The therapeutic nurse-patient relationship is at the core of nursing practice. When established properly, the relationship contributes to a patient’s health and well-being. Show
For this reason, nurses are accountable for establishing and maintaining therapeutic relationships with their patients, including maintaining appropriate professional boundaries. It is also important to know that the relationship lasts as long as the patient needs nursing care. This means that no matter how short or long the time span, a therapeutic nurse-patient relationship is formed. To make sure the patient’s needs are prioritized, nurses must understand that the following five components are always present in a therapeutic nurse-patient relationship: Trust: Trust is critical to the therapeutic relationship. It may be fragile at first, and you need continual effort to maintain it. Respect: To respect is to recognize that every individual has inherent dignity, worth and uniqueness, regardless of socio-economic status, personal attributes and the nature of their health problem. Professional Intimacy: When nurses provide intimate care activities to their patients, such as bathing, it creates professional closeness. Professional intimacy can also involve being privy to psychological, spiritual and social elements that are identified in patients’ plans of care. Empathy: A nurse shows empathy by understanding, validating and confirming what the health care experience means to the patient. Nurses must ensure that they maintain appropriate emotional distance from the patient to ensure objectivity and an appropriate professional response. Power: The nurse-patient relationship is one of unequal power. The nurse has more authority and influence in the health care system, access to confidential information and the ability to advocate for the patient. If a nurse misuses this power, it is considered abuse. Nurses’ responsibility to establish and maintain the therapeutic nurse-patient relationship also includes maintaining proper boundaries. This means that nurses must not engage in any behaviour or activity that could be perceived as violating a boundary. Violating a boundary means a nurse is misusing their power and trust in the relationship to meet personal needs or is behaving in an unprofessional manner with the patient. Page 11 of the Therapeutic Nurse-Client Relationship practice standard has a decision tree which helps to determine whether an activity or behaviour is appropriate within the context of the nurse-patient relationship and meets a therapeutic purpose. For more information about nurses’ accountabilities to their patients, read the Code of Conduct. It is also important to be aware of the differences between professional and social relationships. Nurses must make sure they set appropriate boundaries that prevent a professional relationship from becoming a social one. For more information, read the Ask Practice FAQ: Professional versus social relationships. A solid therapeutic relationship is vital for clients to get the most out of therapy and remain in treatment (DeAngelis, 2019). It’s as powerful, if not more so, than the treatment chosen by the therapist (DeAngelis, 2019). Because we can use the quality of the therapeutic relationship to predict clinical outcomes, it’s essential to get the alliance right (Ardito & Rabellino, 2011). This article explores the skills and techniques that therapists need to build a healthy therapeutic alliance and successful outcome. Before you continue, we thought you might like to download our three Positive Psychology Exercises for free. These science-based exercises will explore fundamental aspects of positive psychology including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees. How to Establish a Healthy Therapeutic AllianceAll therapists require a depth of relating with their clients. In Cognitive-Behavioral Therapy (CBT), this may be described as a close relationship, while for person-centered and experiential therapy, it is considered core to the treatment (Knox & Cooper, 2015). Even though the therapeutic alliance may vary over the course of therapy, its quality impacts the successful outcome of treatment and, therefore, deserves special attention (Ardito & Rabellino, 2011). The degree to which the alliance is correlated with the therapeutic outcome is clear; its growth is linked to the successful resolution of ruptures, breaches, and repairs (Ardito & Rabellino, 2011). There are two clear phases in establishing a healthy therapeutic alliance (Ardito & Rabellino, 2011):
Early on in therapy, a rupture to the therapeutic relationship can affect commitment to the process, potentially leading to early termination. As long as it is repaired and resolved quickly, conflict may be positive and even necessary to a successful outcome (Ardito & Rabellino, 2011). So how do we establish a healthy therapeutic alliance? The therapist must begin the relationship by considering the therapeutic frame and boundaries they want to put in place (Knox & Cooper, 2015). “The therapeutic frame refers to the fixed elements of the therapeutic relationship that provide the context for the therapeutic work” (Knox & Cooper, 2015, p. 1). The boundaries define the rules and limits to the relationship from the outset and ensure a safe, supportive, and contained environment for work to take place. The setting in which counseling takes place is vital. While it will vary depending on the context in which the client is seen, points to consider include the following (Knox & Cooper, 2015):
Ultimately, the location should feel safe and secure, a place where the client can talk openly without being overheard or interrupted. If the therapy space is located within the therapist’s home, it is vital to consider the visibility of personal items and their potential impact. For example, family pictures may be upsetting if the client discusses losing a loved one (Knox & Cooper, 2015). The timing for the therapeutic work should be agreed upon and set early in the process. Consider the following questions with the client (modified from Knox & Cooper, 2015):
Clients need to become comfortable and familiar with the process, and knowing the time remaining in a session can influence the degree to which they open up.
Social media can bring other issues and challenges, and it is advisable to keep therapeutic relationships separate from social ones (Knox & Cooper, 2015). Putting in place the practices above and ensuring that the following softer components are addressed can lead to a healthier and more productive therapeutic alliance. Components of the Therapeutic RelationshipThere are several crucial factors and components to building and maintaining a therapeutic relationship.While not exhaustive, the following sections introduce key features of therapy that require focus and, often, ongoing attention.
Then, of course, feedback must be put into action, with therapists improving their skills, managing their mistakes, and trying new or alternative interventions (DeAngelis, 2019).
Such distancing behavior may result from a lack of trust or the client feeling judged or misunderstood. If the therapist senses the start of a breakdown or a strain in the relationship, they must not let it grow but clarify any issues and repair mistakes (Knox & Cooper, 2015).
Empathic listening requires that the counselor experience the client’s feelings as though they were their own; such active listening is more intense than typically found in our daily lives.
A strong, authentic therapeutic relationship can facilitate a positive and deep connection between the therapist and client that will benefit the treatment and outcome (Knox & Cooper, 2015). 2 Examples of a Supportive Therapeutic AllianceA supportive therapeutic alliance is crucial to client perseverance and a positive treatment outcome (Ardito & Rabellino, 2011). The following two examples taken from case reports provide examples of the results of healthy therapeutic relationships between the client and therapist. Psychodynamic therapyHaving been married for 29 years, ‘Wendy’ was shocked to be told by her husband that he wanted a divorce (Tamplin, 2014). Unable to cope with constant crying and feelings of extreme anxiousness, Wendy sought help. Wendy attended 18 therapy appointments over 8 months to help her cope. From the outset, her therapist, ‘C,’ encouraged Wendy to express her feelings as much and as often as possible regarding the sudden and drastic life changes. Wendy found support in the empathy and understanding that her relationship with C fostered (Tamplin, 2014). C asked Wendy to think of the things she had wanted but had previously sacrificed for the sake of her marriage. With the support of their alliance, Wendy ultimately found the courage to move forward and live her life as though her husband wasn’t returning. Obsessive-Compulsive Disorder‘Darcy’ and her psychologist, ‘Marian,’ had a particularly strong therapeutic alliance that got them through 12 years of treating Darcy for obsessive-compulsive disorder (Australian Institute of Professional Counsellors, 2013). Following decades of compulsive behavior that included elaborate prayer routines to keep everyone safe, Darcy had sought treatment. Marian felt and displayed enormous compassion for Darcy. She began by working with her to achieve emotional stability before starting a long-term process of changing her thinking habits. Over the years, Darcy discontinued all medication and ultimately married a “wonderful” man with whom she had a daughter. “Marian felt blessed to have had Darcy as a client” (Australian Institute of Professional Counsellors, 2013). 10 Skills of Effective TherapistsInternational research about what makes a great therapist explored what such professionals were doing, thinking, and feeling when they were at their most effective (Novotney, 2013).Results suggest that effective therapists have sophisticated interpersonal skills, including (Novotney, 2013):
And they are highly capable of:
Identifying these characteristics of effective counselors is crucial to providing the best training for healthy therapeutic alliances. 3 Helpful Techniques for CounselorsThere are several techniques that counselors can adopt to improve the therapeutic relationship. Create a therapeutic bondCreating a bond requires building warmth and trust within the relationship. The client should feel heard, supported, and able to connect deeply with the therapist when needed (Knox & Cooper, 2015). While the counselor cannot always change whether the client sees them as the right person to work with, there are some techniques that can help them foster client trust (modified from Knox & Cooper, 2015):
There is no single recipe that works for all clients, but an ongoing awareness of client needs will improve trust conditions. Ask for feedbackSometimes the best way to find out what is working and what needs to change is to ask. At the end of each session, consider asking your client the following questions (modified from Knox & Cooper, 2015). What did you find helpful today? Prepare for empathyEmpathy is one of the most important aspects of being a good therapist and developing successful alliances. Some techniques can help you prepare for empathic listening, including (modified from Knox & Cooper, 2015):
6 Communication TipsWhen the therapeutic alliance appears to fail, it is worthwhile considering your approach to communication (Knox & Cooper, 2015).
Reflect on your answers to these questions and consider how you can improve your ability to build rapport with your clients. Assessing Your Relationship: 2 Questionnaires & ScalesClient feedback can help therapists recognize psychological distress and improvements to wellbeing (Knox & Cooper, 2015). The Outcome Questionnaire-45.2 is a 45-question instrument valuable for collecting feedback before each therapy session and assessing psychological symptoms. Results help counselors identify clients likely to drop out of therapy, assisting them in tailoring future treatments (DeAngelis, 2019). The Penn Helping Alliance Scales measure how supportive the therapist is perceived to be and the degree of therapeutic collaboration (Ardito & Rabellino, 2011). Rita Ardito and Daniela Rabellino (2011) from the Department of Psychology at the University of Turin offer a complete review of questionnaires and scales for scoring the therapeutic alliance. PositivePsychology.com’s Relevant ResourcesFor even more resources to help strengthen the therapeutic relationship between you and your clients, check out the following free worksheets and exercises.
A Take-Home MessageResearch confirms the importance of the link between healthy therapeutic relationships and positive treatment outcomes. The quality of the alliance appears even more crucial than the type of intervention or therapeutic model employed (Ardito & Rabellino, 2011). Indeed, “a good relationship is essential to helping the client connect with, remain in, and get the most from therapy” (DeAngelis, 2019). Setting up a calm and safe environment and ensuring empathy, confidentiality, warmth, and caring help build and maintain a healthy relationship between the client and therapist. Furthermore, through adequate preparation, feedback, and reflection, mistakes can be managed and a rupture to the therapeutic process overcome. Therefore, it remains vital that soft skills that build the therapeutic relationship receive the attention needed and are tailored according to clients’ needs. As therapists and counselors, we must continue to seek training, supervision, and feedback to identify further growth and development opportunities. Why not use this article and awareness of your strengths and weaknesses to reflect upon how you can develop your skills? Use the learnings to put in place robust and healthy relationships with your clients and increase the potential for a successful treatment outcome. We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free.
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