copyright © 2014 wolters kluwer health | lippincott williams & wilkins chapter 5 therapeutic...
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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 5
Therapeutic Relationships
Chapter 5
Therapeutic Relationships
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Therapeutic RelationshipTherapeutic Relationship
• One of the most important skills a nurse can develop
• Crucial to success of interventions with clients requiring psychiatric care
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Components of Therapeutic RelationshipComponents of Therapeutic Relationship
• Trust – Behaviors such as caring, interest, understanding,
consistency, honesty, promise keeping, listening (see Box 5.1)
– Congruence is essential.
• Genuine interest – Self-comfort, self-awareness of strengths and
limitations, clear focus
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Components of Therapeutic Relationship (cont.)Components of Therapeutic Relationship (cont.)
• Empathy– Putting oneself in client’s shoes
• Client and nurse giving “gift of self”
– Different from sympathy (feelings of concern or compassion; focus shifting to nurse’s feelings)
• Acceptance (no judgments; set boundaries)
• Positive regard (unconditional nonjudgmental attitude)
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Self-AwarenessSelf-Awareness
• Know self– Values (sense of right and wrong, code of conduct for
living)• Values clarification
• Choosing• Prizing• Acting
– Beliefs– Attitudes (see Boxes 5.2 and 5.3)
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QuestionQuestion
• Is the following statement true or false?
• A nurse displays empathy by showing feelings of concern and compassion.
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AnswerAnswer
• False
• Rationale: Empathy is putting oneself into the client’s shoes.
– Sympathy is showing feelings of concern and compassion.
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Therapeutic Use of SelfTherapeutic Use of Self
• Use of aspects of personality, experience, values, feelings, intelligence, needs, coping skills, perceptions to establish relationships beneficial to clients
– Concept developed by H. Peplau
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Therapeutic Use of Self (cont.)Therapeutic Use of Self (cont.)
• Johari window: tool to learn about oneself
– 4 quadrants: open/public self; blind/unaware self; hidden/private self; unknown
– Goal: move qualities from quadrants 2, 3, 4 into quadrant 1
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Therapeutic Use of Self (cont.)Therapeutic Use of Self (cont.)
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Patterns of KnowingPatterns of Knowing
• Ways of observing, understanding client interactions
• Four patterns (Carper, 1978; see Table 5.1)– Empirical (derived from nursing science)
– Personal (from life experiences)
– Ethical (from moral nursing knowledge)
– Aesthetic (from art of nursing)
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Patterns of Knowing (cont.)Patterns of Knowing (cont.)
• Fifth pattern : unknowing (Munhall, 1993)
– Nurse admits lack of knowledge of client or understanding of client’s subjective world
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Types of RelationshipsTypes of Relationships
• Social– Purpose of friendship, socialization, companionship,
or task accomplishment– Superficial communication; shifting roles; outcomes
rarely assessed
• Intimate– Emotional commitment of two persons– Individual needs met; assistance with helping each
other meet needs
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Types of Relationships (cont.)Types of Relationships (cont.)
• Therapeutic
– Focus on needs, experiences, feelings, ideas of client only
– Use of communication skills, personal strengths, understanding of human behavior by nurse
– Joint agreement on areas to work on; outcome evaluation
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QuestionQuestion
• Is the following statement true or false?
• A social relationship involves superficial communication for the purposes of friendship or task accomplishment.
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AnswerAnswer
• True
• Rationale: A social relationship occurs for friendship, socialization, companionship or task achievement. It involves superficial communication with shifting roles.
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Establishing a Therapeutic RelationshipEstablishing a Therapeutic Relationship
• Peplau’s model of three phases
– Orientation
– Working
– Termination (see Table 5.3)
• Overlapping, interlocking of phases
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Establishing a Therapeutic Relationship: Orientation PhaseEstablishing a Therapeutic Relationship: Orientation Phase• Meeting nurse, client
• Establishment of roles
• Discussion of purposes, parameters of future meetings
• Clarification of expectations
• Identification of client’s problems
• Nurse–client contracts/confidentiality, duty to warn/self-disclosure
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Establishing a Therapeutic Relationship: Working PhaseEstablishing a Therapeutic Relationship: Working Phase
• Problem identification: issues or concerns identified by client; examination of client’s feelings and responses
• Exploitation: examination of feelings and responses; development of better coping skills, more positive self-image, behavior change, independence
• Possible transference/countertransference
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Establishing a Therapeutic Relationship: Termination PhaseEstablishing a Therapeutic Relationship: Termination Phase
• Begins when client’s problems are resolved
• Ends when relationship is ended
• Deals with feelings of anger or abandonment that may occur; client may feel termination as impending loss
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Behaviors Diminishing Therapeutic RelationshipsBehaviors Diminishing Therapeutic Relationships
• Inappropriate boundaries (relationship becomes social or intimate)
• Feelings of sympathy, encouraging client dependency
• Nonacceptance of client, avoidance (see Box 5.4)
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QuestionQuestion
• During the working phase of a nurse–client relationship, which of the following would occur?
– A. Expectations are clarified.
– B. Nurse–client contracts are established.
– C. Feelings of loss are addressed.
– D. Client feelings are examined.
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AnswerAnswer
• D. Client’s feelings are examined.
• Rationale: During the working phase, the client identifies issues or concerns, and his or her feelings and responses are examined.
– Expectations are clarified, and contracts are established during the orientation phase. Feelings of loss are addressed during the termination phase.
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Therapeutic Roles of the Nurse in a RelationshipTherapeutic Roles of the Nurse in a Relationship
• Teacher (coping, problem solving, medication regimen, community resources)
• Caregiver (therapeutic relationship, physical care)
• Advocate (ensuring privacy and dignity, informed consent, access to services, safety from abuse and exploitation)
• Parent surrogate (see Box 5.5)
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Self-Awareness IssuesSelf-Awareness Issues
• Nurse’s self-awareness: crucial to developing therapeutic relationships
• Helpful activities: values clarification, journaling, group discussions, reading
• Development of self-awareness: continual, ongoing process