Contemporary Therapeutic Relationship for a Professional Practitioner - Essay Example

Contemporary Therapeutic Relationship for a Professional Practitioner Introduction The therapeutic alliance between the nurse and the client assumes utmost significance in mental healthcare setting as the patients are greatly in need of personal counseling, guidance and care. Nurses should have professional knowledge and skills to establish effective therapeutic relationships with the clients and they should specially be trained in displaying caring attitudes and behaviors towards the clients. The ultimate aim of the therapeutic alliance is the physical and mental well-being of the clients and as such the therapeutic relationship should be “based on trust, respect, empathy and professional intimacy, and requires appropriate use of the power inherent in the care provider’s role” (College of Nurses of Ontario, 2009, p. 3). The five components of effective nurse-client relationships have been identified as “trust, respect, professional intimacy, empathy and power” (College of Nurses of Ontario, 2009, p. 3). Nurses who work as catalytic agents of change should have good interpersonal skills and a thorough knowledge regarding the dynamics of the therapeutic relationship. While maintaining effective and healthy therapeutic alliances they should also be able to maintain professional boundaries distinguishing their personal or social relationships from that of the therapeutic relationships. Patients or clients in the mental healthcare are more likely to suffer from feelings of alienation, isolation and seclusion. Similarly, they come across many crises, troubles, doubts, difficulties, frustrations or concerns in their lives which cannot be tackled without the assistance of a competent therapist or counselor. It is a fact that many of these patients in the mental healthcare do not receive any such positive support or care from their family members or relatives. As such, it is imperative that the nurses offer them ‘unconditional positive regard, accurate empathy, and genuineness’ which are very much essential for the therapeutic relationship and its progress (Egan, 2010, p. 36). It is also important that the negative attitudes and behavior patterns of the clients are addressed at the earliest and that they are assisted to convert these into positive attitudes and behaviors. In a therapeutic relationship, the values, thoughts, and feelings of the nurses interact with those of the clients and therefore it is very much essential that the nurses maintain professional boundaries and stick to the ethical guidelines of professional nursing practice. This paper seeks to explore the significance of maintaining effective and meaningful therapeutic relationships in mental healthcare setting. Literature Review Critical analysis Many researchers and psychologists have pointed out the importance of therapeutic relationships in mental healthcare. Researchers such as Elder, Evans and Nizette (2009, p. 2) regard developing therapeutic relationships as the key to effective mental health nursing and for them therapeutic alliances are very much necessary for the growth and recovery of patients in the mental healthcare. The authors also highlight the need to maintain professional boundaries during the therapeutic alliance. Similarly, they also hold that mental health nurses should have a thorough knowledge of not only human and biological sciences; they also be trained to develop effective therapeutic relationships with the patients. The importance of the nurse’s therapeutic use of self has been well-documented in the literature. Effective therapeutic alliance between the nurse and the mental health client involves healthy interpersonal processes whereby the nurses make use of their skills and knowledge for achieving therapeutic goals. According to Elder, Evans and Nizette (2009, p. 4), “therapeutic use of self involves using aspects of the nurse’s personality, background, life skills and knowledge to develop a connection with a person who has a mental health problem or illness.” However, nurses’ willingness to make use of their selves for the therapeutic purpose should stem out of genuine interest and understanding rather from the burden of professional responsibility or compulsion from an external agency. It is a great relief to the mental health patients that they are listened to in an effective manner and this may help them to come out of the shackles of seclusion, alienation and isolation. Therefore, it is imperative that mental health nurses are specially trained in the process of using self therapeutically. Through appropriate dialogue and constant interaction nurses should develop a thorough understanding of the current situation (which includes their physical and mental health) of the clients. Effective self-disclosure, genuine sharing and meaningful interaction from the part of the clients occur only when they realize that the nurses have ‘genuine interest, concern and desire’ to understand them and that the nurses have empathetic concerns towards them (Elder, Evans & Nizette, 2009, p. 5). Mutual respect, recognition, feelings of reciprocity and connectedness, and the ability to empathize with the clients are significant indicators of the therapeutic use of the mental health nurses’ selves. It has also been pointed out by researchers that the nurses should transcend their own selves to move towards the individual selves of their clients. This is very well suggested by Stein-Parbury when the author postulates that in professional therapeutic relationships, “the nurse’s focus of concern is away from self and towards the other-the patient” and that the nurses should always display genuine interest in the distressing experiences of the patients (Stein-Parbury, 2009, p. 28). It is also significant that the nurses relate their theoretical understandings with the actual experiences, belief systems, socio-cultural backgrounds, thought processes and inner feelings of the clients. Client empowerment is a major objective of the therapeutic alliance between the nurses and clients. The nurses have to teach clients to own self-responsibility for their actions and behaviors and effective client empowerment calls for mutual respect, empathetic feelings, and unbiased attitudes from the part of the nurses. Similarly, the nurse-counselor also has a great role in boosting self-awareness among the clients. As pointed out by Egan (2010, p. 47) “the client’s inductive understanding of self and the world are more important than the helper’s deductive understandings (from theory, research, and practice) about the client.” Therefore, it is essential that the clients are trained to indulge in an ongoing introspection regarding their own frustrations, concerns, fears, confusion, mistakes, obstacles and views of life. The significance of empowerment and participation in the therapeutic alliance between the patient and the nurse has also been pointed out by researchers such as Elder, Evans and Nizette. According to them, empowerment and client participation go hand in hand as true empowerment would take place only when the clients actively participate in the therapeutic process and take responsibility for their health. The clients are privileged to have meaningful interactions with the healthcare providers apart from having access to universal healthcare and resources. Active participation also means that the patients are no longer passive recipients of care but are active participants in the therapeutic process. As pointed out by Elder, Evans and Nizette (2009, p. 27) participation suggests “the shift in practice from people being viewed as passive recipients of ‘expert’ care, to people being viewed as active participants and directors of their care based on their self-identified needs” (Elder, Evans & Nizette, 2009, p. 27). The nurse-therapists can empower the patients by promoting their self-awareness, by helping them to identify their own needs and by training them to own responsibilities for their actions. The counseling role of the nurse: The counseling role of the nurses has assumed special significance in mental healthcare as the patients in acute psychiatric units or mental healthcare are more vulnerable towards frustrations, mental break downs and complications. Effective counseling necessitates considerable amount of interpersonal skills from the nurses apart from having strong therapeutic skills and professional knowledge. Similarly, building rapport and trust with the patient is equally significant in the therapeutic alliance (McQueen 2000). There are many researchers who have argued that the interpersonal relationships between patients and nurses have humanized healthcare and that the nurse’s knowledge regarding the experiences, feelings and socio-cultural backgrounds of the clients are added advantages to the healthcare professionals in the therapeutic alliance (Stein-Parbury, 2009).The author also argues that in therapeutic relationships the nurses show their ‘concern, care and commitment’ and offer the patients “knowledgeable assistance and direct aid, as well as interpersonal support and comfort” (Stein-Parbury, 2009, p. 26). The patients in mental healthcare, in particular, are very much in need of this therapeutic and interpersonal support. A dedicated nurse can perform the counseling role either through personalized individual counseling or through group counseling of patients with similar issues or problems. With the emergence of holistic approaches to health nurse’s role as counselor and therapist has considerably been increased. Nurses thus need to develop trusting relationships with the clients need to convince their clients that they understand the patients’ suffering and “are aware of their unvoiced needs, provide comfort without actually being asked, and are reliable, proficient, competent and dedicated in their care” (Mok & Chiu, 2004, p. 475). Besides, the nurse therapist or counselor should possess professional expertise and should also be willing to assist the needy patents. It is also necessary for the nurse therapists to follow the ethical guidelines and to ensure the confidentiality of each of the clients. Theoretical perspectives in counseling and their application in therapeutic practices The significance of therapeutic alliance in mental healthcare can be traced back to the theoretical advancements in nursing theories and the shift from dualistic health approaches to holistic healthcare. While dualism regarded body and mind as two separate entities and paid attention to only symptoms and deficits in the functioning of the body “holistic practices within nursing has as its main goal the healing of the whole person, recognizing the importance of the interrelationships between biological, psychological, social and spiritual aspects of the individual” (Elder, Evans & Nizette, 2009, p. 18). Holistic approaches to healthcare make it clear that the patient’s social needs cannot be separated from the treatment and therefore holistic healthcare exhorts the healthcare professionals to pay attention to all aspects of the individual consisting of the patient’s physical, psychological and mental well-being. As part of the holistic healthcare the nurses have a pivotal role in identifying the patient’s “relationships with themselves, others, society, and their citizenship within the great cultural context of the community” and the basic principles that underline such therapeutic alliance between the client and patient “include trust, hope, respect for individual freedom and allowing people to exercise their rights as citizens” (Elder, Evans & Nizette, 2009, p. 18). Thus, from a holistic healthcare point of view, therapeutic relationship between the healthcare professionals and the nurses are significant in treating patients who suffer from psychiatric or mental problems. Similarly, there have been many studies that proved that mere physical care was not sufficient for treating patients in the mental care. Among them, Peplau (1952) stressed on the need for effective nurse–patient relationship in healthcare. For Peplau nursing practice should consist of four distinct phases: orientation, identification, exploitation and resolution (1952, p. 475). The specific therapeutic relationship, for her, comes to an end only with the resolution of the issues. Similarly, one can also notice that theoretical advancements in healthcare have replaced the term ‘patient’ with that of ‘consumer.’ It is thus evident that in modern healthcare the customer (patient) is entitled to certain rights to receive quality healthcare services. According to researchers such as Elder, Evans and Nizette (2009, p. 21) the patients who are viewed as consumers play a more active role in healthcare as they are citizens who possess “rights, responsibility and a more equitable relationship with the care provider.” This change from ‘patient’ to ‘customer’ has revolutionized the provision of quality healthcare as well. In the same way, the theoretical formulations of cognitive behavioral theorists and psychoanalytical theorists have offered new insights to the therapeutic relationship between the clients and the nurses. For instance, Freud regarded empathy as a significant factor essential to build up therapeutic alliance and rapport with his clients whereby he could know the mind of the patient (Bohart & Greenberg, 1997). In the same way, Carl Rogers’ client-centered approach, Carl Rogers also highlighted the significance of empathy, positive regard, unconditional treatment and congruence between the patient and the therapist as essential in bringing about desirable therapeutic changes among the patients (Rogers, 195). The two types of therapeutic alliances propagated by Luborksy (1976) also deserve attention in this regard. In his Type I alliance, Luborksy stresses the warmth and genuineness offered by the therapist in a highly supportive and helpful environment and in Type II alliance the emphasis is on the accomplishment of the therapeutic goals (Luborksy 1976). One can also find theoretical insights for therapeutic alliance in Bordin’s three components of alliance namely patient-therapist agreement on treatment goals, patient-therapist agreement on tasks to achieve the goals, and the development of an affective bond between the patient and therapist (Bordin 1976). All these theoretical formulations have offered new dimensions to the therapeutic practices in mental healthcare. There are a number of factors that facilitate or contribute towards effective counseling and strong therapeutic intimacy. According to Stein-Parbury (2009, p. 32) therapeutic intimacy in mental healthcare “is characterized by a high degree of openness and self-disclosure, accompanied by an expectation of acceptance and understanding.” The author goes on to argue that the extent of self-disclosure, the skills of listening, understanding and exploring, and a client centered approach are also essential to effective therapeutic relationship in the healthcare setting. Therapeutic alliance, to be effective, should be client centered; it should be individualized and context specific; rather than being merely task-oriented the therapist should always try to understand things from the clients’ perspectives as well. Therapeutic superficiality leads to therapeutic intimacy in effective and healthy therapeutic alliances. The levels of nurse involvement and the degree to which they should maintain professional boundaries are also significant. While mutual involvement and mutual trust are significant indicators of effective therapeutic relationship nurses should take special efforts not to cross their professional boundaries. In this respect, Elder, Evans and Nizette (2009, p. 6) point out that maintaining professional boundaries is essential in “all areas of healthcare, but in mental health nursing they have an increased importance due to the nature of the work of mental health nurses and the vulnerability of the client population” (Elder, Evans & Nizette, 2009, p. 6). However, the patient-nurse relationship in a therapeutic alliance should never be one-sided. On the other hand, the nature of the relationship should be reciprocal: “reciprocity and mutuality are essential to establishing the human connection needed for a therapeutic patient-nurse relationship (Stein-Parbury, 2009, p. 33). It is also worthwhile to analyze the goals as well as the behaviors that contribute towards therapeutic alliance in mental healthcare. Therapeutic communication differs from personal individual communication as the former is goal-oriented and addresses specific aspects of the client’s mental and physical well-being. As rightly suggested by White (2005, pp. 114-115) the communication that takes place in a therapeutic alliance is “purposeful and goal directed, creating beneficial outcome for the client” and the “focus of the conversation is the client, the client’s problems, or the client’s needs, not the problems or needs of the nurse.” Thus, it can be seen that the therapeutic relationship is completely aimed at the benefit and well-being of the clients and the nurses are supposed to remain as catalytic agents who initiate desirable changes among the patients. In order to create healthy and meaningful therapeutic relations with the clients the nurses have to develop trust and confidence among the clients so that they can completely be frank and open with the nurses. The nurses should make use of their professional knowledge and expertise to bring about or cultivate positive behaviors among the clients. The positive behaviors or attitudes that would contribute towards effective therapeutic alliance include “warmth, active listening, caring, genuineness, empathy, acceptance and respect, and self-disclosure” (White, 2005, p. 115). While caring forms the basis of effective therapeutic relationship it is significant that the nurses accept and understand the values and beliefs of the clients which can be quite different from theirs. This has been pointed out by Elder, Evans and Nizette (2009, p. 6) when the authors postulated that “nurses need to be aware of the belief systems and values that arise from their [the patients’] cultural, social and family backgrounds.” From the part of the mental health nurses it is essential that they indulge in meaningful reflection whereby they can “examine both their practice (actions) and the accompanying cognitions (thoughts) and affective meanings (feelings) in relation to values, biases and knowledge and in relation to the context in which the situation occurred” (Elder, Evans & Nizette, 2009, p. 6). The nurses can also disclose or share their own experiences to the clients without overburdening them with a view to boost their morale and confidence. However, the nurses come across a number of tense situations in their day to day life and therapeutic relationships may enhance the inner stress of nurses. It is therefore important that the mental health nurses are trained to monitor and manage their own stress. Conclusions To conclude, it can be stated that effective therapeutic relationship is an essential prerequisite as far as mental healthcare is concerned. While nurses have to continuously interact with the clients as part of their professional responsibilities it is imperative that they get ample time to indulge in healthy therapeutic relationships with the nurses so that they can evaluate, plan, and execute their counseling roles to perfection. However, it is a fact that very often the hectic job schedule prevents the nurses from exercising their counseling and therapeutic roles. As pointed out by Nelson and Gordon (2006, p. 37) “the limited time with the patients jeopardized the therapeutic relationships through which nurses gather, exchange, and act on relevant information about their patients” (Nelson & Gordon, 2006, pp. 37-38). Therefore, it is necessary that the work schedule of nurses who work in the mental healthcare units are restructured so as to offer them sufficient time to develop healthy therapeutic relationship with the clients. It can also be seen that effective therapeutic alliance is a two way reciprocal relationship between the client and the nurse counselor that is completely aimed at the well-being of the patients. Therefore, the relationship needs to be based on professionalism, caring, mutuality, and empathy. It can also be seen that nurses in acute psychiatric and mental healthcare settings have a greater responsibility to assist the vulnerable patients who are in greater need of therapeutic alliance and for this it is imperative that they possess the necessary therapeutic knowledge and skills. References Bohart, A. C. & Greenberg, L. S. (1997). Empathy: Where are we and where do we go from here? In A. C. Bohart & L. S. Greenberg (Eds.), Empathy Reconsidered: New directions in psychotherapy (pp. 419-450). Washington, DC: American Psychological Association. Bordin, E. S. (1994). Theory and research on the therapeutic working alliance: New directions. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research and practice (pp. 13-37). New York: John Wiley & Sons, Inc. College of Nurses of Ontario. (2009). Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006. Retrieved 15 July 2012, from http://www.cno.org/Global/docs/prac/41033_Therapeutic.pdf Egan, G. (2010). The skilled helper - a problem-management and opportunity-development approach to helping (9th edn.). Australia: Brooks/Cole. Elder, R., Evans, K. & Nizette, D. (2009). Psychiatric and mental health nursing. (2nd edn.). Sydney: Mosby/Elsevier. Luborsky, L. (1976). Helping alliances in psychotherapy. In J. L. Cleghorn (Ed.), Successful psychotherapy (pp. 92-116). New York: Brunner/Mazel. McQueen A. 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