Therapeutic Relationships


A major expectation of the key worker is that they develop a therapeutic relationship with the client. Its quality is a major factor in helping engagement in treatment and so bringing about meaningful changes in behaviour[1]. This term is appearing in a number of drug and alcohol contexts, again without proper definition.
New Brunswick nurses have developed standards they can use to examine how the therapeutic relationship is working and maintain its health. They see that it has four components. These are
“• Power: The therapeutic nurse-client relationship is one of unequal power. Although nurses may not perceive themselves as having power in the relationship, nurses have more power than the client. The power of the nurse comes from the authority of own position in the health care system, specialized knowledge, influence with other health care providers and the client’s significant others, and access to privileged information.
In any professional-client relationship, there is an imbalance of power in favour of the professional, and is reinforced in health care services by the inherent vulnerability of a client needing care.
• Trust: Clients expect the nurse to have the necessary knowledge and skills and to demonstrate caring attitudes and behaviours, and so entrust their care to the nurse. Trust is critical, as the client is in a vulnerable position in the relationship. Part of trust is keeping promises to clients. If trust is breached, then it becomes very difficult to re-establish it.
• Respect: Respect for the dignity and worth of the client is fundamental to the relationship.
The nurse needs to know and understand the culture and other aspects of the client’s individuality and to take these into account when providing care. Part of respect is being non-judgmental of the client, and seeking to discover the meaning behind certain of the client’s behaviours.
• Intimacy: This does not refer to sexual intimacy. Intimacy relates to the kinds of activities nurses perform for and with the client which create personal and private closeness on many levels. This can involve physical, emotional and spiritual elements.”[2]
So, in establishing a therapeutic relationship a worker offers to the client:
  • dedicated time
  • their full attention
  • a commitment to help them get their needs met
  • a supportive,  boundaried and ethical relationship
  • empathy- (not the I know what it was like, I was there too – but rather ‘’skillful reflective listening that clarifies and amplifies the person’s own experience and meaning, without imposing the counselor’s own material’[3] Or more informally; the ability to be with someone who is in distress without being overwhelmed.
  • a suspension of normal moral judgment as the client tries to work out what has been happening for them – often called ‘unconditional positive regard’
  • reflective comment and feedback.
Offering this kind of relationship is itself an important resource for the client involving what is known as ‘modeling’. The client can learn from the worker ways of effective communication, handling conflict and so on from how they are dealt with. If the worker behaves in certain ways the client may see this as an acceptable way of dealing with others. This relationship becomes an important place where the skills, attitudes and values necessary for a dependency free life are rediscovered or learned
 
Extracted from the Essential Drugs and Alcohol Worker by Tim Morrison, DrugScope 2006

[1]  The influence of the therapeutic relationship in treatment for alcohol dependency Alison Ritter A1, Stephen Bowden A2, Tania Murray A3, Paula Ross A4, Janet Greeley A5, John Pead A6  Drug and Alcohol Review  Volume 21, Number 3 / September, 2002  261 - 268
[2] Standard For The Therapeutic Nurse-Client Relationship Nurses Association Of New Brunswick Nurses Association Of New Brunswick, 2000
[3] Miller and Rollnick Motivational Interviewing 2nd ed  Guildford press London and New york 2002