Therapeutic Relationships and Talking Therapies Notes

Therapeutic Relationships and Talking Therapies

Learning Objectives

  • Explore the role of the nurse in working therapeutically with an individual and their whānau.
  • Develop and practice key skills involved in establishing therapeutic alliance including active listening and solution-focused approaches.
  • To develop knowledge and understanding of the basic principles of therapeutic interventions in a stepped care approach.

Active and Reflective Listening

  • How miscommunication happens (and how to avoid it) - Katherine Hampsten.

Therapeutic Relationships

  • Nursing relationships focus on meeting the needs of the health consumer.
  • It is an interpersonal process designed to be therapeutic by:
    • Encouraging consumers to take an active role in decisions about their health care.
    • Genuinely involving family, significant others, and communities in the care and support of consumers.
    • Being proactive in the care and support of consumers, in support of citizenship and human rights.

Mana Enhancing Relationships

  • All communication is across an unknown space – the gap between your understanding of the world and mine.
  • Conflict, lack of clarity, and differing expectations and understandings easily occur when we assume our communication style and needs are the same.
  • Mana-enhancing communication is a process where we can close the space between different understandings, while building trust and mutual respect (MHF, nd).

Mana-Enhancing Practice

  • One of the earliest references to the term is seen in Dr. Leland Ruwhiu’s work which promoted the development of mana-enhancing practice in the social service sector.
  • Important components to ‘mana enhancing practice’ are the recognition of historical relationships particularly in the context of Te Tiriti o Waitangi, the valuing of cultural identity, and the elements of Māori wellbeing (Ruwhiu, 2009).
  • Mana enhancing practice is not the same as strengths based practice as its origins emerge out of Māori ways of doing, thinking and feeling
  • Mana enhancing and mana maintaining approaches encourage practitioners to reflect on the therapeutic relationship and the factors that construct this relationship.

Manaakitanga

  • Key elements of this relationship, are the authenticity of the practitioner who adheres to the principles of respect, integrity and dignity in their approach with the client and their whānau.
  • Successful therapeutic relationships begin with an understanding of a tangata whaiora’s position within their whānau, family and community, and of their whānau connections both historical and current.
  • Before any helping process can begin, time must be taken to make connections to both place (where people come from and where they are currently located) and to people (who they are connected to and the significant generational links).
  • Mana enhancing practice is a way of engaging with others that cares for the spiritual, emotional, physical, and intellectual dimensions of a person.
  • One of the key and fundamental principles is manaaki.

Therapeutic Relationships

  • Partnership involves working with the person and their whānau, family/carers to provide support in a way that makes sense to them, including sharing information and working with people in a positive way to help them reach their goals
  • The therapeutic relationship is underpinned by the nurse's use of self
  • Key knowledge and skills for an effective therapeutic relationship include Use of self, empathy and developing a therapeutic alliance. (Foster et al, 2021)

Use of Self

  • The term therapeutic use of self is used to refer to nurses' conscious efforts to optimize their interactions with health consumers.
  • Or the “planned use of his or her personality, insights, perceptions, and judgments as part of the therapeutic process” (Punwar & Peloquin, 2000, p. 285).
  • Relationships are viewed as partnerships that invite and inspire both parties to learn and grow
  • Trusting relationships are built between people through an emphasis on connection, openness, transparency and respect. This is essential because many consumers have experienced loss of trust, betrayal and/or ‘power-over’ relationships.

Use of Self

  • Nurses use self-disclosure as a way of developing therapeutic relationships.
  • Relationship is a partnership where both parties pays attention to how they have made sense of our experiences, and then uses this to create new ways of seeing, thinking, and doing.
  • Self-disclosure should be used consciously and carefully.
  • The decision about what to disclose about your life needs to be made in advance.
  • Self-disclosure does not include unburdening your personal problems.
  • Decisions about what to share varies according to the length and nature of the relationship. (Foster et al.,2021)

Transference and Counter Transference

  • Professional boundaries are invisible yet powerful lines that mark the territory of the nurse.
  • They define a role and allow the nurse to say: ‘This is what I do. This is the purpose of my presence here.
  • It is important to establish what the therapeutic relationship is and is not.
  • It is a professional relationship which is person-centered.
  • It is not a friendship or an intimate relationship.
  • When the person seeking treatment transfers their feelings (positive or negative) onto the clinician it is called Transference: the unconscious transference of emotional issues from one person to another.
  • It is important to be aware that this may result in you over-identifying with the person (this makes it about you and not the person).
  • When this happens is called Countertransference: the transfer your feelings onto the person. Often clinicians don’t realize when this happens.

Empathy

  • Research suggests that empathetic engagements with consumers have a major impact – from decreasing levels of depression and distress, increasing adherence to treatment plans and improving physiological outcomes, from tissue healing to blood pressure(Levett-Jones et al., 2019)
  • Having empathy enhances nurses' clinical reasoning ability and is linked to job satisfaction, resilience and coping skills.
  • Other research has indicated that nurses are at a higher risk of burnout, distress, depression and attrition if they don’t have the required level of empathy skills(Levett-Jones et al., 2020).

Empathy

  • It has been demonstrated that the people who get the least empathy from healthcare professionals are those who need it most – that is, indigenous people, people from culturally and linguistically diverse (CALD) backgrounds, and people with physical or intellectual disabilities, mental illnesses or lifestyle-related diseases (Levett-Jones, 2019)

Therapeutic Alliance

  • The therapeutic relationship is the foundation of effective mental health nursing practice (Browne et al. 2012).
  • A therapeutic alliance is characterized by the development of mutual partnerships between consumers and nurses and has been linked with greater consumer satisfaction with care
  • As nurses we bring our knowledge and attitudes to mental distress, our identities (e.g. cultural and gender) and our values, knowledge, experience and skills in nursing. This shapes how we develop a therapeutic relationship with consumers.

Therapeutic Alliance

  • The therapeutic alliance can have a significant impact on consumer outcomes and that it is possibly one of the most important factors contributing to the effectiveness of a health service
  • People who have a positive relationship with their clinician have better outcomes
  • However, a therapeutic relationship alone may not be sufficient to sustain health improvements, and so a combination of both therapeutic relationships and the technical skill of specific therapeutic approaches may provide the best outcomes (Foster et al., 2021)

Compassion, Collaboration, and Empowerment

  • However, there is a unilateral aspect to therapeutic relationships in healthcare, with one person acting as helper to a ‘helpee’.
  • These roles can replicate power imbalances and reinforce a sense of oppression, disability and/or helplessness.
  • A therapeutic relationship doesn’t start from the assumption of a problem. From a mental health perspective, there are even more issues to consider in relation to nurse caring.
  • For example, for consumers who are compelled to accept care under Mental Health legislation Trauma-informed practices use strengths-based approaches that are empowering and support individuals to take control of their lives and service use.

Trauma Informed

  • The fundamental shift in providing support using a trauma-informed approach is to move from thinking ‘What is wrong with you?’ to asking, ‘What happened to you?’.
  • Prolonged exposure to trauma and/or repetitive traumatic events MAY
    • Cause an individual’s natural alarm system to no longer function as it should
    • Create emotional and physical responses to stress
    • Result in emotional numbing and psychological avoidance
    • Affect an individual’s sense of safety
    • Diminish an individual’s capacity to trust others

Power, Threat, Meaning

  • The Power Threat Meaning Framework is an alternative to functional psychiatric diagnosis.
  • It is a new perspective on why people sometimes experience a whole range of forms of distress, confusion, fear, despair, and troubled or troubling behavior and how we as nurses can engage with this distress (Johnstone et al, 2018).
  • The framework can be distilled into four key questions:
    • What has happened to you? (Power)
    • How did it affect you? (Threats)
    • ‘What sense did you make of it? (Meaning)
    • ‘What did you have to do to survive? (Threat responses)
  • This then also leads to the questions: What are your strengths? and to integrate all the above: ‘What is your story?’

Power, Threat

  • What has happened to you?
    • Interpersonal – e.g., neglect, bullying, abuse, invalidation
    • Economic & material – e.g., access to money, housing, food
    • Social/cultural capital – e.g., access to education, leisure, belongingness
    • Coercive - power by force (e.g., violence)
    • Legal – laws/policies that might give/take away power
    • Biological/embodied – e.g., attractiveness, physical health, strength
    • Ideological - control of language, meaning & perspective (e.g., How did it affect you?
    • Relationships – e.g., disrupted attachments
    • Emotions/feelings– e.g., overwhelming emotions, despairing
    • Social/community – e.g., feeling excluded
    • Economic/material – e.g., not having enough to eat
    • Environmental – e.g., lack of safety/security
    • Bodily – e.g. ill-health, disability
    • Values, identity & meaning making – e,g., lack of opportunity to develop own beliefs and meanings, loss of purpose

Asking About Trauma – What Happened to You?

  • Research (Read et al, 2017) recommends that practitioners should:
    • ask everyone about their experiences of trauma and abuse
    • ask at the initial assessment, but not during a crisis
    • ask in the context of the person's general psychosocial history
    • preface trauma questions with a brief normalizing statement
    • use specific questions, with clear examples.
  • Questions should be asked sensitively and at the person's pace.
  • Consumers should be reassured that they do not have to disclose abuse or trauma if they do not want to and that they can refuse to answer questions.

Threat Responses

  • Regulating overwhelming feelings - self-injury, memory fragmentation, bingeing/purging, ‘high’ & low mood, hearing voices, D&A use, denial
  • Meeting emotional needs/self-soothing – rocking, skin-picking, bingeing, alcohol use
  • Protection from physical danger – hypervigilance, insomnia, flashbacks, suspicious thoughts, isolation, aggression
  • Maintaining sense of control – self-starvation, rituals, violence
  • Seeking attachments – idealization, appeasement, use of sexuality
  • Protection against attachment hurt - distrust, self-blame, violence,
  • Preserving identity & self-esteem – grandiosity, entitlement, perfectionism, aggression
  • Preserving place within social group – striving, appeasement, self-silencing, self-blame
  • Communication about distress, elicit care – self-injury, unusual beliefs, voice-hearing, self-starvation
  • Finding meaning and purpose –unusual –unusual beliefs, overwork, high moods

Meaning

  • What sense did you make of it?
    • “Unsafe, Attacked, Emotionally overwhelmed, Empty, Abandoned, Rejected, Helpless, Powerless, Hopeless, Failed, Inferior, Isolated, Lonely, Guilty, Blameworthy, Shamed, Sense of meaninglessness, Betrayed, Silenced, Different, Abnormal, Evil, Bad, Unworthy”
    • And then what strengths and resources do you have to overcome it
    • “Loving & secure early attachments, Supportive partners, family & friends, Social support & belongingness, Leisure & educational opportunities, Having access to knowledge (e.g., on mental health), Positive/socially valued aspects of identity , Skills/abilities – e.g., intelligence, resourcefulness, determination, talents, Bodily resources – e.g., appearance, strength, health, Belief systems”

Key Skills in Strengths-Based Nursing Practice

  • Nurses use therapeutic skills to keep interactions future-focused, goal-directed, and focuses on solutions, rather than on the problems that brought people to seek help
  • The approach assumes that all people have some knowledge of what would make their life better, even though they may need some help describing the details of their better life and that everyone who seeks help already possesses at least the minimal skills/strengths necessary to create solutions.

Motivational Interviewing

  • Motivational interviewing is a therapeutic intervention that involves enhancing a person’s motivation to change.
  • The approach uses the Prochaska and DiClemente Stages of Change model (1992) and offers a conceptual framework for understanding the incremental processes that people pass through as they change a particular behavior.
  • This change process is modeled as a progression from an initial precontemplative stage, where the individual is not considering change; to a contemplative stage, where the individual is actively involved in change.
  • Using MI techniques, the RN can tailor motivational strategies to the individual's stage of change
  • The acronyms EARS and OARS can help you remember the stages of active listening and motivational interviewing

EARS: Engage and Elaborate, Amplify, Reflect and Re-inforce, Summarise and Set Goals

  • E – Engaging and Elaborating on reports of change
    • Engaging and elaborating the situations where useful change is already happening by asking questions like:
      • What is already going well?
      • When were things slightly better?
      • When has this already happened?
      • How do others notice the change?
  • A - Amplifying the change
    • Focusing specifically on what was different in the situation of the exception:
      • What made it possible?
      • What was the role of the individual?
      • How can this success be extended
  • R – Reflecting and Reinforcing the change
    • Draw out person's own ideas
      • Asking questions like:
        • What goes better?
        • How does that help?
        • How did you do that?
  • S – Summarize and set achievable goals
    • Plan and set goals for more change.
      • Asking for more examples:
        • What else goes better?

OARS

  • Open-Ended Questions: Establish a safe environment and help to build rapport and a trusting and respectful professional relationship.
    • Learn about the person’s experiences, thoughts, feelings, beliefs, and hopes for the future.
    • You may ask:
      • ✓ What… brings you to the clinic today?
      • ✓ Where… will you get the support you need?
      • ✓ Who… have you talked to before?
      • ✓ How… have you made decisions before
      • ✓ Tell me more about…?
  • Affirming: Build rapport, demonstrate empathy, and affirm strengths and abilities.
    • Build on person’s level of self-efficacy and share a belief that they can be responsible for their own decisions and life choices.
    • You may ask:
      • ✓ It’s great that you are here today. It’s not always easy
      • ✓ It sounds like you’ve been really thoughtful about your decision.
      • ✓ You’re really trying hard to…
      • ✓ It seems like you are really good at…
  • Reflective Listening: Listen to help you gain a deeper understanding of their life.
    • Listen, observe, and share (reflect on) your own perceptions of what the person shares.
    • Reflect on the words that they use and behavior and feelings
      • ✓ You seem [to be feeling]…sad/ frustrated/excited/ angry
      • ✓ I noticed… tears in your eyes… your voice sounds shaky… you smiled when you said that
  • Summarizing: Check that you are understanding the person’s goals and preferences.
    • So let’s go over what we have talked about so far.
    • A minute ago you said you wanted to talk about…
    • Would you like to talk more about how you might try?
    • So you’ve just described your plan.
    • What other questions do you have before you leave today?

Strengths Based Nursing Practice

  • Future Focus: Problems are best solved by focusing on what is already working, and how a person would like their life to be, rather than focusing on the past and the origin of problems.
  • Solutions: Most people have previously solved many, many problems and probably have some ideas of how to solve the current problem.
  • Exceptions: Even when a person does not have a previous solution that can be repeated, most have recent examples of exceptions to their problem
  • Validating: what people are already doing well and encouraging the person to change while giving the message that the therapist has been listening and cares. (McCormack, 2007; Gottlieb, 2014; Gottlieb. & Ponzoni, 2015)

Strengths-Based Approaches

  • Using a Strengths based approach starts from encouraging a strengths assessment rather than the traditional problem focused assessment.
  • An approach to care that enlarges the conversation from “What’s wrong?” to include “What’s right?” (Gottlieb, 2014)
  • And the concept of curious inquiry…“How did you survive all that to be here today?” (McCormack,2007).

Strengths Discovery Questions?

  • Possibility questions: Conversations start from the point that things will get better or will happen – this is called pre-suppositional language
  • Exception questions: Conversations start from the point that things were once different, and therefore could be different again.
  • Change questions: Change questions are similar to exception questions in that they focus on one part of the person’s life and what could be different.
  • Scaling questions: The questions focus on specific qualities or attributes of the individual and where they place themselves on a scale.
  • Esteem questions: The question focuses on which part of the person’s story makes them most proud.
  • Perspective questions: The nurse encourages the person to step out from themselves and look in on their own story by taking another role or perspective.
  • Survival questions: The RN supports the person to recap on what their survival skills are and how they have overcome the challenges they have faced.

The Miracle Question?

  • Imagine tonight, while you are asleep a miracle occurs
  • When you wake your problem (what brought you here) is gone.
  • Because you were asleep you will not know that a miracle has happened, but you will somehow know that the problem is gone.
  • How will you know?
  • What will tell you that the problem is gone?
  • How would you feel, think, behave to discover this?

Talking Therapies: Stepped Care Approach

  • More than any other aspect of service I’ve received, talking therapies gave me a chance to tell my stories in a purposeful way – to be heard, to hear myself, and with support to start making meaning from my experiences… Through this process I’ve been able to integrate my experience of mental distress positively into my identity and my life“. – Fiona Clapham- Howard, service user.

Brief Intervention

  • Brief interventions are suitable for people with mild to moderate levels of problems, whereas people with more severe or complex problems are referred to specialist services
  • Evidence shows that brief interventions for anxiety and depression are effective during the emerging stages of people's mental distress.
  • There is also strong evidence to support the use of brief interventions for people with alcohol use problems, and the use of opportunistic screening and referral to treatment for common mental health and addiction issues among adults (SAMHSA, 2011).

Acceptance and Commitment Therapy (ACT) or (FACT)

  • Aims to help the person accept the difficulties that come with life.
  • Is mindfulness-based therapy, theorizing that greater well-being can be attained by overcoming negative thoughts and feelings.
  • Looks at your character traits and behaviors to assist you in reducing avoidant coping styles.
  • Addresses your commitment to making changes, and what to do about it when you can't stick to your goals.
  • ACT focuses on 3 areas:
    • Accept your reactions and be present
    • Choose a valued direction
    • Take action.
  • FACT is a condensed version.
  • FACT uses acceptance and mindfulness strategies to help people transform their relationship with unwanted, distressing experiences, such as disturbing thoughts, unpleasant emotions, painful memories, or uncomfortable physical symptoms.

Cognitive Behavioural Therapy (CBT)

  • A structured psychological therapy that attempts to make sense of the person’s historical experiences, developed belief systems and thoughts, physiological symptoms, emotional experiences and behavior within the context of their current environment.
  • Proposes that our day-to-day thoughts, core beliefs, imagery and memories play a major role in behavior reactions and physiological responses and may promote or reinforce emotional states.
  • Changes within these factors can support emotional regulation, physiological symptom relief, give more clarity around thought processes and enhance helpful, life-enhancing behaviors.
CBT E-Therapy
  • Beating the Blues [NZ]: Treats depression and anxiety by using CBT. Requires doctor referral.
  • CALM Website, Computer Assisted Learning for the Mind [NZ]: An online resource with has tools for coping with stress and managing life.
  • The Journal [NZ]: Part of the National Depression Initiative, designed to teach you skills that can help get through mild to moderate depression more effectively.
  • The Lowdown (NZ): An interactive website for young people featuring a self-test, fact sheets, a moderated message board and video clips from popular musicians and high-profile young sports people talking about their experiences of depression.
  • Moodgym: Australian program based on CBT and interpersonal therapy. It may be useful in reducing depressive symptoms and dysfunctional thoughts.
  • SPARX (NZ): A self-help computer program for young people with symptoms of depression. Uses a 3D fantasy game environment and a custom-made soundtrack. The program teaches skills to manage symptoms and CBT techniques for dealing with symptoms of depression.

Dialectical Behavioural Therapy (DBT)

  • A therapeutic program to work with people who experience difficulty regulating emotions in a functional
  • Dialectical – two opposing views (of self) with this conflict continuously and simultaneously.
  • Incorporates both Eastern ‘Mindfulness’ and Western ‘Behaviorism’ to develop a ‘wise mind’.
  • Encourages effective reflection. – being present even when thinking about the future or past.
  • Being present also means being able to tolerate distress/ emotions –right now:
  • Mindfulness Strategies are put in place to help gain mastery over our actions and how we interact with others: Behaviorism

Emotional Freedom Technique

  • Emotional Freedom Techniques, (EFT) is a psychological acupressure technique
  • Uses traditional acupuncture to treat physical and emotional ailments but without the invasiveness of needles
  • Tapping with the fingertips is used to input kinetic energy onto specific meridians on the head and chest while the person thinks about their specific problem, whether it is a traumatic event, an addiction, pain, etc. and voice positive affirmations.

Eye Movement Desensitization and Reprocessing (EMDR)

  • This psychotherapy treatment was developed to alleviate distress associated with traumatic memories.
  • Therapy should only be provided by trained and approved clinicians.
  • During EMDR therapy the client attends to emotionally disturbing material in brief sequential doses while simultaneously focusing on an external stimulus.
  • Therapist directed lateral eye movements are the most commonly used external stimulus but a variety of other stimuli including hand- tapping and audio stimulation are often used

Self-Awareness and Mindfulness Strategies

  • Focus on The Senses 5.4.3.2.1
    • Find 5 things you can see.
    • Find 4 things you can touch.
    • Find 3 things you can hear.
    • Find 2 things you can smell.
    • Find 1 thing you can taste.
  • Connect to Nature
    • Go outside and walk barefoot through the grass.
    • Sit outside in a relaxed lotus position: legs crossed, hands with palms open on knees.
    • Do slow, deep breathing.
  • Move
    • Take a walk.
    • Do a few yoga poses.
    • Jump on a trampoline.
    • Run in place.
  • Calming
    • Embrace the Aut
  • Control the Environment to Calm the Senses
    • Turn down the lights for a few minutes.
    • Turn on soothing music or sounds.
    • Light a scented candle; watch the flame.
    • Wrap yourself like a burrito in a regular or weighted blanket.
    • Drink ice water or go warm with hot tea.
    • Give yourself a mini hand massage with a fragrant lotion.
    • Color or draw.
    • Look through recipes.
    • Listen to a calming playlist.
    • Play an instrument.
    • Sing.
  • Nurture
    • Water plants.
    • Clip dead leaves.
    • Gather seeds for growing or sharing.
    • Pick flowers.
    • If you have a garden, pick fruits or veggies or weed.
  • Connect with the Animal Kingdom
    • Watch fish in an aquarium.
    • Do bird watching.
    • Pet your furry family members.
    • Fill bird feeders and see who comes to the seed buffet.
    • Take a few minutes with a journal outside and track the creatures you observe.

References

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  • Bundy, C., (2004). Changing behaviour: using motivational interviewing techniques. Journal of the Royal Society of Medicine, 97(44), 43-47.
  • Foster K, Marks P., O’Brien, A., and Raeburn, T. (2021) Nursing and mental health in context CHAPTER 2, 19-36 In Mental Health in Nursing Nursing and mental health in context- ClinicalKey for Nursing
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  • Gottlieb, L.N. & Ponzoni, N. (2015). Strengths-Based Nursing: A value-driven approach to practice. (Chapter 4: 44-59). in J. J. Fitzpatrick and A.L. Whall. Conceptual Models of Nursing: Analysis and application: Global perspectives (5th Edition). New York, NY: Pearson Publisher.
  • Johnstone, L., & Boyle, M., with Cromby, J., Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D., & Read, J. (2018). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behavior, as an alternative to functional psychiatric diagnosis. Leicester: British Psychological Society
  • Levett-Jones, T., Cant, R. & Lapkin, S. (2019). A systematic review of the effectiveness of empathy education for undergraduate nursing students. Nurse Education Today. 75, 80-94 https://www.sciencedirect.com/science/article/pii/S026069171830501X
  • Levett-Jones, T. & Cant, R. (2020). The Empathy Continuum: An evidenced-based teaching model derived from contemporary nursing literature. International Journal of Nursing Studies.
  • McCormack, J. (2007). Recovery and Strengths-Based Practice. SRN Discussion Paper Series. Report No.6. Glasgow, Scottish Recovery Network.
  • Mental Health Commission, 2001. Recovery Competencies: Teaching Resource Kit. Wellington: Mental Health Commission.
  • Neacsiu, A.D., Rizvi, S.L., Linehan, M.M. (2010). Dialectical Behavioural Therapy Skills use as a mediator and outcome treatment for borderline personality disorder. Behaviour Research and Therapy, 48(9), 832-9.
  • Punwar, A. J., & Peloquin, S. M., (2000). Occupational therapy principles and practice(3rded.). Baltimore, MD: Lippincott, Williams & Wilkins
  • Read J, Harper D, Tucker I, et al. (2017) Do adult mental health services identify child abuse and neglect? A systematic review. International Journal of Mental Health Nursing, 27: 7–19.
  • Scott, G. (2010). Motivational Interviewing 1: Background, principles and application in healthcare. Nursing Times, 106(34), 21-2.
  • The Royal Australian and New Zealand College of Psychiatrists, 2000. Involving Families – Guidance Notes. Wellington: Ministry of Health.
  • Wells, A. (1997). Cognitive Therapy of Anxiety disorders: A Practice Manual and Conceptual Guide. Chichester: John Wiley & Sons.