MENTAL HEALTH NURSING

UNIT V: THERAPEUTIC COMMUNICATION & IPR

TOPIC: PHASES OF THERAPEUTIC RELATIONSHIP
CONDITIONS ESSENTIAL TO DEVELOPMENT OF A
THERAPEUTIC
RELATIONSHIP

SUBMITTED TO
BY

SUBMITTED

DR. K LALITHA

NEETHU ROSE

PROFESSOR
Nsg

1ST YEAR Msc

NIMHANS
NIMHANSINTRODUCTION
A relationship is defined as a state of being related or a state of affinity between
two individuals. The nurse and patient interact with each other in the healthcare
system with the goal of assisting the patient to use personal resources to meet his
or her unique needs. In a therapeutic relationship nurse and patient work towards
the goal of assisting the patient to regain the inner resources to meet life challenges
and facilitate growth. The interaction is purposefully established, maintained and
carried out with the anticipated outcome of helping the patient gain new coping and
adaptation skills.
PHASES AND TASKS OF THERAPEUTIC RELATIONSHIP
Four phases of relationship process have been identified;
1.
2.
3.
4.

Pre interaction phase

Introductory or orientation phase
Working phase
Termination phase

PRE INTERACTION PHASE

This phase begins when the nurse is assigned to initiate a therapeutic relationship
and includes all that the nurse thinks, feels or does immediately prior to the first
interaction with the patient. The nurses initial task is one of self exploration. The
nurse may have misconceptions and prejudices about psychiatric patients and may
have feelings and fears common to all novices. Many nurses express feelings of
inadequacy and fear of hurting or exploiting the patient. Another common fear of
nurses is related to the stereotyped psychiatric patients abusive and violent
behavior.
The nurse should also explore feelings of inferiority, insecurity, approval seeking
behavior etc. This self- analysis is necessary task because to be effective she should
have a reasonably stable self concept and an adequate amount of self esteem.
NURSES TASK IN PRE INTERACTION PHASE
Explore own feelings, fantasies and fears
Analyze own professional strengths and limitations
Gather data about patient whenever possible
Plan for first meeting with patient
PROBLEMS ENCOUNTERED
DIFFICULTY IN SELF ANALYSIS AND SELF ACCEPTANCE

Promoting a patients self realization and self acceptance is facilitated by the nurses
acceptance of herself and behaving in ways congruent with her own personality.
Also the nurse should have enough sources of satisfaction and security in her non
professional life to avoid the temptations or using her patient for the pursuit of her
personal satisfaction or security. If she does not have sufficient personal fulfillment
she should realize it so that it does not interfere with the success of therapeutic
relationship.
ANXIETY
Quite frequently the nurse may experience anxiety of varying intensity during pre
interaction phase due to role threat, feeling of incompetence, fear of being hurt or
of causing distress, fear of losing control and fear of rejection. The nurse need to
become aware of what is being experienced, identify the threats and decide what
needs to be done about it. This is important so that the patient is not unduly
affected by the nurses anxiety.
Apart from anxiety nurse may also experience boredom, anger, indifference
and depression. The cause of such feelings must be identified, which is the
first step in devising ways to cope with them.
WAYS TO OVERCOME

The nurse needs help from her supervisor and peers in self analysis and
facing reality in order to help patients do likewise. This provides an
opportunity to explore feelings and fears and develop useful insight into ones
professional role.
It is also helpful to conceptualize in advance what she wishes to accomplish
during the relationship. The nurse may in consultation with her supervisor
identify in writing goals for the initial interaction and decide the methods to
be used in achieving the goals.
The nurse also needs to be consciously aware of the reasons for choosing a
particular patient. She may also attempt to assess the nurse who is able to
analyze herself and recognize her assets and limitations, is able to use this
information in relating to patients in a natural, congruent and relaxed
manner.

INTRODUCTORY OR ORIENTATION PHASE

It is during this phase that the nurse and patient meet for the first time. One of the
nurses primary concerns is to find out why the patient sought help. This forms the
basis of the nursing assessment and helps the nurse to focus on the patients
problem and to determine patients level of motivation.
NURSES TASK IN THE ORIENTATION PHASE

Establish rapport, trust and acceptance

Establish communication; assist in the verbal expression of thoughts and
feelings.
Gather data including patients feelings, strengths and weaknesses.
Define patients problems; set priorities for nursing intervention.
Mutually set goals.

PROBLEMS ENCOUNTERED
The major problem encountered during this phase is related to the manner in
which the nurse and patient perceive each other. A nurse may react to a
patient not in terms of her uniqueness but in terms of the nurses stereotyped
view of a psychiatric patient, or she may, because of her theoretical
background, read in terms of diagnostic categories. Sometimes the nurse
may relate to a patient as if he were a significant individual from the past.
The nurse may then displace the feelings she has for the significant
individual. Since interaction is a reciprocal process, the patient also perceives
the nurse in his own idiosyncratic manner. Thus perception of each other as
unique individuals may not take place.
Problems related to establishing an agreement or pact between the nurse
and patient:
The patient may feel that since the nurse is here only for a few weeks much
help cannot be expected from her in the short span of time. The same
feelings may be experienced by the nurse, in that she feels she cannot do
much for the patient during his stay in the hospital due to factors like limited
time, overwork or the nurses opinion that the patient is suffering from a
major psychiatric problem. Because the establishment of an agreement or
pact to work together is a mutual process, such misperceptions can greatly
hinder it.
WAYS TO OVERCOME

The nurse must be willing to relate honestly to her perceptions, thoughts

and feelings and to share the data collected during the nurse patient
interaction with her supervisors. The supervisor must provide an
atmosphere in which the nurse feels free to reveal self without any fear of
criticism.

Difficulties may be faced in assisting a nurse who experience counter

transference. She is usually not aware of doing so, since most of this

behavior is unconsciously determined. An alert supervisor can detect this

problem most easily. It may be necessary to bring this problem to the
nurses attention so that she can examine her behavior. Gradually with
assistance the nurse is able to audit her behavior and then change it.
WORKING PHASE
Most of the therapeutic work is carried out during the working phase. The
nurse and the patient explore relevant stressors and promote the development of
insight in the patient. By linking perceptions, thoughts, feelings and actions the
nurse helps the patient to master anxieties, increase independence and coping
mechanisms. Actual behavioral change is the focus of attention in this phase of
relationship.
NURSES TASK IN THE WORKING PHASE

Gather further data; explore relevant stressors

Promote patients development of insight and use of constructive coping
mechanisms
Facilitate behavioral change; encourage him to evaluate the results of his
behavior
Provide him with opportunities for independent functioning
Evaluate problems and goals and redefine as necessary
PROBLEMS ENCOUNTERED

TESTING OF THE NURSE BY THE PATIENT: the patient may test the nurse in a
number of ways and for a number of reasons. For example he may wish to
check her ability to set limits and abide by them. A patient with problems
related to aggression may deliberately attempt to provoke the nurse to
determine whether or not she will become punitive.
PROGRESS OF THE PATIENT: it is common for the patient to show desirable
behavioral changes in the beginning and then remain fixed. A nurse who was
enthusiastic about the patients improvement may then become discouraged
when he does not progress at a steady state.
THE NURSES FEAR OF CLOSENESS: if the nurse fears closeness too much she
may react by being indifferent, rejecting or being cold towards the patient.
LIFE STRESSES OF THE NURSE: a nurse who has difficulty in coping with her
own life problems cannot help a patient in making appropriate behavioral
changes.
RESISTANCE BEHAVIORS: it is the patients attempt to remain unaware of
anxiety producing aspects within him. According to Wolfberg, different forms of
resistance are;
- Suppression and repression of relevant information
- Intensification of symptoms
- A helpless outlook on the future

Breaking appointments
Acting out or irrational behavior
Expressing an excessive liking for the nurse and claiming that nobody can
replace her
- Reporting physical symptoms which may occur only during the time the
patient is with the nurse
- Hostility, dependence, provocative remark, and sexual interest in the nurse.
TRANSFERENCE AND COUNTER TRANSFERENCE REACTIONS
WAYS TO OVERCOME

Conferences with the supervisors and group discussions with other members
of the staff helps the nurse to increase her ability to collect and interpret
data, apply concepts and synthesize the data obtained.
Seek emotional support from the supervisor when she feels no progress in
gaining knowledge or helping the patient.
Handling resistance: the first thing to do is to listen. When she recognizes
resistance, she uses clarification and reflection of feelings; clarification helps
the nurse a more focused idea of what is happening while reflection of
content helps the patient to become aware of what has been going on his
own mind.
It is not sufficient to merely identify that resistance is occurring; the behavior
must be explored and possible reasons for its occurrence analyzed. Ignoring
transference can perpetuate the pattern. Also being overly critical of the
patient, withholding information or being over involved in making decisions
for the patient can encourage the dysfunctional behavioral pattern. It is
important that the nurse maintains an open communication with her
supervisor who can then guide her in making adequate progress in handling
such resistance reactions.
TERMINATION PHASE
This is the most difficult but most important phase of therapeutic nurse
patient relationship. Goal of this phase is to bring a therapeutic end to the
relationship.
CRITERIA
FOR
TERMINATION

DETERMINING

PATIENTS

READINESS

FOR

Patient experiences relief from presenting problems

Patients social function has improved and isolation has decreased
Patients ego functions are strengthened and he has attained a sense
of identity
Patient employs more effective and productive defense mechanisms
Patient has achieved the planned treatment goals

NURSES TASK

Establish reality of separation

Mutually explore feelings of rejection, loss, sadness, anger and related
behavior
Review progress of therapy and attainment of goals
Formulate plans for meeting future therapy needs

PROBLEMS ENCOUNTERED

Patients may perceive termination as desertion and may demonstrate

angry behavior
Some patients attempt to punish the nurse for this desertion by not
talking during the last few interactions or by ignoring termination
completely; they may act as if nothing has changed and the
interactions will go on as before.
Other patients react to the threatened loss by becoming depressed or
assuming an attitude of not caring.
Fault- finding is another behavior; the patient may state that the
therapy is not beneficial or not working; he may refuse to follow
through on something that has been agreed upon before.
Resistance often comes in the form of flight to health which is
exhibited by a patient who suddenly declares that there is no need for
therapy; he claims to be all right and wants to discontinue the
therapeutic relationship; this may be a form of denial or fear of the
anticipated grief over separation.
flight to illness occurs when a patient exhibit sudden return of
symptoms; this is an unconscious effort to show that termination is
inappropriate and that the nurse is still needed; the patient may
disclose new information about him or more problems or even threaten
to commit suicide in an attempt to delay parting.
The barriers to goal accomplishment during this phase also seem to be
related to the nurses inability or unwillingness to make specific plans
and implement them. Plans for termination are essential and the nurse
needs to conceptualize these plans in advance. A nurse who does not
discuss frankly the reasons for termination or elicit from the patient his
thoughts and feelings about the impending termination cannot help to
prepare him psychologically. Similarly a nurse who cannot explore her
own thoughts and feelings about separation from the patient is also
unable to accomplish the goals related to termination.

WAYS TO OVERCOME

The nurse should be aware of the patients feelings and be able to deal
with them appropriately. The nurse can assist the patient by openly

eliciting his thoughts and feelings about termination. For some patients
termination is a critical experience because many of their past
relationships were terminated in a negative way that left them with
unresolved feelings of abandonment, rejection, hurt and anger. Learning
to bear the sorrow of the loss while incorporating positive aspects of the
relationship into ones life is the goal of termination in the therapeutic
nurse patient relationship.
During this phase, the supervisor may notice that the nurse is showing
less interest in the patient than shown earlier and may be disengaging
self from the patient several days before the final interaction. This may
be a psychological defense mechanism by which she tries to decrease or
delay anxiety she is experiencing as a result of the impending
termination of relationship. The task of the supervisor is to discuss
frankly with the nurse the meaning of the behavior. The supervisor then
initiates action to assist the nurse to persevere and intensify her efforts
to prepare both self and patient for his eventual release from the
hospital.

COMPONENTS OF NURSE- PATIENT RELATIONSHIP

RAPPORT
It is a relationship or communication especially when useful and harmonious. It is
the crux of relationship between the nurse and the patient. It is

A willingness to become involved with another person.

Growth towards mutual acceptance and understanding of individuality.
The end result of ones care and concern for another.

The nurse establishes rapport through demonstration of understanding, warmth and

non- judgmental attitude. A skilled nurse will be able to establish rapport that will
alleviate the patients problems. When rapport develops the patient feels
comfortable with the nurse and finds it easier to self- disclose. The nurse also feels
comfortable and recognizes that an interpersonal bond or alliance is developing.
EMPATHY
Empathy is an ability to feel with the patient while retaining the ability to critically
analyze the situation. It is the ability to put oneself in another persons
circumstances and feelings. The nurse need not necessarily have to experience it,
but has to be able to imagine the feelings associated with the experience.
In empathy process the nurse receives information from the patient with an open,
non judgemental acceptance, and communicates this understanding of the
experience and feelings so that the patient feels understood. This serves as a basis
for the relationship.

Sympathy is often confused with empathy. In sympathy, the nurse actually feels
what the patient feels but in the process objectivity is lost, and the nurse becomes
focused on relief of personal distress rather than on assisting the patient to resolve
the problem. With empathy while understanding the patients thoughts and feelings
the nurse is able to maintain sufficient objectivity to allow the patient to achieve
problem resolution with minimal assistance.
WARMTH
Warmth is the ability to help the patient feel cared for and comfortable. It shows
acceptance of the patient as a unique individual. It shows acceptance of the patient
as a unique individual. It involves a non- possessive caring for the patient as a
person and a willingness to share the patients joys and sorrows.
GENUINENESS
Genuineness involves being ones own self. This implies that the nurse is aware of
her thoughts, feelings, values and their relevance in the immediate interaction with
a patient. The nurses response to the patient is sincere and reflects her internal
response. It is also important that the nurses verbal and non-verbal communication
corresponds with each other.
CONCLUSION
In a therapeutic relationship the nurse and patient work together towards the goal
of assisting the patient work together towards the goal of assisting the patient to
regain the inner resources to meet life challenges and facilitate growth. The
interaction is purposefully established, maintained and carried out with the
anticipated outcome of helping the patient gain new coping and adaptation skills.
REFERENCE

1. Sreevani R. A Guide to Mental Health & Psychiatric Nursing. 3 rd edition. Jaypee brothers
medical publishers(p) ltd;2010
2. Townsend C Mary. Essentials of Psychiatric Mental Health Nursing. 4 th edition. Davis
Plus Publishers (p) ltd;2008
3.

Peplau, Hildegard E. Interpersonal Relations in Nursing. New York: G.P. Putnam's Sons,
1952. Interpersonal Theory in Nursing Practice: Selected Works of Hildegard E. Peplau.
New York: Springer Publishing Company, 1989.

4.

Arnold, E., & Underman-Boggs, K. (2011). Interpersonal Relationships: Professional

Communication Skills for Nurses (sixth edition). St.Louis, Missouri: Elsevier Saunders

5. Therapeutic Nurse-Client Relationship, Revised 2006. (1 March 1999). 1 June 2009,

Retrieved from http://www.cno.org/Global/docs/prac/41033_Therapeutic.pdf