THERAPEUTIC RELATIONSHIP

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.
1. Empathy

○ the nurse should be able to perceive

and experience the feelings of

the patient to be able to understand

the patient.

• Empathy is therapeutic but sympathy is not

therapeutic because sympathy is pity.

• Sympathy leads the patient to develop a “poor me” self

concept.
2. Genuineness

o this is manifested when the nurse is sincere and honest in her

relationship with the patient. Consistency conveys sincerity that in

turn foster the development of the patient’s trust. The nurse must
maintain an honest and open communication.
3. Concreteness and specificity
o this pertains to the nurse’s ability to identify the client’s feelings and make the

client be aware of them. Only when the nurse listens actively and
is sensitive enough can she help the patient to gain awareness and insight

regarding the latter’s feelings, thought and behaviors in relation to

situations and person’s to the patients life in the past and in the present.
4. Respect

o the nurse considers the patient, like any other

human being with dignity, to be deserving of high regard. This is manifested
 when the nurse does not belittle or judge the patient’s

feelings, verbalizations and behaviors.

o Respect is shown when the nurse realizes that several patients may have the
same diagnosis but their individuality sets them apart and different from each

other. As such, the nurse approach must be appropriate for each

patient. Respect can be shown by being consistent yet flexible when the
circumstance warrants being so.

*Transference – occurs when the client transfers conflict/ feelings

from the past to the nurse. Ex. Client becomes overly dependent to

the nurse because client may transfer the maternal longings to

the nurse.
* Counter-transference – when nurse responds to the client emotionally on a

personal level. When the nurse begins to react to the

patient personal level, often unaware of it and may lose her objectivity.

The nurse should discuss with the other members of the health team
any negative or strong feeling she has developed towards the client so she can be
helped to maintain her focus and perspective.
5. Immediacy of relationship

o this refers to the nurse’s ability to recognize her own feelings as

she deals and communicate with the patient. It also refers to the

ability to realize when it is appropriate to share them with the

patient.
6. Self-exploration

o it is necessary that the nurse makes the patient

realize the necessity of the patient exploring, identifying and

 understanding his own feelings and thought to be able to
understand himself better, and find appropriate solutions to his problems.
7. Self – disclosure

o the nurse willingness to share her own points of view in a

therapeutic manner can be an indication of genuineness, this

encourages the patient to become more open to the

nurse in return.
8. Confrontation
o patients sometimes behave inappropriately because they perceive the environment
unrealistically. It could also be due to excessive use of defense mechanisms.
These in appropriate behaviors and unrealistic perceptions can be corrected by

the nurse by pointing out the patient in a matter of

fact and non-judgmental manner, the inconsistencies and discrepancies in the

patients behaviors, perceptions, verbalizations and feelings.

The nurse also set limits on the patients behavior.

THERAPEUTIC AND NON-THERAPEUTIC COMMUNICATION

Quick Checklist for Effective Communication: (1) Open
ended questions (2) Focus on feelings (3) State behaviors
observed (4) Reflect, restate, rephrase verbalization of patient (5)
Neutral responses

Effective Communication: (1) Appropriate (2)

Simple (3) Adaptive (4) Concise (5) Credible
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 patient’s 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 don’t think I understand what you are saying”.
15. Verbalizing the implied
• rephrasing patient’s 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 patient’s 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 can’t sleep. I stay awake all night.
• Nurse: You can’t 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 patient’s feelings.

• “It’s 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 don’t 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 don’t, 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.
• “I’ll 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. Cliché

7. Giving approval
8. Asking WHY?
9. Changing subject
10. Defending doctors and other health team members.
Non-therapeutic Technique
1. Overloading
• talking rapidly, changing subjects too often, and asking for more information than can be
absorbed at one time.
 • “What’s your name? I see you like sports. Where do you live?”
2. Value Judgments

• giving one’s own opinion, evaluating, moralizing or implying one’s values

by using words such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”.
• “You shouldn’t do that, its wrong”.
3. Incongruence

• sending verbal and non-verbal messages that contradict one another.

• The nurse tells the patient “I’d like to spend time with you” and then
walks away.
4. Underloading
• remaining silent and unresponsive, not picking up cues, and failing to give feedback.

• The patient ask the nurse, simply walks away.

5. False reassurance/ agreement
• Using cliché to reassure client.
• “It’s going to be alright”.
6. Invalidation

• Ignoring or denying another’s presence, thought’s or feelings.

• Client: How are you?
• Nurse responds: I can’t talk now. I’m too busy.
7. Focusing on self
• responding in a way that focuses attention to the nurse instead of the client.
• “This sunshine is good for my roses. I have beautiful rose garden”.
8. Changing the subject
• introducing new topic
• inappropriately, a pattern that may indicate anxiety.
• The client is crying, when the nurse asks “How many children do you have?”
9. Giving advice
• telling the client what to do, giving opinions or making decisions for the client, implies
client cannot handle his or her own life decisions and that the nurse is accepting
responsibility.
• “If I were you… Or it would be better if you do it this way…”
10. Internal validation
 • making an assumption about the meaning of someone else’s behavior that is not validated
by the other person (jumping into conclusion).
• The nurse sees a suicidal clients smiling and tells another nurse the patient is in good
mood.
Other ineffective behaviors and responses:
1. Defending – Your doctor is very good.
2. Requesting an explanation – Why did you do that?
3. Reflecting – You are not suppose to talk like that!
4. Literal responses – If you feel empty then you should eat more.
5. Looking too busy.
6. Appearing uncomfortable in silence.
7. Being opinionated.
8. Avoiding sensitive topics
9. Arguing and telling the client is wrong
10. Having a closed posture-crossing arms on chest
11. Making false promises – I’ll make sure to call you when you get home.
12. Ignoring the patient – I can’t talk to you right now
13. Making sarcastic remarks
14. Laughing nervously
15. Showing disapproval – You should not do those things.
THERAPEUTIC COMMUNITY OR MILIEU THERAPY
by:Lhynnelli
Sullivan envisioned the goal of treatment as
the establishment of satisfying interpersonal
relationships. The therapist provides a
corrective interpersonal relationship for the
client. Sullivan coined the term participant
observer for the therapist’s role, meaning that
the therapist both participates in and observes
the progress of the relationship.
Credit is also given to Sullivan for the

developing the first

therapeutic community or
milieu therapy with young men with
schizophrenia in 1929 (although that term
was not used extensively until Maxwell Jones
published The Therapeutic Community in 1953). In the concept of therapeutic or
milieu therapy, the interaction among clients is seen as beneficial, and treatment
emphasizes the role of this client-to-client interaction. Until this time, it was believed that
the interaction between the client and psychiatrist was the one essential component to the
client’s treatment. Sullivan and later Jones observed that interactions among clients in

safe, therapeutic setting provided great benefits to clients. The concept of

milieu therapy, originally developed by Sullivan, involved clients’ interactions with one
another; i.e., practicing interpersonal relationship skills, giving one another feedback
about behavior, and working cooperatively as a group to solve day-to-day problems.

Milieu therapy was one of the primary modes of treatment in the acute
hospital setting. In today’s health care environment, however, inpatient hospital stays are
often too short for clients to develop meaningful relationships with one another.

Therefore the concept of milieu therapy receives little attention.

Management of the milieu or environment is still a primary role for the nurse in terms of
providing safety and protection for all the clients and promoting social interaction.