MENTAL

HEALTH
NURSING
RNB30803
TOPIC 1
Table of contents

01 Topic
1.1 Concepts of Mental health
1.2 Social Changes and the evolution of mental
healthcare
1.3 Cultural issues related mental health care
1.4 Patients rights and legal issues
1.6 Mental Health services and role if a nurse
LEARNING OUTCOME
At the end of the session, students should be able to:
● discuss the concept of mental health
● describe normal health
● describe mental health
● explain the promotion of positive mental health
● explain issues related to mental health care
● discuss the mental health care in the community
● discuss the mental health service in a and the nurses role
 INTRODUCTION
According to WHO mental health is defined as a
state of well-being in which every individual
realizes his or her own potential, can cope with
the normal stresses of life, can work
productively and fruitfully, and is able to make
a contribution to her/his community.
1.1 Concept of Mental Health

A NORMAL HEALTH

WHAT is NORMAL HEALTH?

 NORMAL HEALTH
Definition
Normal health is defined as a state of
physical, mental, socio-economical and
spiritual wellbeing of an individual and
not merely the absence of disease.
 INTER-RELATION OF BODY AND MIND
• Our humanistic interaction view is that physical and mental factors
are inter-related and that a change in any one may result in a
change in another
• An invading organism, a decrease in neurotransmitter, or a
structural change in the body can alter thought processes
• Low self esteem can result in hunched shoulders and severe skeletal
muscle contractures.
 CONCEPT OF MENTAL
HEALTH
• Positive attitudes towards self
• Growth, development and self actualization
• Integration and emotional responsiveness
• Autonomy and self-determination
• Accurate reality perception
• Environmental mastery and social
competency
 PROMOTING MENTAL WELL-
BEING
• Harmonious family relationship
• Freedom from physical, financial, and social ills
• Economical stability
• Recreational activities involving all family members
• Quality time utilization
 PROMOTING MENTAL WELL-
BEING
• Acceptable physical, social activities to balance with studies
• Counselling facilities for those under stress
• Mentally healthy work-force
• Inter-school activities to promote social skills
• Provision of physical health facilities
 PROMOTING MENTAL WELL-
BEING
• Good interpersonal relationship among members
• Tolerance of cultural, religious and racial differences
• Provision of health facilities
• Organized community activities to foster relationship and develop
social and interaction skills
PREVENTION OF MENTAL ILLNESS

1. Primary Prevention
2. Secondary prevention
3. Tertiary prevention
PREVENTION OF
MENTAL ILLNESS
Primary Prevention
● Focus on avoiding new

cases of mental disorder

by counteracting harmful
stressor or other risk
factors
PREVENTION OF MENTAL ILLNESS
Secondary prevention:
● Attempts to shorten the duration of
a mental health disorder through
early case finding and treatment
● To reduce the prevalence of
disorder in a given segment of the
population
Prevention of Mental
Illness
Tertiary prevention:
• Treatment and rehabilitative
services for client with
diagnosed illnesses to prevent
and reduce disabilities that
are consequences of those
disorders
Prevention of Mental
Illness
Tertiary prevention:
• Help the severely and
persistently mentally ill to
manage their symptoms and
adjust their environments to
permit optimal quality of life
as defined by the individuals
IMPLICATION
FOR MENTAL
HEALTH
NURSING
IMPLICATION FOR MENTAL
HEALTH NURSING
1. The nurse patient relationship forms the basis of all
psychiatric nursing

2. The nurse – patient is a therapeutic relationship. It is a

psychiatric set up and serves the purpose of
friendship, enjoyment, socialization or achieving a
purpose. Therefor the nurse-patient relationship is a
goal directed interpersonal process to help the patient
with his emotional or physical health needs.
IMPLICATION FOR MENTAL
HEALTH NURSING
3. Meaning arise in one’s social world
• Meanings arise in the process of interaction with others
• Psychiatric nurses take into account the social and cultural
environment of each client
• Patients can learn new definitions for life situations and new
repertoires for action within interpersonal interaction
IMPLICATION FOR MENTAL
HEALTH NURSING
• The sensitive, intelligent and humanistic use of
self within interpersonal relationship is a key part of
the psychiatric nurse’s skill
• Nurse have a potential for helping patients redefine
their experiences in more satisfying ways, learn new
patterns of coping with stress, and generally
enhance the quality of their lives and social worlds
IMPLICATION FOR MENTAL
HEALTH NURSING
• People handle situations in terms of what they
consider vitally important about the situation.
• To understand patient’s action, the psychiatric nurse
must identify the meanings those action have for
them
1.3 Cultural Issue related to
Mental Health
 WHAT IS CULTURE?

• Culture refers to meanings, values and behavioural norms

that are learned and transmitted in the dominant society
and within it’s social groups
• Culture powerfully influences cognition, feelings and self
concept as well as the diagnostic process and treatment
decisions.
 IMPACT OF CULTURE TO MENTAL HEALTH

● Culture shapes how and what psychiatric symptoms are

expressed
● Culture influences the meanings that are given to
symptoms
● Culture also impacts the interaction between the patient
and the health care system
 THE ASSUMTIONS OF THE DSM

● Four basic psychological paradigms

 Psychodynamics
 Cognitive – behavioural
 Humanistic
 Biological
 FOUR STEPS TO BLAME THE VICTIM

1. Identify a social problem

2. Study those affected by the problem to discover how
they are different from those who are not affected by the
problem
3. Define the differences as the cause of the problem itself
4. Create a humanitarian action
THERAPEUTIC IMPLICATIONS OF BLAMMING VICTIM

Implication 1: Environmental factors are often ignored or

minimized in assessment and treatment

Implication 2: Some individuals are more likely to be

negative affected by implication 1 than others
THERAPEUTIC IMPLICATIONS OF ECOLOGICAL MODEL
● Psychopathology, even individual psychopathology can
only be understood within the context of a person’s family,
community, sociocultural environment. This may include
 Gender
 Race/ethnicity/culture/religion
 Immigration status
 Sexual orientation
 Socioeconomic status
 PSYCHOPATHOLOGY BEHAVIOR
● Given above, a client’s “psychopathological” behaviour
 May be influenced by the therapist’s attitudes regarding
client’s demographic characteristics
 May not actually violate cultural norms and thus not
“pathological”
 May be driven by society’s deficits, rather than the
client’s
 May be treated more appropriately and efficiently
through community interventions
 FUNDAMENTAL QUESTIONS ON PSYCHOTHERAPY
● Should we focus on race, ethnicity and culture in therapy?

Two good arguments not to:

1. We are all fundamentally the same
2. Each of us is a unique person with unique life experience
 ASSUMPTIONS OF MULTICULTARILISM
● Diversity is valuable and should be pursued
 Group differences should be recognized
 Group differences should be respected
 Group differences should be valued
 THREE DIMENSION OF CULTURAL COMPETENCE

● Therapist is aware of own assumptions, values and

biases
○ Role that race/ethnicity/culture plays in own life
○ Role that race/ethnicity/culture plays in mental health
○ Role that race/ethnicity/culture plays in
psychotherapy
 THREE DIMENSION OF CULTURAL COMPETENCE

● Therapist focuses on understanding the racial ideology

and worldview of culturally different clients
○ How clients perceive mental health and
psychotherapy
○ How client perceive the therapist
 THREE DIMENSION OF CULTURAL COMPETENCE

● Therapist develops appropriate counselling strategies

and techniques
 THE CULTURALLY COMPETENT THERAPIST
● Is cognizant of cultural explanations of phenomena
 The behaviours displayed may not considered
maladaptive or abnormal in the other culture
 There may be a cultural explanation for the client’s
experiences
 Experience of racism and prejudice may account for
certain beliefs/behaviours
 Talking to a therapist is a very “cultural” experience that
may take considerable adjustment and trust-building
 BIELIEFS ABOUT TRADITIONAL HEALER
● May be relevant in all patient groups.
● Often not readily admitted by the patient, fearing it to be
unacceptable to the doctor
● Knowledge of all therapies a patient is receiving important in
assessment
● May complementary therapies may be very helpful
● A few have dangers or may interact
● Compliance compromised if advice conflict with that of
traditional healer
 BIELIEFS ABOUT TRADITIONAL HEALER
● The clinical features of any given mental disorder may vary
from one cultural group to another and this is reffered to as
the “pathoplastic” effect of culture
 CULTURE-BOUND SYNDROME

● Culture-bound syndromes are classified on the basis of

common etiology (magic, evil spells, or angry ancestors), so
the clinical pictures vary
● Sleep paralysis (amafufanyane) – occurs for normal people
that the somatic symptom include abdominal pain, paralysis,
blindness and amnesia
 CULTURE-BOUND SYNDROME

● Sudden mass assault – engage furiously in battle, the

syndrome is seen in Malaysia
● It is associated with a sudden, unprovoked outburst of wild
rage, causing the person to run madly about with a weapon
and attack or kill people and animals before being
overpowered or committing suicide
● Amok is often preceded by a period of preoccupation,
brooding and mild depression and they claim it is magical
possessions by demons and evil
 ETHNICITY AND PSYCHOPARMACOLOGY

● Non-biological issues affect psychopharmacology

● Cultural beliefs – Cultural shaped beliefs play a major role in
determining whether an explanation and treatment plan will
make sense
 ETHNICITY AND PSYCHOPARMACOLOGY

● Patient compliance may be affected by poor therapeutic

alliance and lack of community support, money or
transportation
● Other factors – misdiagnose of a psychiatric condition, a
placebo response, mistrust of the health care system may
affect drug response
PATIENT’S
RIGHT AND
LEGAL ASPECT
 LEGAL ASPECT IN MENTAL HEALTH CARE

● The mentally ill patient, when admitted or treatment in the

community, is under legal obligation to be prevented from
harming themselves, others and property
● The admission procedure requires specific form to be
filled up prior to the event
● Criminal cases admitted under the “ruler’s pleasure” cannot
be discharged unless pardoned by the state ruler
 LEGAL ASPECT IN MENTAL HEALTH CARE

● All suicidal attempts and cases are considered police

cases
● Treatment cannot be administered unless the patient has
been certified mentally ill
● Family members sign consent forms for treatment of
patients
 LEGAL ASPECT IN MENTAL HEALTH CARE

Psychiatric patient may:

● Be placed in treatment against their will
● Pose a risk to themselves
● Have been judged to have committed a crime while legally insane
● Be unable or unwilling to consent to treatment
● Be incapable of fully understanding medication risks
● Require restraint for their caretakers to warn potential victims
● Undergo forensic evaluation that requires the nurse to testify in court
 LEGAL ASPECT IN MENTAL HEALTH CARE

Client’s right

● To privacy
● To keep personal items
● To enter into legal contracts
● Of habeas corpus
● To informed consent
● To refused treatment
 LEGAL ASPECT IN MENTAL HEALTH CARE

● Informed consent
○ For psychotherapy
● Concept of professional abandonment
○ Obligation to provide continuing care & to arrange
appropriate follow-up care and to arrange appropriate
follow-up care in providers absence
 LEGAL ASPECT IN MENTAL HEALTH CARE

Professional Negligence
○ Failure to prevent dangerous client behavior
○ Failure to inform
○ Failure to recognize suicidal risk
○ Sexual involvement with patient
○ Breaching confidentiality
○ Failure to honor individuals rights
 LEGAL ASPECT IN MENTAL HEALTH CARE

Control of Violent or Self-Destructive Behaviors

○ Protecting patient & those around him
○ One-to-one staffing
○ On-site police or other guard
○ Seclusion
○ Physical restraints
○ Chemical restraints
 CRIMINAL CASE
○ Patient admitted under court order for observation of his mental status for
14 days, often after committing a crime (extension may be granted if there
is need)
○ Once convicted but found insane during the time of the offence, patient is
admitted “under the ruler’s pleasure”
○ He will be placed in the security ward for life unless pardoned by the state
ruler
○ An appeal may be made by his family to the ruler for his release. Should a
pardon be granted, the family has to guarantee good behavior of the
patient and pay a bond for it
 FORMS USED IN PSYCHIATRIC
Introduction
Patient means a person registered as an outpatient or
admitted as inpatient or admitted under the order of medical
Doctor, medical officer, registered medical practitioner or
upon the order of the Court under the Act;
 LEARNING OUTCOME

End of session students should be able to:

• List the different kind of form used for admission
• Identify the form to be used to admit the patient
• Explain the need for each forms
 FORMS
FORMS
The forms in the First Schedule are prescribed for the use
under these regulations
Part II
Procedure for admission, Detention, Examination and Review of
Patient in, And Discharge or transfer of patient from psychiatric
hospital
 FORMS

1. An application for admission as a voluntary patient into

any psychiatric hospitals under subsection 9(1) of the
Act shall be made in Form 1
2. An order for detention of voluntary patient in
psychiatric hospital by a medical officer or registered
medical practitioner under subsection 9(5) of the Act
shall be made in Form 2
 FORMS

Application, recommendation or order for admission or

detention of involuntary patient into psychiatric hospital
1. An application for admission as involuntary patient into
psychiatric hospital by relative of a person who is
suspected to be mentally disordered under paragraph
10(1) (a) of the Act shall be made in Form 3
 FORMS

Application, recommendation or order for admission or

detention of involuntary patient into psychiatric hospital
2. The relative of person referred to in subregulation (1)
who gives any false information in Form 3 commits an
offence and shall, on conviction, be liable to a fine not
exceeding ten thousand ringgit or a team of
imprisonment not exceeding six months or both
 FORMS

Application, recommendation or order for admission or

detention of involuntary patient into psychiatric hospital
3. A recommendation for admission as involuntary patient
into a psychiatric hospital by a medical officer or
registered medical practitioner under paragraph 10(1)(b)
of the Act shall be made in Form4
 FORMS

Application, recommendation or order for admission or

detention of involuntary patient into psychiatric hospital
4. An order for admission as involuntary patient into a
psychiatric hospital by a medical officer or registred
medical practitioner under section 14 of the Act shall be
made in Form 5
 FORMS

Order for detention and order for continued detention of

involuntary patient into psychiatric hospital by a Medical
Director and others
1. An order for detention of an involuntary patient in a
psychiatric hospital by a Medical Director of the psychiatric
hospital under subsection 10(5) and 14(4) shall be made
in Form 6
 FORMS
Order for detention and order for continued detention of
involuntary patient into psychiatric hospital by a Medical
Director and others
2. An order for a continued detention of an involuntary
patient in a psychiatric hospital by two medical officers or
two registered medical practitioners, as the case may be,
under paragraphs 10(8)(b) and 14(7)(b) of the Act shall be
made in Form 7
 FORMS

Order for continued detention of involuntary patient in psychiatric hospital

by Visitors
7. An order for the continued detention of an involuntary patient into a
psychiatric hospital by the Visitors under paragraph 44(2)(b) of the Act
shall be made in Form 8
8. A direction for further detention into a psychiatric hospital by the Visitors
under paragraphs 45(2)(c), (4)(c) and subsection 45(5) of the Act shall be
made in Form 9
 FORMS

Application for discharge of involuntary patient from psychiatric hospital

9. (1) An application for discharge of involuntary patient from a psychiatric
hospital by the involuntary patient or a relative of the patient under section
16 of the Act shall be made in Form 10
9. (2) The Medical Director shall inform the decision of the application to
the applicant specified in Form 10 within fourteen days from the date of
receipt of the application.
 FORMS

Notification regarding the discharge of patient to the Court

10. Notification under section 21 of the Act by the Medical Director to the
Court regarding the discharge of patient detained in accordance to section
55(1) or section 73 of the Act shall be made in Form 11
 FORMS

Transfer of involuntary patient

11. (1) An order to direct the transfer of involuntary patient from a

government psychiatric hospital or a gazetted private psychiatric hospital to
another government psychiatric hospital or gazetted private psychiatric
hospital by the Director General or any person authorized by him under
section 19 of the Act shall be made in Form 12
 FORMS

Transfer of involuntary patient

11. (1) An order to direct the transfer of involuntary patient from a

government psychiatric hospital or a gazetted private psychiatric hospital to
another government psychiatric hospital or gazetted private psychiatric
hospital by the Director General or any person authorized by him under
section 19 of the Act shall be made in Form 12
 FORMS

Transfer of involuntary patient

11. (2) The licensee and the person in charge of the gazetted
private psychiatric hospital or the Medical Director of a
government psychiatric hospital shall, before executing the
order referred to in subregulation (1), ensure that –
(a) prior arrangements are made with the receiving
psychiatric hospital;
 FORMS

Transfer of involuntary patient

(b) a clinical summary of the involuntary patient is provided;
and
(c) the involuntary patient is sent in suitable custody.
3. The receiving government psychiatric hospital or gazetted
private psychiatry hospital shall ensure the continuity of the
detention order instituted prior to the transfer of the involuntary
patient to such psychiatric hospital.
 1.5 MENTAL HEALTH CARE IN THE COMMUNITY

General overview of community Mental health

Care
■Background
■Preventive Mental health and New Public
Health
■Why we need CMH?
 INTRODUCTION

• Mental health is the capacity of individuals within groups

and the environment to interact with one another in ways
that promote subjective well-being, optimal development
and use of mental abilities (cognitive, effective and
relational) and achievement of individual and collective
goals consistent with justice.
 COMMUNITY MENTAL HEALTH OVERVIEW

1. Historical - Asylum and psychiatric hospitals

2. Drawback - repeated increase in readmission

- cases lost to follow up
- lack of family involvement
- poor clinical outcomes
 MENTAL HEALTH AS PUBLIC HEALTH CONCERN

○ Epidemiology studies – new understanding that

burden from mental & neurological disorders is a
major health concern
 MENTAL HEALTH AS PUBLIC HEALTH CONCERN

1. Humanitarian
2. Moral
 Institutional
 Social breakdown syndrome
3. Economic – 70% mental health budget
4. Scientific – 19 -20 studied found alternative care
are more effective and less costly
 WHY WE NEED COMMUNITY MENTAL HEALTH CARE?

• Provide a pathway to overcome widespread fear

and the stigma surrounding mental illness
• Better care for sufferers
 MENTAL HEALTH SERVICE IN MALAYSIA

• Started in 1911 – custodial care

• Paradigm shift (1998) – community based care
• Community mental health programme till now
 COMMUNITY MENTAL HEALTH PROGRAMME

Goals
○ To promote positive Mental health through life
style education
○ To reduce prevalence of mental disorders
thorugh screening and intervention
○ To facilitate independent functioning of mentally ill
○ To provide continuing care in the community
 MOH HEALTH SERVICE GOAL

1. Wellness focus
2. Person focus
3. Person empowerment
4. Self care and self help
5. Care closer to the home
6. Seamless, continuous, integrated care
7. Care tailored to need of individuals and groups
8. Affordable, effective and efficient care
ROLE OF A PSYCHIATRIC NURSE
MENTAL HEALTH
NURSING
RND 31502
KOGI.S
 LEARNING OUTCOME
After the session the students should be able to:
• define therapeutic milieu
• discuss the role of the nurse in the psychotherapeutic process
• explain various phases of the therapeutic relationship
• discuss different factor that are considered important in the
establishment of the nurse-patient relationship
 INTRODUCTION
• Custodial care remained the mainstay of the treatment of
mentally ill person for a considerable period of time and the role
of a nurse was merely providing basic amenities to the patients
without much contact with them.
• Mental health care has become a multidisciplinary approach
with an attempt to meet the varied needs of the patients with
mental illness.
 THERAPEUTIC MILIEU
• Milieu is a term which encompasses all the elements in the
environment which includes the:
 Setting
 Structure
 people
 environment
• Therapy milieu uses a combination of the social environment and
therapeutic approaches for healing purposes.
 THERAPEUTIC MILIEU

• The goal of therapeutic milieu is to provide a supportive and safe

environment for the patient.
• Group activities enhance the functional ability of the patient and
prepare the patient to go back to society.
• The patient will feel accepted and respected, and can practice new
skill without any fear
 ROLE OF A PSYCHIATRIC NURSE
• At the center of the mental health team is a psychiatric nurse
who plays multiple roles.
• The nurse-patient relationship provides an opportunity for the
nurse to obtain information that is important to the other team
members.
• The nurse also serves as a liaison between the therapist and the
patient.
• The nurse performs three major function of care,
communication and management
 ROLE OF A PSYCHIATRIC NURSE

• A psychiatric nurse support the patient as a

 Caregiver
 Educator
 Counsellor
 Coordinator
 Health Promoter
 ROLE OF A PSYCHIATRIC NURSE
• A psychiatric nurse as a caregiver:
 direct care involves administering medication, assessing for side
effects, helping with personal hygiene and feeding as necessary.
 assess the appropriate and inappropriate behaviors as well as
various precipitating and reinforcing factors.
 reinforces and encourages the patient to participate in
psychotherapy and occupational therapy
 assess the progress and effectiveness of treatment
 document all information in patient’s file and communicate to other
team members
 ROLE OF A PSYCHIATRIC NURSE
• A psychiatric nurse as a educator:
 provides information about the illness and its treatment to the
patient
 discuss the need for compliance with the treatment
 the nurse can provide the information verbally or with the help of
educational material such as pamphlets, booklets and videos
 ROLE OF A PSYCHIATRIC NURSE
• A psychiatric nurse as a counsellor:
 willing to listen actively as well as with empathy encourages the
patient to express his feeling and discuss his problems without
any fear of being ridiculed
 should also help and support the patient to learn new coping
and problem-solving skills
 ROLE OF A PSYCHIATRIC NURSE

• A psychiatric nurse as a advocate:

 protect the rights of the patient
 provides unconditional acceptance and support for the
decisions made by the patient
 listen with empathy to understand the situation for the patients
perspective and assist the patient in making decisions by
providing necessary resources
 ROLE OF A PSYCHIATRIC NURSE

• A psychiatric nurse as a coordinator:

 requires teamwork to plan and work together to help the patient
 establishes and maintain communication with the patient, family
members and various members of treating team
 maintain coordination between various member, various activities,
therapy schedules and agencies
 ROLE OF A PSYCHIATRIC NURSE

• A psychiatric nurse as a health promoter:

 identify high-risk group and in preventing the occurrence of mental
illness in them
 early identification and proper referral and in the rehabilitation
process
 NURSE PATIENT RELATIONSHIP

• The nurse-patient relationship forms the basis of all psychiatric nursing

treatment approaches.
• A social relationship serves the purpose of friendship, enjoyment,
socialization or achieving a purpose of friendship, enjoyment,
socialization or achieving a purpose
• A therapeutic relationship focus on the needs and problem of the
patient
 NURSE PATIENT RELATIONSHIP
• Phases of nurse-patient relationship
a) Orientation phase
b) Working phase
c) Termination phase
 NURSE PATIENT RELATIONSHIP
• Orientation phase
• It may last for few session or may be prolonged especially in
severely and chronically ill patients with mental illness
• It starts with the meeting of two strangers who do not know
anything about each other, but react according to one’s past
experiences, expectations and values.
• The projection of feelings by the patient onto the nurse is known
as transference and the projection of feeling by the nurse onto the
patient is termed counter-transference
 NURSE PATIENT RELATIONSHIP
• Orientation phase
• Issues addressed during this stage
 defining and clarifying the roles of both the nurse and the patient
 discussing the purpose of the meeting
 drawing a written or verbal contract that discuss the time, place, date,
duration and the number of session
 identifying the problems and setting the goals of treatment
 discussing the issue of confidentiality, that is the information given by the
patient will not be shared with others outside the treating team without the
permission of the patient
 NURSE PATIENT RELATIONSHIP
• Working phase
• Focus on identifying and exploring the problems and needs of
the patient
• The nurse will assist the patient to develop new coping and
problem solving skills and facilitate the appropriate behavioral
changes
• The therapeutic relationship allows the patient to try new and
more adaptive skills in a safe and trusting environment
 NURSE PATIENT RELATIONSHIP
• Termination phase
• The termination phase is the final phase of the therapeutic
relationship
• The end of working relationship often causes strong feelings in
both the nurse and the patient
• If the patient has unresolved feelings of rejection, loneliness and
abandonment, these feelings may come up again during
termination phase
 ESTABLISHMENT OF THERAPEUTIC
RELATIONSHIP
• Factors promoting establishment of therapeutic relationship – Nurse
Factor
 consistency
 positive attitude
 active listening
 setting the pace
 control
• Factors promoting establishment of therapeutic relationship –
Patient factor
Trust
participation
 ESTABLISHMENT OF THERAPEUTIC
RELATIONSHIP

Nurse factor
 Consistency
• The same nurse works with the patient
• The meetings between the nurse and the patient are regular
and frequent, following a set routine.
• The nurse is honest and consistent with what she tells the
patient
 ESTABLISHMENT OF THERAPEUTIC
RELATIONSHIP
Nurse factor
 Positive attitude
• A positive attitude and concern towards the patient helps to
foster a good therapeutic relationship between the nurse and
the patient
 Active listening
• Not just hearing what is said or being there when the patient is
talking, rather it means allowing the patient to talk, encouraging
the freedom of expression, and recognizing the emotions and
feelings behind the words
 ESTABLISHMENT OF THERAPEUTIC
RELATIONSHIP
Nurse factor
 Setting the pace
• allowing the patient to set the pace according to his moods
and needs, helps to foster a good therapeutic relationship
 Control
• Maintaining a balance in the therapeutic relationship that is,
not being too strict or too lenient
 ESTABLISHMENT OF THERAPEUTIC
RELATIONSHIP
Patient factor
 Trust
• The ability of the patient to form a trusting relationship with the nurse
is a deciding factor
• A patient who does not trust the nurse will not be able to talk freely
about his needs and problems
 Participation
• Active participation and willingness to change on the part of the patient
enhances the relationship
• The patient should be open and willing to share without any hesitation
and condition
 ESTABLISHMENT OF THERAPEUTIC
RELATIONSHIP
Factors hindering establishment of therapeutic
relationship – Nurse factor
• Inconsistency
• Unavailability
• Negative attitude
• Lack of confidentiality
Factors hindering establishment of therapeutic
relationship – Patient factor
• Resistance
• Illness factor
 ESTABLISHMENT OF THERAPEUTIC
RELATIONSHIP
Factors hindering establishment of therapeutic
relationship – Nurse factor
Inconsistency
• A reluctance or refusal by the patient to spend time with the nurse as well
as resistance to change himself are important negative factors
 Illness Factors
• Certain illness such as paranoid schizophrenia or other forms of psychosis
with paranoia as the key symptom hinder in the establishment of a trusting
relationship