7 Forming, maintaining and ending therapeutic relationships
• To identify the theory and evidence that underpin the importance of the therapeutic relationship in mental health practice
• To consider the skills and attributes that facilitate the development and maintenance of the therapeutic relationship
• To discuss the challenges and complexities present at various stages of the therapeutic relationship
Introduction
The concept of the therapeutic relationship is central to mental health nursing practice. It enables the provision of nursing care through engagement and delivery of specific clinical skills such as assessment, care planning, intervention and supporting the person to move on from mental health services. Despite the central position of the therapeutic relationship within mental health nursing, it is often difficult to define or identify exactly what it looks like in practice. Aldridge (2006) acknowledges that it is due to its complexity and the level of skill required to develop this aspect of practice. Definitions often imply it is a purposeful human interaction that has a specific intent or goal aimed at meeting a service user's needs or best interests. It is based upon building a genuine human alliance which enables collaborative approaches to practice (Barker & Buchanan-Barker 2005). It may be a brief interaction or a relationship that spans over several years.
This chapter will explore and apply the theories that underpin the rationale for the importance of the therapeutic relationship, and consider approaches which may be helpful to you in your practice when developing skills which facilitate the forming, maintaining and ending of therapeutic relationships.
As a student mental health nurse you will have the opportunity to spend a great deal of time with people who are using mental health services. This will provide you with the opportunity to begin to develop these skills right from the beginning of your journey to becoming a qualified nurse.
Underpinning theory
The concept of the therapeutic relationship is largely related to the work of Carl Rodgers (1951) and person-centred approaches. Rodgers maintains that therapeutic relationships should be underpinned by core conditions which are conducive to emotional growth and wellbeing. These include genuineness or congruence, unconditional positive regard and empathy.
Genuineness or congruence
This refers to being honest within the relationship and being open to offering some of yourself in order for the person to recognise you as human and not just as a professional.
Consider the following situations:
1. You are working with a service user who is having difficulties with her daughter coming home late and not wanting to get up for school. This is having a negative effect on their relationship and leading to daily arguments. You tell the service user that you also have a daughter of a similar age who is behaving in a similar way. You disclose that you are also finding it hard to deal with and share her concerns about how it is affecting your relationship with your daughter.
2. You are working with a service user who continuously attempts to kiss or hug you during every interaction. You find yourself wanting to avoid him as it makes you feel uncomfortable. You arrange a one-to-one session with the service user and explain how it makes you feel when he approaches you in this way. You clarify that you do want to spend time with him but that his behaviour makes you feel uncomfortable and is not appropriate within a professional relationship.
Unconditional positive regard
This describes the ability to see beyond a person's behaviour to recognise them as an individual. This requires you to be aware of your prejudgements and have the willingness to show absolute acceptance.
Consider the following examples below:
1. You are working with a service user who tells you that she is using illicit drugs while she is pregnant. She is aware of the harm she may be doing to her unborn baby but is not able to stop. You explore with her the reasons why she continues to take the drugs and identify that it provides her with escapism from the memories of a prior abusive and violent relationship. This enables you to understand her behaviour and work with her to consider other ways of responding to her distress. You let her know that her drug taking is understandable but that she does have other options.
2. You have been working with a service user for a number of months to support him to move on from the residential rehabilitation unit. Other members of the team are sceptical that he will go through with the move as he has reached this stage in the past but has then engaged in behaviour which the team describes as sabotaging his move. Despite this view, you maintain a positive attitude towards him and reiterate your belief in his potential to live independently.
Empathy
This refers to being able to see the world from the view of another person in order to experience their thoughts and feelings. This allows you to explore how their thoughts and feelings might influence their actions and behaviours.
Think about the examples in the scenarios above.
1. Identify the elements of the examples which show how empathy towards the service user has been demonstrated.
2. Consider how you may feel if you were working with the service users described here.
3. What might influence your reaction and response?
4. What might challenge you in demonstrating empathy towards the person?
5. How might you work around this in order to provide the core conditions of the therapeutic relationship?
Forming therapeutic relationships
It is often assumed that the formation of therapeutic relationships is inevitable and that service users should automatically trust a healthcare practitioner due to their role and title. This is often not the case in mental health services for a number of reasons:
• The person may not agree that they have a mental health problem and therefore do not require your support. This is sometimes referred to as lacking insight.
• The person may have had negative experiences in the past with mental health practitioners or other people they perceive as having authority and therefore are sceptical or suspicious about your intentions.
• The person may have found previous contact with mental health services traumatic.
• The person may be concerned about the stigma associated with being involved with mental health services and therefore reluctant to have any association with you.
• The person may be fearful that they will be forced to make changes to their lifestyle which they do not want to alter.
• The person may have been advised by their community not to have contact with mental health services due to their cultural or religious beliefs about mental health problems and their perception of Western service and treatments.
• The person may be sceptical about the value of your involvement and have little faith in your ability to make a difference to their distress.
• The person may feel that the type of service you are providing does not meet their needs.
• The person may not be able to meet with you during your working hours due to other commitments.
You may hear service users referred to as ‘difficult to engage’. This label is often about blaming the service user for their reluctance to fit in to the service we are offering. However, as you can see from the list above, there are many reasons why a person may not wish to be involved with mental health services. Therefore, the skill of engagement is extremely relevant to mental health practitioners. In order to facilitate the process of engagement, the following tips could be useful.
Tips for facilitating engagement
• Wherever possible, we should aim to meet the person on their terms and in an environment that they are comfortable with. By offering a flexible and imaginative approach, an atmosphere of cooperation is more likely to be fostered from the outset.
• Be aware of the impact of the environment you are meeting the person within and attempt to make them comfortable in their surroundings. If it is on an in-patient ward, they may feel threatened and frightened, particularly if they are unsure why they are there, what might happen to them and whether they can leave.
• Adopt a friendly approach, using good eye contact and attentive listening skills which will help the person to develop trust in you.
• Offer a clear introduction of yourself which identifies who you are and why you are there.
• Allow the person to connect to you as a person as well as a mental health nurse.
• If the person is initially reluctant to engage with you, be persistent without being intrusive. Initial rejection could be part of the person's emotional problems and should not be viewed as the end of your attempts to initiate a relationship.
• Show you are willing and interested in getting to know the whole person and do not base your judgements of their needs solely on previous history or the opinion of other professionals who have been involved in their care.
• Respect the person's views and rights and work with them to define their needs and priorities. This may involve support initially with practical tasks which will enable the service user to view you as useful to them. This can then provide the basis of the relationship and allow you to address more complex issues.
Maintaining therapeutic relationships
Maintaining therapeutic relationships is required to enable the delivery and review of a plan of care. Once the therapeutic relationship has been established, we should not assume that it is indestructible. There are a number of situations in which you may feel elements of your role as a nurse places the therapeutic relationship under threat.
The following scenarios are examples of these situations. Read the scenario and identify how you may respond to the situation in order to promote continued engagement. Suggested solutions are provided at the end of the chapter for each; however, these are not definitive and you may well have identified alternative approaches which are equally valid.
Scenario 1
Mohammed is a service user who you have been working with since the beginning of your placement. He has been involved with mental health services for many years and has been admitted to hospital under a Section in the past. Mohammed is very suspicious of mental health practitioners as he believes they have been involved in forcing him to take medication which has made him feel unwell. You have worked with him to understand his beliefs about medication and reconsider his perception of mental health practitioners.
Over the next few months Mohammed experiences a number of stressors in his life which have a negative effect on his mental health. He becomes withdrawn and is reluctant to see you. You share your concerns with your mentor and visit his home together. When you visit you see that his door has been boarded up from the inside and there are pieces of furniture in the garden which appear to have been thrown out of the window. You speak with your mentor who advises that a Mental Health Act assessment is required which will involve calling the police to break down his door. You are concerned that this will reinforce Mohammed's previous beliefs about mental health practitioners and destroy the relationship you and your mentor have developed with him.
Scenario 2
Jamal is a young man who has experienced psychosis for the first time. He is fully engaged in a package of care which involves a number of activities and groups aimed at supporting him to return to work and prevent future relapse. You are preparing to discharge him from mental health services, however his parents are very reluctant to agree to this decision. They are concerned that without the care package in place, Jamal will relapse and will end up back in hospital. Jamal's parents put in a complaint about you to the service team leader stating that you are not working for Jamal's best interests and they no longer want you to be involved in his care. You feel that if you withdrew, this would be detrimental to Jamal's progress due to the strength of the therapeutic relationship you have built with him. However, you are aware that Jamal is concerned about his parents' opinion and is highly influenced by their views.
Scenario 3
You have been working with Anna, a 45-year-old lady, who has a diagnosis of borderline personality disorder. Anna regularly expresses her wish to die and has taken overdoses in the past. When Anna is distressed, she contacts the team and demands that someone comes and sees her at that moment. You answer the phone to Anna and when you inform her that you are unable to meet her demands, she tells you that if you do not come she will take an overdose. You are aware that this pattern of behaviour is a result of her need for support and her difficulties with asking for help in other ways. However, your mentor informs you that it is not helpful to respond to her threats as this reinforces this behaviour. You visit Anna the next day with your mentor as previously planned. She lets you in but tells you that you are just the same as the rest because you won't be there when she needs you.
Scenario 4
You are working on a busy acute admissions ward. Aaliyah approaches you to talk about her benefits which have recently been stopped due to her admission to hospital. You don't have time to talk with her about this and tell her that you will come over as soon as you get a minute. Aaliyah slams the office door and shouts ‘I will believe that when I see it!’. You are aware that this issue is important to Aaliyah but you have been set a number of tasks by your mentor which you need to complete by the end of your shift.
Ending therapeutic relationships
The ending of a therapeutic relationship may occur for various reasons. Most commonly, as a student nurse, you will have completed your allocated time in the specific placement area and so will be moving on. It is important to consider how this is managed, as how relationships end can have significant implications for the service user. This is particularly relevant if the person has had a history of disruptive relationships in the past and therefore may perceive the ending of a relationship as a repeated rejection by someone they have grown to trust.
The parameters of the relationship, such as its nature, aims and duration, should be incorporated into the care plan. This can be discussed openly and mutually negotiated with the service user. There may be a natural ending to a therapeutic relationship when a goal within the care plan has been achieved. If this is not the case, you can use the following strategies to ensure that the ending of the relationship maintains its therapeutic focus.
Tips for ending relationships
• Be clear at the onset of the duration of your involvement with the service user.
• Remind them at regular intervals how much longer you will be working with them.
• Work with the mental health practitioner who will be picking up from where you left off. This may involve referring to another service, facilitating their introduction to the person over a couple of meetings or providing a detailed handover of what you have achieved.
• Plan for your final contact with the person. Ensure that this is focused upon evaluation and review rather than opening up new areas. This may involve a more informal interaction where you plan to do something that the person will enjoy.
• Indentify with the person what you have learnt from working with them and thank them for the opportunity they have given you.
1. Discuss the issue of ending therapeutic relationships with your mentor. Ask them to suggest ways in which you might approach this with the service users you will be working with on this placement.
2. Plan and implement this with a service user and reflect with your mentor on how they responded.
3. Identify what you can learn from putting this into practice.
Professional boundaries should be maintained throughout a relationship. This is stated within the Nursing and Midwifery Council Code (2008) and is therefore an ethical and professional responsibility. Part of establishing professional boundaries is about being clear about the purpose of the relationship, what it is and what it isn't. This contributes to ensuring the relationship does not foster a level of dependency that cannot be maintained. If you suspect that the service user is solely relying upon you to provide practical or emotional support, this may indicate that the relationship has developed to a level of dependency which is beyond professional boundaries. In order to address this, it should be identified at the onset that the relationship is not a friendship or permanent. Bearing this in mind, it is not appropriate to continue to maintain contact with a service user once your placement is complete.
Aldridge J. The therapeutic relationship. In: Jukes M., Aldridge J. Person-centred practices: a therapeutic perspective. Wiltshire: Quay Books, 2006.
Barker P., Buchanan-Barker P. The Tidal Model: a guide for mental health professionals. London and New York: Brunner-Routledge; 2005.
Nursing and Midwifery Council. The code: standards of conduct, performance and ethics for nurses and midwives. London: NMC; 2008.
Rodgers C. Client centred therapy – its current practices, implications and theory. Miffin, Boston: Houghton; 1951.
Possible solutions to scenarios
Scenario 1
You agree with your mentor that a Mental Health Act assessment is required in order to ensure Mohammed's safety.
1. Prior to the incident, you or your mentor could have worked with Mohammed to develop a relapse prevention plan or an advanced directive such as the ones described in Chapter 13. This would enable you and Mohammed to establish an agreement about how situations like this might be dealt with and what would make them less distressing for him. This would enable you to ensure Mohammed is in agreement with your actions and allow you to revisit this with Mohammed once he has recovered from the distressing event.
2. If this agreement had not been established, you could ensure that the way in which the Mental Health Act assessment was carried out was as sensitive as possible, based on what you have learnt about Mohammed and what helps him when he is distressed. You could then communicate this to the individuals involved in the assessment so they are clear how to respond to him and manage the situation in a way that is responsive to Mohammed's personal triggers and coping strategies. If Mohammed requires medication, you would also be able to explain to the care team his beliefs about different medications and what his preference would be.
3. Following the incident, it is important to explain to Mohammed why you took the actions that you did. Often people understand that this is in their best interests if the rationale is explained to them thoroughly. It may take some time for Mohammed to see your view and it is important to acknowledge the impact the event may have had on his perception of you and your mentor.
Scenario 2
You are clear that it is important for you to re-establish a relationship with Jamal's family in order to support his recovery and facilitate the maintenance of his natural social networks.
1. You may wish to start by establishing Jamal's views on his parents’ concerns and how they are impacting on his perception of his own ability to move on from the service. This will determine the nature of the action you will take.
2. If Jamal is unsure about moving on against his parent's wishes, you may wish to initiate a series of group discussions involving Jamal and his parents. (The format and process of how this might work is described in Chapter 13.) This will enable you to work with the family as a whole to address their concerns and share information about the potential for recovery from mental health services. It will also enable you to acknowledge the family's anxieties and ensure that they are aware of your intentions.
3. If Jamal is happy with the prospect of moving on from services, you can support him to think about how he can express his views to his parents. This may involve considering the best way to frame his views and role playing the scenario in order for him to practise his responses.
Scenario 3
You acknowledge that you understand Anna's distress and frustrations with getting the help that she feels she needs. You explain that you are committed to her and her care but that you cannot respond to her in the way she expects due to the nature of your role and responsibilities to other people. You and your mentor suggest the following options and agree with Anna which she feels most comfortable with.
1. You set a time each day for Anna to talk to a member of the team for 15 minutes in addition to your fortnightly visits. If Anna is feeling distressed then she will use these phone calls to identify how she will manage her distress and consider personal coping strategies.
2. If Anna feels that she cannot manage her own distress and does take an overdose, she agrees to arrange an ambulance to A&E to receive medical intervention. Your mentor agrees with the A&E staff that they will inform you if this occurs.
3. You work with Anna to engage with a specific personality disorder service that provides you both with advice and direction on how to change unhelpful patterns of behaviour.
Scenario 4
You recognise that Aaliyah has been let down in the past by members of staff and you are keen to ensure that she does not feel that you are not interested in her concerns.
1. You leave your current task to speak with Aaliyah and identify a time when you will be able to speak with her about her concerns.
2. You consider the tasks you have been given to complete by your mentor and prioritise or delegate to other members of the team in order for you to find time for Aaliyah.
3. In your meeting with Aaliyah, you explain the challenges of meeting everyone's needs on the ward and explain that this is an issue that has no reflection on your commitment to her or her care.