Therapeutic relationship - is a relationship that is established

between a health care professional and a client for the purpose of assisting the client to solve his problems. Components of a Therapeutic Relationship One of the most important skills of a nurse is developing the ability to establish a therapeutic relationship with clients. For interventions to be successful with clients in a psychiatric facility and in all nursing specialties it is crucial to build a therapeutic relationship. Crucial components are involved in establishing a therapeutic nurse-patient relationship and the communication within it which serves as the underpinning for treatment and success. It is essential for a nurse to know and understand these components as it explores the task that should be accomplish in a nurse-client relationship and the techniques that a nurse can utilize to do so. TRUST Without trust a nurse-client relationship would not be established and interventions wont be successful. For a client to develop trust, the nurse should exhibit the following behaviors:

Friendliness Caring Interest Understanding Consistency Treating the client as human being Suggesting without telling Approachability Listening Keeping promises Providing schedules of activities Honesty

GENUINE INTEREST

Another essential factor to build a therapeutic nurse-client relationship is showing a genuine interest to the client. For the nurse to do this, he or she should be open, honest and display a congruent behavior. Congruence only occurs when the nurses words matches with her actions. EMPATHY For a nurse to be successful in dealing with clients it is very essential that she empathize with the client. Empathy is the nurses ability to perceive the meanings and feelings of the client and communicate that understanding to the client. It is simply being able to put oneself in the clients shoes. However, it does not require that the nurse should have the same or exact experiences as of the patient. Empathy has been shown to positively influence client outcomes. When the nurse develops and utilizes this ability, clients tend to feel much better about themselves and more understood. Some people confuse empathizing with sympathizing. To establish a good nurse-patient relationship, the nurse should use empathy not sympathy. Sympathy is defined as the feelings of concern or compassion one shows for another. By sympathizing, the nurse projects his or her own concerns to the client, thus, inhibiting the clients expression of feelings. To better understand the difference between the two, lets take a look at the given example. Clients statement: I am so sad today. I just got the news that my father died yesterday. I should have been there, I feel so helpless. Nurses Sympathetic Response: I know how depressing that situation is. My father also died a month ago and until now I feel so sad every time I remember that incident. I know how bad that makes you feel.

Nurses Empathetic Response: I see you are sad. How can I help you? When the nurse expresses sympathy for the client, the nurses feelings of sadness or even pity could influence the relationship and hinders the nurses abilities to focus on the clients needs. The emphasis is shifted from the clients to the nurses feelings thereby hindering the nurses ability to approach the clients needs in an objective manner. In dealing with clients their interest should be the nurses greatest concern. Thus, empathizing with them is the best technique as it acknowledges the feelings of the client and at the same time it allows a client to talk and express his or her emotions. Here a bond can be established that serves as a foundation for the nurse-client relationship. ACCEPTANCE Clients are unpredictable. There are times that they outburst with anger or act out their inappropriate desires. A nurse, who does not judge the client or person no matter what his or her behavior, is showing acceptance. Acceptance does not mean accepting all the inappropriate behavior but rather acceptance of the person as worthy. When the client displays an improper behavior, the nurse can communicate with the client by being firm and clear without anger or judgment. In this way, the nurse allows the client to feel intact but at the same time aware that his certain behavior is unacceptable. Lets take a look at the given example. Situation: A client tries to kiss the nurse. Inappropriate response: What the hell are you doing?! Im leaving maybe Ill see you tomorrow. Appropriate response: Adam, do not kiss me. We are working on your relationship with your girlfriend and that does not require you to kiss me. Now let us continue. POSITIVE REGARD

Positive regard is an unconditional and nonjudgmental attitude where the nurse appreciates the client as a unique worthwhile human being that shows respect for the client regardless of his or her behavior background and lifestyle. The following ways are example of how to promote respect and positive regard to a client:

Calling the client by name Spending time with the client Listening to the client Responding to the client openly Considering the clients ideas and preferences when planning care

SELF-AWARENESS Self-awareness is the process of understanding ones own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths and limitations. Before a nurse can understand clients he or she should be able to understand him or herself. The first step in preparing oneself to build a therapeutic nurse-patient relationship is to understand oneself. THERAPEUTIC USE OF SELF A nurse can only use his or her personality, experiences, values, feelings, intelligence, needs, coping skills and perceptions to build a relationship with clients (therapeutic use of self) when he or she has developed self-awareness and self-understanding.
Therapeutic Technique

1. Offering Self

making self-available and showing interest and concern. I will walk with you

2. Active listening

paying close attention to what the patient is saying by observing both verbal and non-verbal cues. Maintaining eye contact and making verbal remarks to clarify and encourage further communication.

3. Exploring

Tell me more about your son

4. Giving broad openings

What do you want to talk about today?

5. Silence

Planned absence of verbal remarks to allow patient and nurse to think over what is being discussed and to say more.

6. Stating the observed

verbalizing what is observed in the patient to, for validation and to encourage discussion You sound angry

7. Encouraging comparisons

asking to describe similarities and differences among feelings, behaviors, and events. Can you tell me what makes you more comfortable, working by yourself or working as a member of a team?

8. Identifying themes

asking to identify recurring thoughts, feelings, and behaviors. When do you always feel the need to check the locks and doors?

9. Summarizing

reviewing the main points of discussions and making appropriate conclusions. During this meeting, we discussed about what you will do when you feel the urge to hurt your self again and this include

10. Placing the event in time or sequence

asking for relationship among events. When do you begin to experience this ticks? Before or after you entered grade school?

11. Voicing doubt

voicing uncertainty about the reality of patients statements, perceptions and conclusions. I find it hard to believe

12. Encouraging descriptions of perceptions

asking the patients to describe feelings, perceptions and views of their situations. What are these voices telling you to do?

13. Presenting reality or confronting

stating what is real and what is not without arguing with the patient. I know you hear these voices but I do not hear them. I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.

14. Seeking clarification

asking patient to restate, elaborate, or give examples of ideas or feelings to seek clarification of what is unclear. I am not familiar with your work, can you describe it further for me. I dont think I understand what you are saying.

15. Verbalizing the implied

rephrasing patients words to highlight an underlying message to clarify statements. Patient: I wont be bothering you anymore soon. Nurse: Are you thinking of killing yourself?

16. Reflecting

throwing back the patients statement in a form of question helps the patient identify feelings. Patient: I think I should leave now. Nurse: Do you think you should leave now?

17. Restating

repeating the exact words of patients to remind them of what they said and to let them know they are heard. Patient: I cant sleep. I stay awake all night. Nurse: You cant sleep at night?

18. General leads

using neutral expressions to encourage patients to continue talking. Go on You were saying

19. Asking question

using open-ended questions to achieve relevance and depth in discussion. How did you feel when the doctor told you that you are ready for discharge soon?

20. Empathy

recognizing and acknowledging patients feelings. Its hard to begin to live alone when you have been married for more than thirty years.

21. Focusing

pursuing a topic until its meaning or importance is clear. Let us talk more about your best friend in college You were saying

22. Interpreting

providing a view of the meaning or importance of something. Patient: I always take this towel wherever I go. Nurse: That towel must always be with you.

23. Encouraging evaluation

asking for patients views of the meaning or importance of something. What do you think led the court to commit you here? Can you tell me the reasons you dont want to be discharged?

24. Suggesting collaboration

offering to help patients solve problems. Perhaps you can discuss this with your children so they will know how you feel and what you want.

25. Encouraging goal setting

asking patient to decide on the type of change needed. What do you think about the things you have to change in your self?

26. Encouraging formulation of a plan of action

probing for step by step actions that will be needed. If you decide to leave home when your husband beat you again what will you do next?

27. Encouraging decisions

asking patients to make a choice among options. Given all these choices, what would you prefer to do.

28. Encouraging consideration of options

asking patients to consider the pros and cons of possible options. Have you thought of the possible effects of your decision to you and your family?

29. Giving information

providing information that will help patients make better choices. Nobody deserves to be beaten and there are people who can help and places to go when you do not feel safe at home anymore.

30. Limit setting

discouraging nonproductive feelings and behaviors, and encouraging productive ones. Please stop now. If you dont, I will ask you to leave the group and go to your room.

31. Supportive confrontation

acknowledging the difficulty in changing, but pushing for action. I understand. You feel rejected when your children sent you here but if you look at this way

32. Role playing

practicing behaviors for specific situations, both the nurse and patient play particular role. Ill play your mother, tell me exactly what would you say when we meet on Sunday.

33. Rehearsing

asking the patient for a verbal description of what will be said or done in a particular situation. Supposing you meet these people again, how would you respond to them when they ask you to join them for a drink?.

34. Feedback

pointing out specific behaviors and giving impressions of reactions. I see you combed your hair today.

35. Encouraging evaluation

asking patients to evaluate their actions and their outcomes. What did you feel after participating in the group therapy?.

36. Reinforcement

giving feedback on positive behaviors. Everyone was able to give their options when we talked one by one and each of waited patiently for our turn to speak.

Avoid pitfalls: 1. Giving advise 2. Talking about your self 3. Telling client is wrong 4. Entering into hallucinations and delusions of client 5. False reassurance 6. Clich 7. Giving approval 8. Asking WHY? 9. Changing subject 10. Defending doctors and other health team members.