• A therapeutic relationship – is a relationship in which the nurse & client participate with the goal of assisting the client to meet his needs & facilitate growth.
• The development of a therapeutic relationship enables the nurse to join in a partnership with the client to set goals for solving problems.
• Nursing behaviors that indicate caring include:

- Giving of self (you the nurse).

- Providing comfort measures for the patient & family.

• Social relationships – are the MOST COMMON – here equally involved parties are concerned with meeting their own needs. This relationship has no predetermined goal or focus & continuation is not determined at the onset.
• Intimate relationships – are between two individual that are committed to each other; care & respect each another. This type of relationship forms the basis for marriage & other partner-type relationships.
• Therapeutic relationships – an example being – in which the nurse & patient work together toward a goal to regain inner resources & promote growth.
• It is anticipated that the outcome of helping will result in the patient gaining new coping & adaptation skills.
• The therapeutic relationship assists the patient to assume personal responsibility for the initiation of change, which empowers the patient to believe change can be made – relieving feelings of hopelessness & increasing personal confidence.

• Nurses view patients as who they are & who they have the potential to be.
• Each contact with any patient has the potential for being therapeutic, promoting interpersonal growth, for changing behavior, or some benefit.
• Communication should be carefully planned & implemented so patients feel protected, accepted & attempt communication.

• Introductory Phase – Is the initial contact between the patient & nurse. Acknowledge patient by name & introduce yourself (this shows interest).
• This is the time to demonstrate acceptance of behavior, establish rapport & establish trust.
• The nurse’s commitment may be tested by "acting out" of the patient.
• The nurse informs the patient when desired goals are beyond the nurses realm of expertise or the duration of the interaction. Failure to do so would interfere with trust being established.
• Therapy begins when the nurse & patient progress beyond exchanging information & the client begins to share subjective content underlying behavior.
• Before moving to the next phase, the nurse & patient should evaluate/assess the initial stage by asking such questions as:
• Has security & trust been established? Do they feel safe?
• Has the patient verbalized thoughts & feeling?
• Have areas of inadequate stress adaptation been identified?
• Have strengths & weakness been identified?
• Are the goals of the relationship defined?
• Middle or Working Phase – Here the patient & nurse are actively involved in meeting goals.
• The nurse encourages expression of feelings & attempts at new adaptation approaches without danger of punitive treatment & reinforces effective problem solving.
• Nurses should avoid "over helping", controlling (asserting authority or assuming control) or narcissistic (needing to find weakness or helplessness in patients).
• At this point patients are likely to feel more secure & openly discuss topics that could not be discussed previously.

• Tasks of the working phase include:
• Increasing the patient’s awareness & perception of reality related to specific personal experience.
• Develop a realistic self-concept & promote self-confidence.
• Recognize areas of discomfort & verbalize feelings.
• Compare ineffective behavior inside & outside the relationship, & draw conclusions regarding these comparisons.
• Develop a plan of action, implement the plan & evaluate the results of the plan to alter the patient’s behavior.
• Assess the patient’s readiness & provide chances for independent functioning.
• Termination Phase – This is bound by time restrictions established during the initial phase – remind the patient of this.
• The termination of the relationship may be a traumatic event for the client – if the patient feels rejected & insecure at this time regression may occur (teach families that patients may have periods in which they seem worse – these periods can be expected).
• Assist in socialization with others to encourage independence.
• It is helpful to focus on the following for termination:
• Space contacts – begin to decrease the amount of time with each contact.
• Establish more relaxed, less intense interactions.
• Focus on the future.
• Discourage cues that lead to new areas of exploration.
• Provide necessary referral to others on the health care team.

• During the working phase – the nurse & patient assess the data, plan an action & begin to evaluate the action.
• The termination phase – allows for further evaluation.

• The nurses should focus on the caring model instead of the cure model.
• The focus of care is supporting the patients own healing resources.
• The nurse must constantly reevaluate her/his feelings, thoughts & behaviors in the relationship.

• Patient’s are free to verbalize needs, fears & anxieties in a

therapeutic relationship.

• Nurses urge patients to evaluate adaptive patterns & consequences of defensive behaviors.
• Patients receive positive feedback – and through this experience growth & increased self-esteem.
• Encourage use of these healthier behaviors in interactions outside the relationship.
• The goal is independence for the patient.
• Family is a significant part of the treatment process.

• The nurse must provide hope for the patient to lead a productive life.
• Regardless of a patients present level of adaptation – growth is usually possible.
• The nurse must absolutely accept – not just tolerate the patient.

• An important objective is to – provide patients with the opportunity to recognize the needs that their behaviors meet and to develop more effective inner resources.
• The nurse’s behavior and approaches provide feedback to patients about the appropriateness of their behavior – which needs to consistent (you are a role model).
• The nurse provides emotional support by helping the patient pay attention to their feelings, link their feelings to troublesome behaviors and explore alternative behaviors.

• The most basic and important therapeutic tool is the nurse’s personality.

• The nurse’s commitment to caring is essential.
• Caring distinguishes nursing from other professions.
• Providing therapeutic use of self, identifying and responding to the patient’s needs, and providing basic comfort measures all demonstrate caring.

• Anxiety – is a reaction or apprehension unrelated to any specific object but always occurring as a result of interpersonal process.
• Anxiety – is felt by both the nurse and the patient – the solution to this is to add structure.
• There are four types of anxiety – mild, moderate, severe and panic.
• Nurses should seek out opportunities to help patients learn to trust. Basic example: If you say you’re going to something – do it.
• Components of trust include: honesty (which goes hand in hand with trust), giving accurate information, verbal and nonverbal behavior that must be consistent, giving patients opportunities to be responsible (so when they leave the facility they can problem solve).
• Patients seeking care have not learned how to express aggression appropriately – teach them to express anger in small doses – and not to save up for an explosion – teach them to handle aggression with words.
• Humor – has its place but can be inappropriate at times.
• Be careful about whispering and laughing around mental patients – they may think you are talking about them.
• Be congruent or genuine, which means that your feelings, thoughts and behaviors are consistent – know yourself, be aware of your feelings and free from misleading behaviors. Patients are often incongruent, that is they are unaware that their feelings, thoughts and accompanying behaviors do not fit. In other words their expressed feeling may not match what they really feel or think.