Therapeutic Relationship

1. Therapeutic Relationship Ms. Rica A. Santos, RN

2. Objectives • Differentiate between therapeutic nurse-client relationship and a social relationship • Give emotional support using the nursing processaccording to mental health principles and incorporating transactional analysis concepts. • Effectively use the communicator rolein the therapeutic nurse relationship.

3. Objectives • Use nursing presence and anticipatory guidancein all stages of the nurse-client relationship, facilitating the client’s psychosocial adjustment to life changes. • Describe the caregiver role in creatinga therapeutic environment to help the client move towards health.

4. As according to LaRowe (2004) the very first process between the nurse and the client is to establish an understanding in the client that the nurse is entering into a relationship with the client that essentially is safe, confidential, reliable, and consistent with appropriate and clear boundaries (Varcarolis, et.al.)

5. Types of Relationship • Social relationship • Intimate relationship • Therapeutic relationship

6. Interpersonal Relations in Nursing (1952)

7. Helping Relationship

8. Definition • Interpersonal relationship • Therapeutic relationship • Therapeutic alliance • Is an intellectual and emotional bond between the nurse and the client and is focused on the client. • Respects client confidentiality • Focuses on the client’s well being • Is based on mutual trust, respect and acceptance

9. Definition • Respects the client as an individual, including • Maximizing the client’s abilities to participate in decision making and treatments • Considering ethnic and cultural aspects • Considering family relationships and values • The nurse and the client identify areas that need exploration and periodically evaluate the degree of change in the client

10. Helping is a growth-facilitating process that strives to achieve two basic goals (Egan, 1998) • Help the clients manage their problems in living more effectively and develop unused or underused opportunities more fully. • Help clients become better at helping themselves in their everyday lives

11. Keys to the helping relationship • Development of trust between the nurse and the client • Underlying belief that the nurse cares about and wants to help the client.

12. Mental Health Principles • An individual’s reality is based on his/her subjective experiences. • People make the best choices they can for themselves at any given moment. • The meaning of communication is the response the communication elicits • Because a person cannot NOT respond, nearly everything one does be influences • All behavior is useful in some context

13. Mental Health Principles • It is better to have some choice than no choice • The more flexible, the more control that person has in the system • Individuals possess the psychological resources they need to make the changes they want. • Anything one can pretend, one can master • There are no mistakes, only outcomes

14. Goals in a therapeutic relationship • Facilitating communication of distressing thoughts and feelings • Assisting clients with problem solving to help facilitate activities of daily living (ADL) • Helping clients examine self-defeating behaviors and test alternatives • Promoting self-care and independence

15. The goals of the nurse is to help the client • Feel understood • Identify and explore problems relating to others • Discover health ways of meeting emotional needs • Experience satisfying interpersonal relationship

16. The goals of the nurse is to help the client • Establish and maintain a therapeutic alliance in which the client will feel safe and hopeful that positive change is possible • Once specific needs and problems have been identified, the nurse can work with the client on increasing problem-solving skills, learning new coping behaviors and experiencing more appropriate and satisfying ways of relating to others

17. Nurses must get their needs met outside the relationship.

18. Factors that enhance growth in others • Genuineness • Empathy vs. Sympathy • Positive regard • Attending • Suspending value judgments • Helping clients develop resources

19. Principles in therapeutic relationship • Help the client feel comfortable in talking about himself • Refrain from doing too much talking • Listen carefully – to the whole, the parts, what precedes and follows • Note that the initial topic may not be the most crucial • Attend to the communication cycle and be sure that what is said is what is heard; encoding, decoding, potential for breakdown

20. Principles in therapeutic relationship • Observe vigilantly and constantly • initial contact • use of space • communication choices • how the story unfolds • What is the client’s dress? • Timing • Evaluate progress and validate

21. Establishing Boundaries • Overhelping • Controlling

22. Projection • Transference • Countertransference

23. What do you sense -- specifically -- in your body as you look at him/her? • Where do you tense, relax, become warm, cold, feel bigger, smaller, etc.? • Does your breathing change? How? • What do you feel emotionally as you look at him/her? • Does your body want to move as you look at him/her? How?

24. What happens if you follow the movement? • What fantasies or other pictures come to mind as you look at him/her? • If this person was an animal, what animal would he/she be? • What animal would you be interacting with this person's animal?

25. What do you like about him/her? • What don't you like? • What does he/she like about you? Not like? • How is he/she like you? Different? • Who does he/she remind you most of? How are they alike? Different?

26. What have you learned about your relationship to your therapist? What would be worthwhile, or necessary to share with your therapist?

27. Nursing Boundary Index Self-Check • Have you ever received feedback about your behavior being overly intrusive with patients and their families? • Do you ever have difficulty setting limits with patients? • Do you ever arrive early or stay late to be with your patient for a longer period? • Do you ever find yourself relating to patients or peers as you might to a family member?

28. Nursing Boundary Index Self-Check 5. Have you acted on sexual feelings you have for a patient? 6. Do you feel that you are the only one who understands the patient? 7. Have you received feedback that you get “too involved” with patients or families? 8. Do you derive conscious satisfaction from patients’ praise, appreciation, or affection?

29. Nursing Boundary Index Self-Check 9. Do you ever feel that other staff members are too critical of “your” patient? 10. Do you ever feel that other staff members are jealous of your relationship with your patient? 11. Have you ever tried to “match-make” a patient with one of your friends? 12. Do you find it difficult to handle patients’ unreasonable requests for assistance, verbal abuse, or sexual language?

30. Understanding self and others • Values • Values clarification • Prizing one’s beliefs and behaviors (emotional) • Choosing one’s beliefs and behaviors (cognitive) • Acting on one’s beliefs (Behavioral)

31. Accountability • Focus on client’s needs • Clinical competence • Supervision

32. Phases • Pre-interaction/ Pre-orientation • Introductory/ Orientation • Working • Termination

33. Interacting with Clients with Various Emotional State

34. When Interacting with an Anxious Client • Provide the client with simple, organized information in a structured format • Explain who you are and your role and purpose • Ask simple, concise questions. • Avoid becoming anxious like the client. • Do not hurry and decrease external stimuli.

35. When Interacting with an Angry Client • Approach the client in a calm, reassuring, in-control manner. • Allow him to ventilate feelings. However, if the client is out of control, do not argue with or touch the client. • Obtain help from other health care professionals as needed. • Avoid arguing and facilitate personal space so the client does not feel threatened or cornered.

36. When Interacting with a Depressed Client • Express interest in and understanding of the client and respond in a neutral manner. • Do not try to communicate in an upbeat encouraging manner. This will not help a depressed client.

37. When interacting with a Manipulative Client • Provide structure and set limits. • Differentiate between manipulation and a reasonable request. • If you are not sure whether you are being manipulated, obtain an objective opinion from other nursing colleagues.

38. When Interacting with a Seductive Client • Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors. • Encourage client to use more appropriate methods of coping in relating to others.

39. When Discussing Sensitive Issues • First be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client’s health and may need to be discussed with someone. • Ask simple questions in non-judgmental manner. • Allow time for ventilation of client’s feelings as needed. • If you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate, for example, to a pastoral counselor for spiritual concerns or other specialist as needed.

40. Transactional Analysis

41. Transactional analysis, commonly known as TA to its adherents, is an integrative approach to the theory of psychology and psychotherapy. Integrative because it has elements of psychoanalytic, humanist and cognitive approaches. It was developed by Canadian-born US psychiatrist Eric Berne during the late 1950s.

42. TA emphasizes a pragmatic approach, that is, it seeks to find "what works" in treating patients, and, where applicable, develop models to assist understanding of why certain treatments work. Thus, TA continually evolves.

43. The Ego-State(or Parent-Adult-Child, PAC) Model • At any given time, a person experiences and manifests their personality through a mixture of behaviours, thoughts and feelings. Typically, according to TA, there are three ego-states that people consistently use:

44. Parent ("exteropsyche") • a state in which people behave, feel, and think in response to an unconscious mimicking of how their parents (or other parental figures) acted, or how they interpreted their parent's actions. • For example, a person may shout at someone out of frustration because they learned from an influential figure in childhood the lesson that this seemed to be a way of relating that worked.

45. Characteristics • Sets limits • Gives advice • Disciplines • Guides • Protects • Makes rules • Teaches “how to” • Nurtures • Judges; criticizes

46. Adult ("neopsyche") • a state of the ego which is most like a computer processing information and making predictions absent of major emotions that cloud its operation. Learning to strengthen the Adult is a goal of TA. • While a person is in the Adult ego state, he/she is directed towards an objective appraisal of reality. • Assertive

47. Characteristics • Logical thought – decision making process • Reacts with autonomy, objectivity • Processes reality data • Helps us deal with the outside world safely • Regulates and mediates between the demands of the internal parent and child • Autonomous • Reality Oriented • Objective

48. Child ("archaeopsyche") • a state in which people behave, feel and think similarly to how they did in childhood. • For example, a person who receives a poor evaluation at work may respond by looking at the floor, and crying or pouting, as they used to when scolded as a child. Conversely, a person who receives a good evaluation may respond with a broad smile and a joyful gesture of thanks. The Child is the source of emotions, creation, recreation, spontaneity and intimacy.

49. Characteristics • Angry, rebellious • Frightened • Conforming (pleasing parent) OR • Loving, spontaneous, trusting, joyful, adventurous

50. Transaction The interaction between people and their respective selves within.