Chapter 5-Relationship development and
therapeutic communication
Chapter 5: Relationship Development and Therapeutic
Communication
• Therapeutic Relationship An interaction between two people (usually a caregiver and a
care receiver) in which input from both participants contributes to a climate of healing,
growth promotion, and/or illness prevention
o Therapeutic relationships are goal oriented
o Ideally, the nurse and the patient decide together what the goal of
the relationship will be
o Most often the goal is directed at learning and growth promotion in an effort
to bring about some type of change in the patient’s life
o In general, the goal of a therapeutic relationship may be based on a
problem- solving model
• Therapeutic Use of Self The ability to use one’s personality consciously and in full
awareness in an attempt to established relatedness and to structure nursing
interventions
o Use of the self in a therapeutic manner requires that the nurse have a great deal
of self-awareness and self-understanding, having arrived at a philosophical
belief about life, death, and the overall human condition
o The nurse must understand that the ability to, and the extent to which one can,
effectively help others in time of need is strongly influenced by this internal
value system—a combination of intellect and emotions
Conditions Essential to Development of a Therapeutic Relationship
• Rapport Getting acquainted and establishing a rapport is the primary task in
relationship development; Rapport implies special feelings on the part of both the
patient and the nurse based on acceptance, warmth, friendliness, common interest,
a sense of trust, and a nonjudgmental attitude
• Trust To trust another, one must feel confidence in that person’s presence, reliability
integrity, veracity, and sincere desire to provide assistance when requested
o Trust cannot be presumed; it must be earned
o Trust-worthiness is demonstrated through nursing interventions that convey
a sense of warmth and caring to the patient
o Examples of nursing interventions that would promote trust in an individual
who is thinking concretely include the following:
▪ Providing a blanket when the patient is cold
▪ Providing food when the patient is hungry
▪ Keeping promises
▪ Being honest (e.g., saying “I don’t know the answer to your question,
but I’ll try to find out”) and then following through
▪ Simply and clearly providing reasons for certain policies, procedures,
and rules
▪ Providing a written, structured schedule of activities
,Chapter 5-Relationship development and
therapeutic communication
▪ Attending activities with the patient if he or see is reluctant to go alone
▪ Being consistent in adhering to unit guidelines
▪ Listening to the patient’s preferences, requests, and opinions and
making collaborative decisions concerning his or her care
▪ Ensuring confidentiality; providing reassurance that what is discussed
will not be repeated outside the boundaries of the healthcare team
• Respect To show respect is to believe in the dignity and worth of an individual
regardless of his or her unacceptable behavior.
o Unconditional positive regard The attitude is nonjudgmental, and the respect is
unconditional in that it does not depend on the behavior of the patient to
meet certain standards
o With unconditional positive regard, the patient is accepted and respected for
no other reason than that he or she is considered to be a worthwhile and
unique human being
o Recognition that patients are being accepted and respected as unique
individuals on an unconditional basis can serve to elevate feelings of self-worth
and self- respect
o The nurse can convey an attitude of respect in the following ways:
▪ Calling the patient by name
▪ Spending time with the patient
▪ Allowing for sufficient time to answer the patient’s questions
and concerns
▪ Promoting an atmosphere of privacy during therapeutic interactions
with the patient or when the patient may be undergoing physical
examination or therapy
▪ Always being open and honest with the patient, even when the
truth may be difficult to discuss
▪ Listening to the patient’s ideas, preferences, and requests, and
making collaborative decisions concerning his or her whenever
possible
▪ Striving to understand the motivation behind the patient’s
behavior, regardless of how unacceptable it may seem
• Genuineness The nurse’s ability to be open, honest, and “real” in interactions with the
patient
o To be real is to be aware of what one is experiencing internally and to allow the
equality of this inner experiencing to be apparent in the therapeutic
relationship
o When one is genuine, there is congruence between what is felt and what is
being expressed
o The nurse who possesses the quality of genuineness responds to the patient
with truth and honesty rather than with responses that he or she may consider
more “professional” or that merely reflect the “nursing role”
o Genuineness may call for a degree of self-disclosure on the part of the nurse
,Chapter 5-Relationship development and
therapeutic communication
▪This is not to say that the nurse must disclose to the patient
everything that may relate to what the patient is going through
▪ On the contrary, care must be taken when using self-disclosure to
avoid reversing the roles of the nurse and the patient
o When the nurse uses self-disclosure, a quality of “humanness” is revealed to
the patient, creating a role for the patient to model in similar situations
▪ The patient may then feel more comfortable revealing
personal information to the nurse
o Most individuals have an uncanny ability to detect other people’s artificiality
▪ When the nurse does not bring quality of genuineness to the
relationship, a reality base for trust cannot be established
▪ These qualities are essential to helping the patient actualize their
potential within the nurse-patient relationship and for change and
growth to occur
• Empathy The ability to see beyond outward behavior and to understand the situation
from the patient’s point of view.
o With empathy, the nurse can accurately perceive and understand the
meaning and relevance of the patient’s thoughts and feelings
o The nurse must also be able to communicate this perception to the patient
by attempting to translate words and behaviors into feelings
o It is not uncommon for the concept of empathy to be confused with sympathy
▪ The major difference is that with empathy the nurse “accurately
perceives or understands” what the patient is feeling and encourages the
patient to explore these feelings
▪ With sympathy the nurse actually “shares” what the patient is feeling
and experiences a need to alleviate distress
▪ Empathy means that you can remain emotionally separate from the
other person, even though you can see the patient’s viewpoint clearly.
This is different from sympathy. Sympathy implies taking on the other’s
needs and problems as if they were your own and becoming emotionally
involved to the point of losing your objectivity. To empathize rather than
sympathize, you must show feelings but not get caught up in feelings or
overly identify with the patient’s and family’s concerns
o Empathy is considered to be one of the most important characteristics of
a therapeutic relationship
▪ Accurate empathetic perceptions on the apart of the nurse assist
the patient to identify feelings that may have been suppressed or
denied
▪ Positive emotions are generated as the patient realized that he or she
is truly understood by another
▪ As the feelings surface and are explored, the patient learns aspects
about self of which he or she may have been unaware
, Chapter 5-Relationship development and
therapeutic communication
▪ This insight contributes to the process of personal identification and
the promotion of positive self-concept
o With empathy, while understanding the patient’s thoughts and feelings, the
nurse is able to maintain sufficient objectivity to allow the patient to achieve
problem resolution with minimal assistance
▪ With sympathy, the nurse actually feels what the patient is feeling,
objectivity is lost, and the nurse may become focused on relief of
personal distress rather than on helping the patient resolve
distress rather than on helping the patient resolve the problem at
hand
o Rapport, trust, respect, genuineness, and empathy all are essential to forming
therapeutic relationships, and they can certainly be assets in social
relationships, too
▪ The primary difference between social and therapeutic relationships
are that therapeutic relationships always remain focused on the
healthcare
needs of the patient, they are never for the purpose of addressing the
nurse’s personal needs, and they progress through identified phases of
development for the purpose of helping the patient to solve health-
related problems
Phases of a Therapeutic Nurse-Patient Relationship
• Psychiatric nurses use interpersonal relationship development as the
primary intervention with patients in various psychiatric mental health
settings
• Peplau identified counseling as the major subrole of nursing in psychiatry
• The therapeutic interpersonal relationship is the means by which the nursing process
is implemented
o Through this relationship, problems are identified and resolution is sought
o Tasks of the relationship have been categorized into four phases:
1. Preinteraction phase
2. Orientation (introductory) phase
3. Working phase
4. Termination phase
The Preinteraction Phase: Explore self-perceptions
• Involves preparation for the first encounter with the patient
o Tasks include the following:
▪ Obtaining available information about the patient from his or her
chart, significant others, or other health care team members
• From this information, the initial assessment is begun
• This initial information may also allow the nurse to become aware
of personal responses to knowledge about the patient
▪ Examining one’s feelings, fears, and anxieties about working with
therapeutic communication
Chapter 5: Relationship Development and Therapeutic
Communication
• Therapeutic Relationship An interaction between two people (usually a caregiver and a
care receiver) in which input from both participants contributes to a climate of healing,
growth promotion, and/or illness prevention
o Therapeutic relationships are goal oriented
o Ideally, the nurse and the patient decide together what the goal of
the relationship will be
o Most often the goal is directed at learning and growth promotion in an effort
to bring about some type of change in the patient’s life
o In general, the goal of a therapeutic relationship may be based on a
problem- solving model
• Therapeutic Use of Self The ability to use one’s personality consciously and in full
awareness in an attempt to established relatedness and to structure nursing
interventions
o Use of the self in a therapeutic manner requires that the nurse have a great deal
of self-awareness and self-understanding, having arrived at a philosophical
belief about life, death, and the overall human condition
o The nurse must understand that the ability to, and the extent to which one can,
effectively help others in time of need is strongly influenced by this internal
value system—a combination of intellect and emotions
Conditions Essential to Development of a Therapeutic Relationship
• Rapport Getting acquainted and establishing a rapport is the primary task in
relationship development; Rapport implies special feelings on the part of both the
patient and the nurse based on acceptance, warmth, friendliness, common interest,
a sense of trust, and a nonjudgmental attitude
• Trust To trust another, one must feel confidence in that person’s presence, reliability
integrity, veracity, and sincere desire to provide assistance when requested
o Trust cannot be presumed; it must be earned
o Trust-worthiness is demonstrated through nursing interventions that convey
a sense of warmth and caring to the patient
o Examples of nursing interventions that would promote trust in an individual
who is thinking concretely include the following:
▪ Providing a blanket when the patient is cold
▪ Providing food when the patient is hungry
▪ Keeping promises
▪ Being honest (e.g., saying “I don’t know the answer to your question,
but I’ll try to find out”) and then following through
▪ Simply and clearly providing reasons for certain policies, procedures,
and rules
▪ Providing a written, structured schedule of activities
,Chapter 5-Relationship development and
therapeutic communication
▪ Attending activities with the patient if he or see is reluctant to go alone
▪ Being consistent in adhering to unit guidelines
▪ Listening to the patient’s preferences, requests, and opinions and
making collaborative decisions concerning his or her care
▪ Ensuring confidentiality; providing reassurance that what is discussed
will not be repeated outside the boundaries of the healthcare team
• Respect To show respect is to believe in the dignity and worth of an individual
regardless of his or her unacceptable behavior.
o Unconditional positive regard The attitude is nonjudgmental, and the respect is
unconditional in that it does not depend on the behavior of the patient to
meet certain standards
o With unconditional positive regard, the patient is accepted and respected for
no other reason than that he or she is considered to be a worthwhile and
unique human being
o Recognition that patients are being accepted and respected as unique
individuals on an unconditional basis can serve to elevate feelings of self-worth
and self- respect
o The nurse can convey an attitude of respect in the following ways:
▪ Calling the patient by name
▪ Spending time with the patient
▪ Allowing for sufficient time to answer the patient’s questions
and concerns
▪ Promoting an atmosphere of privacy during therapeutic interactions
with the patient or when the patient may be undergoing physical
examination or therapy
▪ Always being open and honest with the patient, even when the
truth may be difficult to discuss
▪ Listening to the patient’s ideas, preferences, and requests, and
making collaborative decisions concerning his or her whenever
possible
▪ Striving to understand the motivation behind the patient’s
behavior, regardless of how unacceptable it may seem
• Genuineness The nurse’s ability to be open, honest, and “real” in interactions with the
patient
o To be real is to be aware of what one is experiencing internally and to allow the
equality of this inner experiencing to be apparent in the therapeutic
relationship
o When one is genuine, there is congruence between what is felt and what is
being expressed
o The nurse who possesses the quality of genuineness responds to the patient
with truth and honesty rather than with responses that he or she may consider
more “professional” or that merely reflect the “nursing role”
o Genuineness may call for a degree of self-disclosure on the part of the nurse
,Chapter 5-Relationship development and
therapeutic communication
▪This is not to say that the nurse must disclose to the patient
everything that may relate to what the patient is going through
▪ On the contrary, care must be taken when using self-disclosure to
avoid reversing the roles of the nurse and the patient
o When the nurse uses self-disclosure, a quality of “humanness” is revealed to
the patient, creating a role for the patient to model in similar situations
▪ The patient may then feel more comfortable revealing
personal information to the nurse
o Most individuals have an uncanny ability to detect other people’s artificiality
▪ When the nurse does not bring quality of genuineness to the
relationship, a reality base for trust cannot be established
▪ These qualities are essential to helping the patient actualize their
potential within the nurse-patient relationship and for change and
growth to occur
• Empathy The ability to see beyond outward behavior and to understand the situation
from the patient’s point of view.
o With empathy, the nurse can accurately perceive and understand the
meaning and relevance of the patient’s thoughts and feelings
o The nurse must also be able to communicate this perception to the patient
by attempting to translate words and behaviors into feelings
o It is not uncommon for the concept of empathy to be confused with sympathy
▪ The major difference is that with empathy the nurse “accurately
perceives or understands” what the patient is feeling and encourages the
patient to explore these feelings
▪ With sympathy the nurse actually “shares” what the patient is feeling
and experiences a need to alleviate distress
▪ Empathy means that you can remain emotionally separate from the
other person, even though you can see the patient’s viewpoint clearly.
This is different from sympathy. Sympathy implies taking on the other’s
needs and problems as if they were your own and becoming emotionally
involved to the point of losing your objectivity. To empathize rather than
sympathize, you must show feelings but not get caught up in feelings or
overly identify with the patient’s and family’s concerns
o Empathy is considered to be one of the most important characteristics of
a therapeutic relationship
▪ Accurate empathetic perceptions on the apart of the nurse assist
the patient to identify feelings that may have been suppressed or
denied
▪ Positive emotions are generated as the patient realized that he or she
is truly understood by another
▪ As the feelings surface and are explored, the patient learns aspects
about self of which he or she may have been unaware
, Chapter 5-Relationship development and
therapeutic communication
▪ This insight contributes to the process of personal identification and
the promotion of positive self-concept
o With empathy, while understanding the patient’s thoughts and feelings, the
nurse is able to maintain sufficient objectivity to allow the patient to achieve
problem resolution with minimal assistance
▪ With sympathy, the nurse actually feels what the patient is feeling,
objectivity is lost, and the nurse may become focused on relief of
personal distress rather than on helping the patient resolve
distress rather than on helping the patient resolve the problem at
hand
o Rapport, trust, respect, genuineness, and empathy all are essential to forming
therapeutic relationships, and they can certainly be assets in social
relationships, too
▪ The primary difference between social and therapeutic relationships
are that therapeutic relationships always remain focused on the
healthcare
needs of the patient, they are never for the purpose of addressing the
nurse’s personal needs, and they progress through identified phases of
development for the purpose of helping the patient to solve health-
related problems
Phases of a Therapeutic Nurse-Patient Relationship
• Psychiatric nurses use interpersonal relationship development as the
primary intervention with patients in various psychiatric mental health
settings
• Peplau identified counseling as the major subrole of nursing in psychiatry
• The therapeutic interpersonal relationship is the means by which the nursing process
is implemented
o Through this relationship, problems are identified and resolution is sought
o Tasks of the relationship have been categorized into four phases:
1. Preinteraction phase
2. Orientation (introductory) phase
3. Working phase
4. Termination phase
The Preinteraction Phase: Explore self-perceptions
• Involves preparation for the first encounter with the patient
o Tasks include the following:
▪ Obtaining available information about the patient from his or her
chart, significant others, or other health care team members
• From this information, the initial assessment is begun
• This initial information may also allow the nurse to become aware
of personal responses to knowledge about the patient
▪ Examining one’s feelings, fears, and anxieties about working with
