1. Therapeutic Relationships
Psychiatric Mental Health Nursing

2. Objectives
State the goals of the therapeutic nurse- patient relationship
Discuss the personal qualities a nurse needs to be an effective helper
Describe the nurse’s tasks and possible problems in the four phases of the relationship process
Analyze how the nurse can use verbal and non-verbal communication effectively in a therapeutic relationship

3. Objectives
Understand how self-awareness impacts the therapeutic relationship
Use the Jahari Window and the Values Clarification Process to gain increased self- awareness
Demonstrate increasing effectiveness in using therapeutic relationship skills to produce a therapeutic outcome

4. Defined
The therapeutic nurse-patient relationship is a mutual learning experience and a corrective emotional experience for the patient.
Based on: mutual respect; acceptance of sociocultural differences; and the humanity of the patient and nurse.

5. Personal Qualities of the Nurse
SELF ASSESSMENT
Psychological: knowledge of emotions, motivations, self-concept, & personality.
Physical: Knowledge of personal & general physiology (body sensation, body image, & physical potential).
Environmental: components such as socio- cultural, relationships to others, knowledge of relationship between humans & nature.
Philosophical component: sense of life having a meaning, including responsibility to the world & the ethics of behavior.

6. Jahari window Each quadrant describes one aspect of the self. 1
Known to self
And
Others 2
Known only To
others 3
To the self 4
Known neither to
Self nor
To others

7. Self disclosing
Self disclosing is the revealing to others important aspects of the self. It is considered a sign of personality health & a means of achieving a healthy personality.
CAUTIONARY NOTE regarding disclosure with patients - limits, boundaries, professional/therapeutic relationship

8. Values Clarification What is important to me?
Values: concepts that are formed as a result of life experiences with humans, culture, education, work, & leisure.
Values have both a positive and negative component (i.e., honesty vs dishonesty)
A nurse’s challenge is to provide care to persons with differing value systems than their own.

9. Values Clarification Process
Steps in the Process
Choosing
Freely
From alternatives
After thoughtful consideration of the consequences of each alternative
Prizing
Cherishing, being happy with the choice
Willing to affirm the choice publicly
Acting
Doing something with the choice
Repeatedly, in the same pattern of life

10. Exploration of Feelings
Feelings serve as important barometers for feedback about themselves & their relationships to others.
Being open to your feelings helps to understand how you are responding to patients and how you appear to patients.
Your feelings are valuable clues to the patient’s problems.

11. Serving as a Role Model
Nurse has an obligation to model adaptive & growth producing behavior.
It is not possible to separate one’s personal life from one’s professional life…a chaotic personal life results in a chaotic professional practice.
Compartmentalization is not possible in psychiatric nursing because this specialty is the therapeutic use of the self …the whole self…a self that is fulfilled, satisfied and meaningful.

12. Altruism Why do I want to help others?
Altruism is the concern for others.
Maintain a balance between the need to help others and the amount of satisfaction & fulfillment received from work.

13. Phases of the Relationship: Pre-orientation
Self assessment: first contact with patient
What am I feeling? Thinking? What bias or stereotype attitudes do I have about this population? Do I fear closeness, rejection, indifference? How do I feel when a person is rude, hostile or uncooperative? Do I need to feel important and keep patients dependent on me?
Gather Data
Planning first interaction with patient

14. Stages of the Relationship: Introductory or Orientation Phase
Find out why patient sought help
Establish a partnership
Agree on the nature of the problem
Set mutual goals
Establish a contract

15. Introductory phase-forming a contract
Discuss the issue of confidentiality at this time.
Tasks for the nurse are: establish a climate of trust; understanding, acceptance and open communication. Discuss mutually agreed upon specific goals that can be realistically accomplished in the time you have with patient.

16. Stages of the Relationship: Working Phase
Explore stressors
Promote the development of insight – link them to perceptions, thoughts, feelings, & actions.
Translate the insights into action & change in behavior.

17. Stages of the Relationship: Termination Phase
Difficult but most important phase of relationship- whether meeting is one time or many.
Summarize goals and objectives achieved
Discuss ways to incorporate what has been learned/achieved
Exchange memories
Identify future goals and plans

18. Facilitative communication
All communication takes place on two levels (verbal & non-verbal) which can serve to develop a relationship or block it.
Communication is the vehicle psychiatric nurses use to establish relationships with patients.
Communication is the means by which a psychiatric nurse influences the behavior of another.

19. Exchange of messages

20. Verbal communication Occurs through words, either spoken or written.
Not as effective in communicating feelings or subtle meanings between individuals.
A limitation is that words change meaning in different social and cultural groups and words change meaning over time.
Example: bread (the food); bread (can mean money).
Nurses need to be prepared to communicate effectively with a wide diverse population of individuals.

21. Non-verbal communication
Includes all relayed information not involving spoken or written words…including cues from the 5 senses. 55% of meaning is transmitted by body cues.
Non-verbal communication is often unconsciously motivated & is, therefore, more accurate in meaning.

22. Types of non-verbal (NV) communication
NV behaviors
Body
Facial expression
Eye expression
Voice
Observable autonomic responses (e.g., diaphoresis)
Physical characteristics

23. NV behaviors

24. Space
There are four zones of space in Western society:

25. TOUCH
Response to touch is influences by many factors: setting, cultural background, type of relationship, gender of persons, ages, & expectations.
Touch can be nurturing or threatening depending on the person’s experience with it.
TT & Reiki as means of therapy.

26. Interpretation of nv cues
Context
Sociocultural background
Check out the nv cue with the patient…by referring to the specific behavior observed & try to confirm its meaning with the person.

27. Therapeutic communication techniques
Preserve self-respect of both individuals
Communicate acceptance & understanding before giving advice or suggestions. (first listen to their story).
Techniques: listening, broad openings, restating, clarification, reflection, focusing, sharing perceptions, theme identification, silence, humor, informing, & suggesting.

28. Some suggestions & comments
Listening- practice keeping your mouth shut until the person stops talking. Don’t formulate a response until you hear the whole story. Listening itself is therapeutic. You do not have to have all the answers. Listening is a sign of deep respect. While listening, you should not be thinking about yourself.
Broad openings- allows the person to pick the topic most urgent in their minds.
Restating – is a repeating (in your words) of the main theme you are hearing in the person’s statements.

29. Clarification – given the verbal and non- verbal communication you observed in the exchange with the person…try to pull it together and make a statement that reflects what you have heard them say…and then ask, “Is this what you mean?”
Reflection –
refection of content is also called validation…it is the nurse letting the person know they are understood, using fewer words that express the essential ideas the person stated.
Reflection of feeling is a nurse’s response to the person’s feelings…intent is to increase awareness of feelings.

30. Focusing – helps the person expand on a topic, be specific, & clarify its meaning.
Sharing perceptions – involves asking the person to verify the nursing’s understanding of what the person is thinking or feeling.
Theme identification – underlying issues or problems experienced by the person that emerge repeatedly during a conversation.
Silence – “the pregnant pause” silence allows the person time to think & gain insights. Allow the person to break the silence. Maintain nv cues of interest when you use this.

31. Humor – it is a constructive coping behavior
Humor – it is a constructive coping behavior. It can provide insight by making conscious repressed issues. Humor’s use in a relationship depends on the nature of the relationship. See positive uses of humor (Stuart, p. 29, Box 2-6).
Be mindful of its negative effects: It can be inappropriate to the person’s values, or when it ridicules people or belittles others. If used inappropriately, it can be destructive and anxiety producing.

32. Informing – information giving is an essential role of nurses for health teaching or patient education. It is not the same as giving suggestions or advice.
Suggesting – presents alternative ideas to cope or solve problems. It can be negative if it reinforces a person’s dependency needs. Avoid the trap of being responsible for the person’s outcome…shift the responsibility to the person by allowing them to make their own choice of the options presented.

33. Take home concepts Therapeutic relationship Nurses use of self
Mutual learning
Corrective emotional experience for the patient
Occurs in stages
Nurses use of self
Self-awareness of personal attributes
Verbal and non-verbal communication