Establishing positive and trusting therapeutic relationships with patients has long been recognised as an essential component of nursing practice and is important for effective care. There are various challenges in clinical practice that make it increasingly difficult to deliver effective care centred on such relationships. Understanding and addressing these challenges is crucial to ensure a positive experience of care for patients, families, carers and nurses. This article outlines how nurses can use a framework to develop therapeutic relationships with patients and use the best available evidence to deliver effective care. It also explores the challenges in developing effective therapeutic relationships with patients at the healthcare system level, and considers how these challenges can be addressed.
Nursing Standard. doi: 10.7748/ns.2017.e10735
Correspondence
Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated software
Received: 30 October 2016
Accepted: 21 November 2016
Published online: 28 February 2017
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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.
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.
The therapeutic relationship in counselling is also known as the therapeutic alliance. The term is used to identify how counsellors and clients connect with one another and build their relationship together.
The importance of the therapeutic relationship cannot be overlooked; it forms the foundation of all counselling work.
Evidence has shown that the therapeutic relationship is created through a shared feeling of:
Trust
Respect
Genuine care
Honesty
These key points can be linked directly to Carl Rogers’ core conditions.
In this article you will:
Define the therapeutic relationship in counselling.
Explore therapeutic relationship importance in counselling.
Highlight client and therapist relationship details.
Discuss barriers to therapeutic relationships in counselling and psychotherapy.
The client and therapist relationship have been widely researched. Evidence has shown that it forms the basis of success within counselling and psychotherapy.
The therapeutic relationship is fundamentally important to the counselling process. It can enable confidence, reassurance, openness and honesty, paving the way for clients to accept themselves for who they are.
The therapeutic relationship begins from the moment the counsellor and client meet.
Upon first meeting, both people show who and how they are and are able to form an impression of ‘the other’.
Forming a solid relationship can empower clients to delve deeper into the issues they may be facing and ‘open up’ emotionally to the counsellor.
For some clients, this may be the first time that they have ever shared their innermost thoughts and experiences with another, outside of their immediate family or friends. Indeed, it may be the first time they have shared anything about themselves at all.
Within therapeutic relationships, individuals can express themselves honestly and openly, without any immediate attachment or fear of judgement or rejection.
The client or therapist relationship is often different to any other, because of this.
Being a real and genuine person within the relationship can further enable work at relational depth.
Without a therapeutic relationship in counselling and psychotherapy, there would be no basis for work to take place. It is vitally important in ensuring needs are met from the onset.
Barriers can occur within therapeutic relationships in counselling. These may include:
Counsellor not offering the core conditions.
Client not feeling in receipt of the core conditions.
Counsellor, client relationship having poor or no boundaries (overtly friendly, sexual advances, unprofessional etc).
Language barriers
Lack of psychological contact due to substance use, etc.
Previous trauma or attachment issues.
Relationships outside of the therapy room may impact upon the counsellor, client relationship. Transference and countertransference can play a significant part here.
Example:
A client forms a relationship with a counsellor who looks, speaks and acts similarly to a teacher they once had at school that caused them much distress.
As a result, they may react within this counselling relationship as if they were once again that pupil at school, interacting with that teacher.
This could impact the therapeutic relationship.
It is important for counsellors to recognise transference and work with it openly with clients. A useful place for counsellors to work through issues relating to their own transference is in supervision.
Forming a therapeutic relationship is fundamentally important to the holistic process. It can enable confidence, reassurance, openness and honesty, paving the way for clients to accept themselves for who they are.
It also ensures ethical, legal and professional processes are being adhered to.
Therapeutic Relationship in Counselling
Barrett-Lennard, G. (1998) Carl Rogers’ Helping System Journey and Substance. London: SAGE publications.
Feltham et al (2017) The SAGE Handbook of Counselling and Psychotherapy (4th Ed). London: SAGE publications.
