A Therapeutic Nursing Relationship Nursing Essay
For the purpose of this assignment this student will briefly discuss the concept of ‘Recovery’ in the context of mental health, the psychiatric nurses’ role in the provision of ‘therapeutic intervention’ in a clinical environment focusing on the use of a Solutions Focused Brief Therapy drawing on relevant literature.
The Mental Health Act 2001(MHC 2001), is the key legislative document that forms the basis for the provision of Mental Health Services in Ireland today, congruent to this is the document ‘A Vision for Change’ (DoHC.2006), a framework document that underpins the delivery of Mental Health Services within the State. A Vision for Change identifies ‘Recovery’ as a key component in this delivery:
"Public health policy in Ireland has placed strong emphasis on the need for a recovery orientated mental health service" (DoHC.2006)
The dominance of the traditional Medical Model in Irish mental health, focusing, primarily on the biological aspect of mental health does little to promote change from within, address hope or self-efficacy. Traditionally in mental health, there has been minimal alliance between clinicians and patients where both parties predominantly rely on pharmacological interventions (Waldheter, et al. 2008). However as previously outlined, the provision of mental health services is underpinned by the key component of recovery. According to Jacobson (2003) the idea of recovery first appeared in the mid 1980’s resulting from a number of studies published and narrative accounts of individuals recovering and going on to have a full and meaningful life following on from mental health difficulties. Deegan (1988) herself an individual who suffered with mental health difficulties went on to define recovery as:
"…a process, a way of life, an attitude, and a way of approaching the days challenges. It is not perfectly linear process. At times our course is erratic and we falter, slide back, regroup again…"
Another instrumental definition was proposed by Anthony (1993) who defined recovery as:
"…Deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and or/roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness…".
Some, like Collier (2010) and Meehan et al. (2008) may argue that there needs to be more clarity on a defining recovery, as the concept of recovery can be confusing, though welcomed, it must be noted that; by its very nature, ‘recovery’ is a multi-faceted, personal and unique process. Others like Sheppard et al. (2008) identified that recovery, associated with mental illness, is indicative of an individual overcoming the obstacles attributed to suffering from a mental illness.
The Notion of Recovery:
Recovery can be viewed as a ‘process’ whereby an individual can alter their attitudes and beliefs while undergoing their distinct journey (Coleman, 1999). Key elements central to facilitating this recovery process include self-care and empowerment. The World Health Organisation (2010) identified empowerment as the "core concept of the WHO’s vision of health promotion". In Anderson’s et al. (2003) literature review of 28 experiential reports into recovery identified a cyclical theme that included: the restoration of personal goals, personal responsibility and been able to make an individual choice. To this student it appears that the central tenent running through ‘recovery’ literature is hope. Hope that is based on change; facilitated through the use of modes such as: empowerment, resourcefulness, self-care/efficacy, growth and development within the context of an individual’s mental illness. If this hope is absent "a desire and motivation for change seems to be lacking." (Higgins & McBennett 2007) Hope is the stimulus of the recovery process (Anderson et al. 2003) ergo the psychiatric nurse must believe in the patient’s ability to recovery and develop their personal resourcefulness.
A Therapeutic Nursing Relationship:
The majority of interactions between the nurse and patient/service user should have some form of a basis for a therapeutic interaction, irrespective of the interaction. All therapeutic interactions should have some positive elements that are beneficial both to the nurse and the client.
Cowman et al. (2001) acknowledged that the psychiatric nurses’ in their mental health settings are fundamental to the delivery of care, but must adapt to the evolving changes in mental health services. Adapting to these changes, the psychiatric nurse moves away from the patriarchal method of nursing to a more therapeutic one. By utilising skills such as self-awareness, active listening, collecting information by getting to know that patient and by helping to create or maintain an environment that is not only positive, but enriching and healing; built on trust and honesty.
Through their interactions with patients/clients psychiatric nurse’s actions can have either a negative or a positive effect on an individual’s journey to ‘recovery’ (Higgins & McBennett 2007). To promote positive outcomes during the course of their interactions with patients/clients the psychiatric nurse must develop a "therapeutic use of self" (Peplau 1952) as the nurse’s own actions are formed from conscious and unconscious responses moulded by lived experiences and these may create bias in nurse/patient interactions. By respecting the patient’s autonomy, showing them care, respect and valuing them without trying to control them (Todd & Bohart, 1994) we give great credence to establishing a therapeutic relationship.
Irrespective of what model of nursing is used - Strength’s based model, Orem’s Self-Care, The Tidal Model - they all have the scope for the nurse to accomplish an ‘intervention in a therapeutic’ manner, central to this, is the patient’s own involvement. Psychiatric nurse’s, through embracing these therapeutic interventions have facilitated the advent of a wider range of therapies available, thus promoting recovery that is not solely reliant on pharmacological interventions.
Solution Focused Brief Therapy:
One such therapy is the short term, goal focused approach Solution Focused Brief Therapy (SFBT) (de Shazer,1985). SFBT is future focused, goal directed and focuses on solutions rather than problems. SFBT was developed by Steve de Shazer and his wife Insoo Kim Berg, building on the Theories of Erickson (1901-1980) who believed that people had the have the capacity to change through, choice, language and interactions with others.
Key to SFBT is the notion that the patient holds the key (solution) to answering their own problem, they need help and guidance in realising it and this can be achieved through the use of careful questioning and small steps/goals. Minimal value is place on past experiences and problems rather an emphasis is placed on the person, their strengths and previous successes. By being future orientated it installs hope for the future.
There are two concepts that are foremost in establishing the current self-report status of the patient, these are the "miracle question" (Simon & Berg 2004) and the "rating scale"
"If a miracle happened overnight and the problem you have was solved, how would you know it was solved, and what would be different?"
Using the ‘miracle question’ allows the patient to visualise what their life would look like without the problem this in-turn empowers the client to perceive a solution to their problem. This student observed the successful use of this technique in their clinical practice when a patient wanted to discharge themself from the Addiction Programme. The use of the rating scale not only gives the patient but also the nurse a clear insight into where the patient currently perceives themselves to be, where on a scale of 1-10, 0 being the lowest point and 10 the desired outcome.
The use of these concepts in conjunction with open-ended questions allow for goals to be set, goals that are specific, measurable, achievable and timed.
SFBT. in literature:
McDonald (2007) concludes that advocates of SFBT can claim that SFBT is equal to other psychotherapies, but more importantly, SFBT takes less time and resources in treatment. SFBT has proven to be a successful intervention for differing presentations (Miller et al, 1996). In one study (Knekt et al. 2010), comparing the results of psychoanalytic psychotherapy against SFBT in patients suffering from anxiety and depression problems, found that over a 3 year period that it took up to 24 months longer for the psychoanalytic psychotherapy’s to achieve similar success rates as SFBT.
Smith (2010) in his pilot study explored the self-perceived impact of SFBT training in nurses’. Though limited in number, it concluded that there were marked (positive) changes in: how they viewed their patients, process and content of their clinical work and a noticeable change in their "enthusiasm" in working with their patients.
Cepeda and Davenport (2006) proposed integrating SFBT in to existing models of psychotherapy such as CBT, due to its person centred approach and solution focused techniques. While Ferrrazh & Wellmann (2008) are ‘surprised’ that SFBT has not been integrated into research studies within mental health, even though it has a promising approach due to their initial findings that SFBT is "congruent with the philosophical underpinnings of contemporary mental health nursing" however, it must be noted that its efficacy has not been established. However, they go on to imply that due to the "lack of published studies" in the area of SFBT, and the limitations of their study, they are unable to extract any indictors of the efficacy of SFBT within mental health nursing.
There have been great advances in the provision of mental health care in Ireland over the past number of years. Though the medical model of nursing is still predominant model within the provision of mental health, there is a greater focus on ‘recovery’ and the involvement of the patient in their own’ recovery’, which is reflected in recent studies (HSE 2012) 50% of respondents agreed that "their service had adopted a recovery orientated approach". The move towards therapeutic interventions has given rise to the introduction of a number of therapies including SFBT. Though there is limited evidence to support the efficacy of SFBT, reports indicate that there are positive benefits to its use, perhaps even incorporating it into other therapies, as it can be tailored in to managed care and the pressure to provide effective counseling in a briefer time frame, it accentuates positive attributes in clients and can be used effectively with a variety of clients and issues.
However, one must be cognisant of the working constraints placed on the psychiatric nurse. Austerity measures, may mean staff are stretched, administrative duties, paperwork, meetings all mean that there is less time to spend in a therapeutic intervention with a patient (Bowers et al. 2005).