Importance of Therapeutic Relationships in Mental Healthcare - Essay Example

? Development of a publishable paper Topic: Importance of therapeutic relationships in mental healthcare: Nurses’ perceptions and experiences Background The therapeutic alliance between the nurse and the client assumes utmost significance in the mental healthcare setting as the patients are greatly in need of personal counseling, guidance and care. Nurses need to have professional knowledge and skills to establish effective therapeutic relationships with the clients and they should be specially 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 therefore it is significant to know nurses’ perceptions and actual experiences on therapeutic relationships with the clients. Methods A qualitative research methodology is employed for the purpose of the study. The common themes in the literature on the therapeutic relationships between the nurses and clients are identified. The study was administered on a sample target group (who were screened based on their experiences of having worked in mental healthcare) of nurses who work in the psychiatric and mental health care hospitals in and around Melbourne in Victoria Australia. A preliminary mailed questionnaire was used to eliminate nurses with no prior experiences in mental healthcare. A telephonic interview was also administered on these respondents to know their willingness to take part in the sample survey. Thus, the participants for the survey consisted of 40 nurses who worked in and around Melbourne in Victoria Australia with at least two years of working in mental healthcare. The questionnaire comprised of 8 interrelated questions most of which were open ended. Results and Conclusions The results of the study confirmed the common themes identified in the literature review. While therapeutic relationships have been identified as very much significant by the participant nurses they expressed their concern over the inadequacy of ongoing staff training, the heavy work schedule and the problems associated with maintaining professional boundaries. The respondents regarded mutual trust, empathy, confidentiality and non-judgment, feelings of reciprocity and connectedness, and acceptance and understanding as the key factors of effective therapeutic alliance whereas respect, communication and interpersonal skills, and professional knowledge were complementary. On the other hand, the major crippling factors (that prevent effective therapeutic alliance with patients) identified by the respondents consisted of mistrust, breach of confidentiality, ego, lack of communication and interpersonal skills, and lack of professional knowledge. Introduction and Background The therapeutic alliance between the nurse and the client assumes utmost significance in the mental healthcare setting as the patients are greatly in need of personal counseling, guidance and care. Nurses need to have professional knowledge and skills to establish effective therapeutic relationships with the clients and they should be specially 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 needs to have good communication as well as interpersonal skills and a thorough knowledge regarding the dynamics of the therapeutic relationship (McQueen 2000). It is also significant that the nurses are able to build rapport and trust with the patients (McQueen 2000), show trust and commitment (Morse 1991), and ensure confidentiality and non-judgmental attitude (Dexter & Wash 1995) in the therapeutic process. On the other hand, mistrust, manipulation and struggle for control pose threats to effective therapeutic relationships (Ramjan, 2004). While maintaining effective and healthy therapeutic alliances they need to maintain professional boundaries distinguishing their personal or social relationships from that of the therapeutic relationships. Patients or clients in the mental healthcare system are more likely than other patients to suffer from feelings of alienation, isolation and seclusion (Ernst & Cacioppo, 1999). 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. Very often, many of these patients in the mental healthcare system 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 by reviewing and critiquing the relevant literature. Many authors (Nichols, 1993; Elder, Evans and Nizette, 2009) have pointed out the importance of therapeutic relationships in mental healthcare. For Nichols (1993), nurses and healthcare professionals in acute care settings are better equipped to establish therapeutic alliances with patients due to the increased need for physical, psychological and emotional care for their clients. In this regard, 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 need to 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 seclusion, alienation and isolation (Ernst & Cacioppo, 1999). 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 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 (2009, p. 28) 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. It is also significant that the nurses relate their understanding of the therapeutic alliance 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 Elder, Evans and Nizette (2009). 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. Maintaining professional boundaries and withdrawing from therapeutic relationships at the right time are the two key challenges before the nurses. The therapeutic relationship, according to McKlindon and Barnsteiner (1999, p. 238), needs to be ‘caring, clear, boundaried, positive and professional.’ As such, professional nurses need to maintain their therapeutic relationships within clearly defined professional boundaries. In this respect, it is worthwhile to analyze the guidelines on professional boundaries suggested by the Nurses Association of New Brunswick (2011). The association holds the nurses “responsible and accountable for establishing and maintaining boundaries in the therapeutic nurse-client relationship;” as part of their professionalism the nurses are to keep themselves away from personal relationships that do not contribute towards the patients’ health and well being; help the clients realize when their requests are beyond the limits of the therapeutic nurse-client relationship; take conscious efforts to move out of the therapeutic relations once the therapeutic goals are achieved; and they should never compromise when the clients try to cross therapeutic boundaries (Nurses Association of New Brunswick, 2011). Violations of professional boundaries within the therapeutic alliance take place ‘when the client’s needs are no longer the focus of the therapeutic relationship’ (College of registered Nurses of Manitoba, 2012). Therefore, an effective and healthy therapeutic relationship presupposes clearly understood professional ethics and well-defined professional boundaries. 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 (McQueen, 2000; Stein-Parbury, 2009). Effective counseling necessitates a 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). Stein-Parbury (2009), in this respect, argues 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. 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 making the clients aware 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 understand the patient’s needs. 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 relationships 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 (Peplau, 1952; Elder, Evans and Nizette 2009) that strongly suggest 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 (1952, p. 475), nursing practice should consist of four distinct phases: orientation, identification, exploitation and resolution. 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 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 who was a psychoanalyst 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 (p. 195), while explaining his client-centered approach, emphasizes 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 (1976) 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 and had a positive impact on clients and their well-being. 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 needs to be reciprocal rather than being one-sided. For Stein-Parbury (2009, p. 33), reciprocity and mutuality stand at the centre of the therapeutic relationship: “reciprocity and mutuality are essential to establishing the human connection needed for a therapeutic patient-nurse relationship.” 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 whereas the latter is quite personal and lacks any predetermined goals. 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 need to make use of their professional knowledge and expertise to bring about or cultivate desirable 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 overburden them. It is therefore important that the mental health nurses are trained to monitor and manage their own stress. Methodology A qualitative research methodology is employed for the purpose of the study. The common themes in the literature governing the therapeutic relationships between the nurses and clients are identified. This study seeks to explore the nurses’ experiences and perceptions regarding the therapeutic process and for this a case study was conducted among selected nurses from Melbourne area in Victoria Australia. Participants and sample size The study was administered on a sample target group (who were screened based on their experiences of having worked in mental healthcare via carefully designed mailed questionnaire) of nurses who work in the psychiatric and mental health care hospitals in and around Melbourne in Victoria Australia. A preliminary mailed questionnaire was used to eliminate nurses with no prior experiences in mental healthcare. The participants of the study belonged to the leading hospitals from Melbourne in Victoria Australia. A list of all the nurses who worked in these hospitals was obtained and a preliminary mailed questionnaire was sent to them. The questionnaire elicited such details as their designation, age, gender, years of experience, receipt of any prior staff training with regard to therapeutic alliance, and their experience of having worked in mental healthcare. The respondents who did not have any prior experiences in mental healthcare were eliminated from the study. Similarly, all those respondents who did not have at last two years of experience were also eliminated. However, respondents of all ages were included in the study sampling. A telephonic interview was also administered on these respondents to know their willingness to take part in the sample survey. Thus, the participants for the survey consisted of 40 nurses who worked in and around Melbourne in Victoria Australia with at least two years of working in mental healthcare. Questionnaire Design The questionnaire was aimed at collecting qualitative data from the participant nurses on their perceptions and experiences regarding therapeutic relationship with the clients. The questionnaire comprised of 8 interrelated questions. Most of the questions are open ended allowing the participants to share their perceptions and experiences on therapeutic relationships quite freely. Similarly, most of them carry sub questions as well so as to guide the respondents in the right track. The first four questions in the questionnaire are aimed at testing the perceptions of the nurses’ regarding the therapeutic process whereas the next four questions are aimed at reviewing the therapeutic process in accordance with the actual experiences of the participant nurses. Data collection and analysis As already mentioned, the preliminary mailed questionnaire was used to eliminate all those who did not meet the inclusion criteria mentioned in the previous section. Similarly, the telephonic interview was administered on these respondents to know their willingness to respond to the survey questionnaire. The survey questionnaire tested both the perceptions as well as the actual experiences of the nurses regarding their therapeutic relationships with the clients. The data analysis for this paper consists of a) analyzing the perceptions of the participants regarding the therapeutic alliance, and) analyzing their actual experiences with regard to the therapeutic experiences with the clients. The qualitative data on the contributing factors of effective therapeutic process, maintaining professional boundaries, and withdrawing the therapeutic support are also coded separately using thematic analysis of the collected qualitative data. Discussion and analysis The literature on therapeutic alliance between the healthcare professionals and the clients throw light on such aspects as the contributing factors for effective therapeutic practices, the factors that prevent meaningful therapeutic alliances and deals with such aspects as professional intimacy, professional boundaries and withdrawal of the therapeutic support. The literature also emphasizes on the need for staff training on how to build up effective therapeutic alliances. Similarly, the therapeutic process involves professional knowledge or skills (Evans and Nizette, 2009), ‘unconditional positive regard, accurate empathy, and genuineness’(Egan, 2010, p. 36), the counseling ability for personalized individual counseling or group counseling, mutual trust (McQueen, 2000; Morse, 1991; McQueen, 2000), respect and empathy (Elder, Evans and Nizette, 2009; Bohart & Greenberg, 1997), professional intimacy (College of Nurses of Ontario, 2009), communication and interpersonal skills, knowledge regarding the dynamics of therapeutic relationships, confidentiality and non-judgmental attitude (Dexter & Wash, 1995), maintaining professional boundaries (McKlindon and Barnsteiner, 1999; Nurses Association of New Brunswick, 2011; College of registered Nurses of Manitoba, 2012), feelings of reciprocity and connectedness (Elder, Evans and Nizette, 2009), and acceptance, understanding, and high degree of openness (Stein-Parbury, 2009) from the part of the nurses. In the same way, the literature also makes it clear that the therapeutic relationship needs to be purposeful and goal directed (White, 2005) and withdrawal of therapeutic alliance takes place wit the attainment of the therapeutic goals. The literature also throws light on the crippling factors that prevent effective therapeutic alliance with patients which consist of mistrust, manipulation and struggle for control (Ramjan, 2004). Keeping these common themes in the literature the current study seeks to understand the perceptions as well as the actual experience of the nurses in mental healthcare. Nurses’ perceptions on the therapeutic relationship As already mentioned, the first four questions in the questionnaire are related to nurses’ perceptions on the therapeutic process. All the 40 participants of the study unanimously agreed that therapeutic relationships are very much significant in mental healthcare. In the same way, all the participants were of the opinion that effective staff training on how to build up effective therapeutic alliances with the patients was also essential. However, almost 50 percent of the nurses pointed out the inadequacy of ongoing staff training in this regard. There were a large variety of answers with regard to the professional knowledge or skills essential for a nurse to create meaningful therapeutic relationship with the clients (see question 3 in the questionnaire). While all of them stressed on the need to build up rapport and trust with the patients, the other factors pointed out by the respondents included professional intimacy (75%), respect and empathy towards the clients (70 %), professional knowledge and skills (60%), confidentiality (50%) and communication and interpersonal skills (50%). There were also respondents who mentioned such factors as counseling abilities, professional boundaries, understanding and acceptance. On the other hand, the major crippling factors (that prevent effective therapeutic alliance with patients) identified by the respondents consisted of mistrust, breach of confidentiality, ego, lack of communication and interpersonal skills, and lack of professional knowledge. Nurses’ experiences on the therapeutic relationship The participants of the study agreed that a certain amount of counseling skills were essential for the nurses in the therapeutic process. Most of the respondents (90%) were aware of personalized individual and group counseling techniques. However, majority of the participants (almost 85%) confessed that their heavy work schedule often do not permit them for effective therapeutic relationships, personalized individual counseling or group counseling with the clients. This has been identified as a key problem by the nurses. When the participants were asked to arrange the predictors or factors leading to effective therapeutic relationships in the order of their preference majority of the nurses preferred trust, empathy, confidentiality and non-judgment, feelings of reciprocity and connectedness, and acceptance and understanding to other factors as respect, communication and interpersonal skills, professional knowledge etc. Maintaining professional boundaries in therapeutic alliance also has been identified as a significant factor by the respondents. However, a large majority (70%) agreed that maintaining professional boundaries and withdrawing from therapeutic relationships are not so easy in the case of many clients especially with regard to the adolescents. Limitations One of the major drawbacks of the present study is that the results of the study cannot be applied to a larger population as the study sample is competitively low. Similarly, as the participants belonged to different mental healthcare units in and around Melbourne in Victoria Australia it was not possible for the researcher to have a one to one interaction with all the participants. The findings of the study are to be proved with a large scale research that would take into account a larger population and a variety of other factors contributing towards therapeutic alliance. Results and conclusions The results of the study confirmed the common themes identified in the literature review. While therapeutic relationships have been identified as very much significant by the participant nurses they expressed their concern over the inadequacy of ongoing staff training, the heavy work schedule and the problems associated with maintaining professional boundaries. The respondents regarded mutual trust, empathy, confidentiality and non-judgment, feelings of reciprocity and connectedness, and acceptance and understanding as the key factors of effective therapeutic alliance whereas respect, communication and interpersonal skills, and professional knowledge were complementary. On the other hand, the major crippling factors (that prevent effective therapeutic alliance with patients) identified by the respondents consisted of mistrust, breach of confidentiality, ego, lack of communication and interpersonal skills, and lack of professional knowledge. 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 establish therapeutic relationships with the clients so that they can evaluate, plan, and execute their counseling roles to perfection. However, the hectic job schedule often 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.” 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 College of registered Nurses of Manitoba. Professional boundaries for therapeutic relationships. Retrieved 26 September 2012, from http://cms.tng-secure.com/file_download.php?fFile_id=144 Dexter G. & Wash M. (1995) Psychiatric Nursing Skills: A Patient- Centred Approach. Chapman & Hall, London. 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. Ernst, J.M & Cacioppo, J.T. (1999). Lonely hearts: psychological perspectives on loneliness. Applied & Preventive Psychology, 8, 1-22. Luborsky, L. (1976). Helping alliances in psychotherapy. In J. L. Cleghorn (Ed.), Successful psychotherapy (pp. 92-116). New York: Brunner/Mazel. McKlindon D. & Barnsteiner J. (1999) Therapeutic relationships: evolution of the children’s hospital of Philadelphia model. The American Journal of Maternal/Child Nursing 24, 237–243. McQueen A. (2000) Nurse–patient relationships and partnership in hospital care. Journal of Clinical Nursing 9, 723–731. Mok, E & Chiu, P.C. (2004). Nurse–patient relationships in palliative care. Journal of Advanced Nursing, 48(5), 475–483. Morse J.M. (1991) Negotiating commitment and involvement in the nurse–patient relationship. Journal of Advanced Nursing 16, 455– 468. Nelson, S., & Gordon, S. (Eds.). (2006). The complexities of care: Nursing reconsidered. New York: Cornell University Press. Nichols K.A. (1993). Psychological Care in Physical Illness (2nd edn). Chapman & Hall, London. 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Appendix Appendix 1: Questionnaire on nurses’ perceptions and experiences regarding therapeutic relationship with the clients 1. Do you think therapeutic relationships are significant in mental healthcare? 2. Have you received any staff training on how to build up effective therapeutic alliances with the patients? Were such trainings useful to you? 3. What professional knowledge or skills, in your opinion, are essential for a nurse to create meaningful therapeutic relationship with the clients? What measures do you undertake to create such therapeutic alliance with your clients? 4. In your view, what are the crippling factors that prevent effective therapeutic alliance with patients? 5. How do you fulfill the counseling role of the nurses? Does your work schedule permit you sufficient time for personalized individual counseling or group counseling with the clients? 6. Which of the following three, in your experience, are the most significant factors contributing towards effective therapeutic alliance? Arrange them in the order of preference. a) Trust b) Respect c) Empathy d) Professional intimacy e) Communication and interpersonal skills f) Knowledge regarding the dynamics of therapeutic relationships g) Confidentiality and non-judgment h) Maintaining professional boundaries i) Feelings of reciprocity and connectedness j) Client empowerment k) Acceptance and understanding l) Purposeful and goal-oriented relationship 7. What is your understanding of professional boundaries in therapeutic alliance? Are you able to maintain well-defined professional boundaries with the clients? Can you mention some of the difficulties you faced in maintaining professional boundaries? 8. Is it an easy process to withdraw from a therapeutic alliance and, in your opinion, when is the right time to withdraw from a therapeutic alliance? Read More