantasies about the patient.

Recurrent anxiety, unease or guilt feelings about the

patient.

A tendency to focus repeatedly on only one aspect or

looking at the information presented by the patient.

ADVANTAGES OF

COUNTERTRANSFERENCE Powerful tool in exploration & potent instrument for

uncovering inner states. They are dangerous only if

they are brushed aside, ignored or not taken seriously.

It can lead to further information, can bring to light

new materials & help in developing insight.

Nurses understanding of counter transference & her

own feelings help to maintain a working relationship

with the patient.

MANAGEMENT Need not terminate relationship.

Support the nurse.

Assist her identifying counter transference.

Discuss with superiors.

Self examination.

Pursue to find out source of problem.

Exercise control counter transference.

Peer consultation & professional meetings.

GIFT GIVING

Receiving a gift from patient make the nurse to inhibit

independent decision making & created a feeling of

anxiety or guilt.

Gift is something of value is voluntarily offered to

another person, usually to convey a gratitude.

The timing of a particular situation, the intent of giving

& the contextual meaning of giving of the gift.

BOUNDRY VIOLATION It occurs when nurse goes outside the boundaries of

therapeutic relationship & establishes a social,

economic or personal relationship with the patient.

POSSIBLE BOUNDARY VIOLATION RELATED

TO PSYCHIATRIC NURSES

The patient takes the nurse out to lunch or dinner.

Has difficulty in setting limit with patient.

Relates the patient to a friend or family members.

Has sexual feeling towards a patient.

Cont… Feels that she is the only one who understands the

patient.

Receives feedback that she is too involved with a

patient or family.

Feels that other staffs are too critical or jealous of her

relationship with the patient.

VARIOUS PHASES OF NURSE

PATIENT RELATIONSHIP1- PRE INTRACTION PHASE

problems encountered

Difficulty in self analysis & self acceptance.

Anxiety

Boredom

Anger

Indifference

Depression

Cont…WAYS TO OVERCOME

Help from peer and supervisor in self analysis & facing

reality.

Analyze herself & recognize her asset & limitations.

2-ORIENTATION PHASE

Problem Encountered

Perception of each other as unique individual may not

take place.

Problems related to establishing an agreement or pact

between the nurse and patient.

Cont…WAYS TO OVERCOME

Nurse must be willing to relate honesty to her feeling &

share it with supervisor.

Nurse must feel free to reveal self without fear of

criticism.

Difficulty may be faced in assisting a nurse with counter

transference since most of this behaviour is

unconsciously.

A alert supervisor can detect this & guide the nurse

appropriately.

Cont…3-WORKING PHASE

Problem Encountered

Testing of nurse by the patient.

Unrealistic assumption about progress of patient.

The nurses fear of closeness.

Life stressors of nurse.

Resistance behaviour.

Counter transference.

Cont…4- TERMINATION PHASE

Problem Encounter

Anger.

Punitive behaviour.

Depression or assuming non caring attitude.

Flight to health.

Fight to Illness.

Nurses inability or unwillingness to make specific

plan & implement them.

Cont…WAYS TO OVERCOME

Nurse should be aware of patients feeling & be able

with them appropriately.

Assist the patient by openly eliciting his thought &

feelings about termination.

Supervisor can assist the nurse in preparing patient for

discharge.

THERAPUTIC COMMUNICATION

TECHNIQUES Listening

broad opening

Restating

Clarification

Reflection

Humour

Informing

Suggesting

Sharing perception

focusing

Thank you