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.
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
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
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
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
• 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.
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