Enhancing Therapeutic Relationships: Boundaries, Phases, and Cultural Influences

1. Chapter 7 Therapeutic Relationships and the Clinical Interview

2. Nurse-patient relationship • Basis of all psychiatric treatment • Establish an understanding that the nurse is safe, confidential, reliable, consistent, and the relationship is conducted within appropriate and clear boundaries • Creative process unique to each nurse • Therapeutic use of self -Scientifically substantiated as an evidence –based intervention -Takes time

3. Therapeutic vs other types of relationships • Goals of therapeutic relationship -Facilitating -Assisting -Helping -Promoting • Relationship -Interpersonal process that involves 2 or more people -Types • Social • Therapeutic Accountability, focus on patient’s needs, clinical competence, delaying judgment, supervision

4. Establishing relationship boundaries • Allows the establishment of clear patient boundaries that provide safe space through which the patient can explore feelings and treatment issues • Warning signals of blurred boundaries -Overhelping, controlling, narcissism • Transference -When a person unconsciously displaces (transfers) onto individuals in their current life, those patterns of behavior that originated in relation to significant figures in childhood • Countertransference -Tendency of nurse to displace onto patient feelings related to people in nurse’s past

5. Phases of nurse-patient relationship • Preorientation Phase -Prior to 1st meeting, the nurse may have thoughts and feelings related to the 1st clinical session • Orientation Phase -1st time that nurse and patient meet -Initial interview occurs -Establish rapport -Parameters of the relationship -Formal or informal contract -Confidentiality -Termination

6. Phases of nurse-patient relationship • Working Phase -Allows patient to experience increased levels of anxiety and demonstrate dysfunctional behaviors in safe setting while trying out new and more adaptive coping behaviors • Termination Phase -Final phase of the nurse-patient relationship -May occur when the patient is discharged

7. Enhancing the nurse-patient relationship • Consistency -Same pt assignment • Pacing -Let pt set pace • Listening -Let the pt talk when needed • Initial Impressions -Positive initial attitudes and preconceptions • Comfort and control -Promoting pt comfort and balance • Patient factors -Establishing trust and pts active participation

8. Factors that enhance growth • Genuiness -Self awareness of ones feelings as they arise within relationship and ability to communicate • Empathy -Understanding the feelings of others • Sympathy -Feeling the feelings of others • Positive Regard -Attitudes -Actions

9. The clinical interview • Patient leads the interview -Nurse provides opportunity for pt to reach specific goals • Preparing for Interview -Setting -Seating • Introductions -Conveys respect -Gives pt direct control • Initiating Interview -Use open ended questions -Use statements of acceptance

10. Attending behaviors: the foundation of interviewing • Key principles of counseling -Attending behaviors -Listening well • Eye contact -Variation depending on cultural background • Body Language -Kinesics: body movements and posture -Proxemics: personal space • Vocal qualities -Paralinguistics; loudness, pitch, rate, fluency • Verbal Tracking -Tracking what patient is saying

11. Clinical supervision and process recording • Clinical Supervision -Focus is on nurses behavior in the nurse-patient relationship -Review clinical interactions exactly as they occur • Process Recordings -Written record of segment of nurse-patient session that reflect as closely as possible the verbal and nonverbal behaviors of the nurse and the patient

12. Cultural influences and the therapeutic relationship Cultural background has a great deal to do with what nonverbal behavior means to different individuals Degree of eye contact and use of touch are two nonverbal aspects that can be misunderstood by individuals of different cultures A meaningful therapeutic relationship is facilitated when values and cultural influences are considered. Necessary to understand the patients perceptions