therapeutic impasse and its managements
TRANSCRIPT
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