Insufficient or excessive quantity or ineffective quality of social exchange.
• Difficulty trusting others
• Difficulties in relationships with significant others
• Difficulties with others in school or work environment
• Discomfort in social or interactive situations
• Poor social skills
• Feelings of anxiety, fear, hostility, sadness, guilt, or inadequacy
The client will:
• Participate in the trust relationship
• Demonstrate ability to interact with staff and other clients within the therapeutic milieu
The client will:
• Assume increasing responsibility within the context of the therapeutic relationship
• Identify relationships outside the hospital environment to be used as support system
• Terminate the nurse–client relationship successfully
The client will:
• Use community support system successfully
• Participate in follow-up or outpatient therapy as indicated
* denotes collaborative interventions
Introduce yourself to the client. Explain your role on the unit or within the treatment team.
An introduction and explanation will help the client know what to expect from you, other staff, and the hospitalization.
Assess the client’s behavior, attitudes, problems, and needs.
Baseline data are essential for developing a plan of nursing care.
Obtain the client’s perception of his or her problems and what the client expects to gain from the relationship or hospitalization.
The client’s actions are based on his or her perceptions, which may or may not be the same as other people’s perceptions or objective reality.
Make your expectations for the relationship clear to the client.
Defining your expectations helps the client identify his or her role and understand what is expected of him or her.
Be honest in all interactions with the client. Avoid glossing over any unpleasant topics or circumstances. Take a matter-of-fact approach to such problems as commitment, legal difficulties, and so forth.
Honesty is essential if a trusting relationship is to develop. You are not doing the client a favor by avoiding unpleasant areas; the client will need to deal with these problems. You show that you are trustworthy by discussing these issues without judging or rejecting the client.
Let the client know that you will work with him or her for a specified period of time and that the relationship will end when the client is no longer in treatment.
Explaining the time limitations helps to set the limits of the professional relationship. It also conveys your positive expectation that the client will improve and leave the hospital.
Be consistent with the client at all times.
Your consistency demonstrates that you are trustworthy, and it reinforces limits.
Show the client that you accept him or her as a person.
Conveying acceptance can help the client feel worthwhile. It is possible to accept the client yet not accept “negative” or undesirable behaviors.
Avoid becoming the only one the client can talk to about his or her feelings and problems.
Becoming the sole confidant of the client may seem flattering, but it may be manipulative on the part of the client, and it inhibits the client’s ability to form relationships with others.
Let the client know that pertinent information will be communicated to other staff members. Do not promise to keep secrets (eg, from other staff) as a way of obtaining information from the client.
A promise of keeping secrets is not one you can keep. The client has a right to know how information is communicated and used in his or her treatment.
Set and maintain limits on the client’s “negative” or unacceptable behavior; withdraw your attention from the client if necessary.
Lack of attention can help extinguish unacceptable behavior
Do not allow the client to bargain to obtain special favors, to avoid responsibilities, or to gain privileges.
Allowing bargaining permits the client to be manipulative and undermines limits and trust.
Give attention and positive feedback for acceptable or positive behavior.
Desirable behaviors increase when they are positively reinforced.
When limiting the client’s behaviors, offer acceptable alternatives (eg, “Don’t try to hit someone when you‘re angry—try punching your pillow instead”). See “Basic Concepts: Limit-Setting.”
By offering alternative ways to express feelings, you teach acceptable as well as unacceptable behavior. The client is more likely to abandon old behaviors if new ones are available.
Establish a regular schedule for meeting with the client (such as 1 hour each day or 10 minutes every hour), whatever fits your schedule and the client is able to tolerate.
Regular schedules provide consistency, which enhances trust. The client also can see that your interest in him or her continues.
At the beginning of your interaction with the client, inform him or her of how much time you have to spend. If you must interrupt the interaction, tell the client when you expect to return.
Discussing your schedule conveys your respect for the client and lets the client know what to expect from you.
Do whatever you say you will do, and conversely, do not make promises you cannot keep. If extenuating circumstances prevent your following through, apologize and honestly explain this to the client. Expect the client to be disappointed or angry; help him or her to express these feelings appropriately, and give support for doing so.
The client must know what to expect and will trust you more when you follow through. Extenuating circumstances that necessitate a change of plans happen in everyday life; the client has the opportunity to deal with the frustration or disappointment that may ensue in an acceptable manner.
Assist the client in identifying personal behaviors or problem areas in his or her life situation that interfere with relationships or interactions with others.
The client must identify what behaviors or problems need modification before change can occur.
Teach the client a step-by-step approach to solving problems: identifying the problem, exploring alternatives, evaluating the possible consequences of the alternative solutions, making a decision, and implementing the solution.
The client may be unaware of a logical process for examining and resolving problems.
Help the client identify and implement ways of expressing emotions and communicating with others.
The client’s ability to identify and express feelings and to communicate with others is impaired.
Teach the client social skills. Describe and demonstrate specific skills, such as eye contact, attentive listening, nodding, and so forth. Discuss the types of topics that are appropriate for social conversation, such as the weather, news, local events, and so forth.
The client may never have learned basic social skills and how to use them appropriately.
Assist the client in identifying more effective methods of dealing with stress.
The client may be dealing with stress in the most effective way he or she can and may need to learn new skills and behaviors.
Anticipate the client’s anxiety or insecurity about being discharged from the hospital and terminating the therapeutic relationship, including the possibility that the client may revert to manipulative behavior or his or her presenting problem behavior as termination approaches. Remember: The termination phase of the therapeutic relationship actually should begin in the introductory or orientation phase and should be reinforced as a goal and as a positive outcome throughout the entire therapeutic relationship.
Once the client is comfortable in the relationship, you may expect that he or she will perceive the end of the relationship as threatening and the beginning of other relationships as entailing risk. In addition, the termination of the relationship is a loss for the client (and for the staff).
Point out to the client that his or her success in relationships in the hospital can serve as learning experiences to be used in establishing and maintaining other types of relationships after discharge.
The client may not be aware of the steps in building relationships; you can help the client learn about relationships and build social skills by using the client’s current relationships and interactions as examples. Recognizing the client’s successes can help build confidence.
Assist the client in identifying sources of support outside the hospital, including agencies or individuals in the community, as well as significant others in his or her personal life.
Community support may help the client deal with future stress and avoid hospitalization.
Assist the client in making plans for discharge (returning home, employment, and so on).
Making specific discharge plans enhances the client’s chances for success in the community.