‘Take my hand, help me out’: Mental health service recipients’ experience of the therapeutic
relationship
By: Mona M. Shattell, Sharon S. Starr and Sandra P. Thomas
Shattell, M., Starr, S., & Thomas, S. (2007). ―Take my hand, help me out:‖ Mental health service recipients‘
experience of the therapeutic relationship. International Journal of Mental Health Nursing, 16(4), 274-284.
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Abstract:
The purpose of this study was to describe mental health service recipients‘ experience of the therapeutic
relationship. The research question was ‗what is therapeutic about the therapeutic relationship?‘ This study was
a secondary analysis of qualitative interviews conducted with persons with mental illness as part of a study of
the experience of being understood. This secondary analysis used data from 20 interviews with community-
dwelling adults with mental illness, who were asked to talk about the experience of being understood by a
health-care provider. Data were analysed using an existential phenomenological approach. Individuals
experienced therapeutic relationships against a backdrop of challenges, including mental illness, domestic
violence, substance abuse, and homelessness. They had therapeutic relationships with nurses
(psychiatric/mental health nurses and dialysis nurses), physicians (psychiatrists and general practitioners),
psychologists, social workers, and counselors. Experiences of the therapeutic relationship were expressed in
three figural themes, titled using participants‘ own words: ‗relate to me‘, ‗know me as a person‘, and ‗get to the
solution‘. The ways in which these participants described therapeutic relationships challenge some long-held
beliefs, such as the use of touch, self-disclosure, and blunt feedback. A therapeutic relationship for persons with
mental illness requires in-depth personal knowledge, which is acquired only with time, understanding, and
skills. Knowing the whole person, rather than knowing the person only as a service recipient, is key for
practising nurses and nurse educators interested in enhancing the therapeutic potential of relationships.
Key Words: nurse-patient relationship, phenomenology, qualitative methods, therapeutic relationship
Article:
INTRODUCTION
Therapeutic relationships are central to the practice of psychiatric/mental health nursing. Classical theories and
research from nursing and psychology have contributed to our knowledge of these relationships; yet still, we
know little about what recipients of psychiatric/mental health nursing care believe is therapeutic. For recipients
of mental health care, what is therapeutic about therapeutic relationships? The purpose of this paper is to
describe mental health service recipients‘ experience of the therapeutic relationship.
THEORETICAL BACKGROUND
Clinicians aiming to establish therapeutic relationships should be guided by theory: ‗If you have no theory, you
have no tools‘ (Hedges 2006). Any discussion of theories of therapeutic relationships must begin with Freud‘s
(1915, 1935) psychoanalytic theory. Drawing from his clinical cases, Freud formulated the concepts of the
unconscious, repression and other defence mechanisms, free association, transference, and countertransference.
With regard to the therapist–patient relationship, Freud took an authoritarian stance. For example, he told one
patient that she had 24 hours to change her beliefs or she would have to leave the hospital (Freud 1895/1964). In
the psychoanalytic approach, patient improvement was attributed to the therapist‘s hypnotic suggestions or sage
interpretations of dreams and symptoms. Rejected interpretations were seen as resistance. Much of Freud‘s
theory is still influential (Stuart 2005), but his fatal error was his ‗abiding reluctance to test his own theories – to
stand them up against competing explanations – then revise them to accommodate controverting facts‘ (Wilson
1999; p. 81).
Jung (1967) differed significantly from Freud, adopting a more egalitarian approach to working with his
analysands. Rather than having the patient lie on a couch, with the analyst seated behind, as was customary
among Freudians, Jung preferred to have the patient sitting directly across from him. He even disliked the word
‗patient‘, speaking instead of ‗persons working with him‘ (van der Post 1977; p. 59). Today‘s Jungian therapists
retain his view of the therapeutic relationship as a dialectical process which transforms both parties and his
metaphor of the temenos as the space in which the therapeutic relationship takes place (temenos in ancient
Greece being a sacred, protected place dedicated to the gods) (Sedgwick 2001).
In contemporary psychiatry, most clinicians rely on object relations theory, following Winnicott and Klein, or
self-psychology theory, derived from the work of Sullivan and Kohut (Gabbard 1994). In brief, these theories
guide the therapist to enter the service recipient‘s world of depression or chaos and engage in an empathic
investigatory process, enabling the service recipient to relinquish maladaptive defensive structures and envision
new ways of being and relating. To the object relations theorists, we owe insights into primitive defences such
as splitting, projective identification, introjection, and denial; to the self-psychology theorists, we owe the
recognition that attachment, trust, and security are vital issues throughout our lives (Gabbard 1994).
Still another theoretical orientation is existential psychotherapy, in which the clinician assists the client to deal
with the four ultimate concerns of existence: freedom, isolation, meaninglessness, and death (Yalom 1980). In
this approach, the therapeutic relationship is considered beneficial because it provides the client a ‗dress
rehearsal‘ for new ways of relating to significant others, as well as the experience of a genuine relationship with
someone whose caring is indestructible (Yalom 1980). While agreeing with the need for the clinician to exhibit
empathy, genuineness, and positive regard (as delineated earlier by Rogers (1942), Yalom deplored the
textbook emphasis on techniques for conveying these characteristics. Authenticity is lost when one is focused
on technique rather than ‗turning toward another with one‘s whole being‘ (Yalom 1980; p. 410).
Yalom‘s words (1980) provide a segue to the multidisciplinary relational movement in psychotherapy (Hedges
1997; Mitchell 1988). This approach asserts that the therapist and the service recipient co-create and co-
interpret intersubjective realities as the therapeutic relationship unfolds (Hedges 1997). While paying homage to
founding fathers such as Freud and Sullivan, relational theorists also embrace postmodern, social
constructionist, and feminist perspectives.
Within the discipline of nursing, the theoretical literature on the therapeutic relationship is dominated by Peplau
(1952, 1992, 1997) and Travelbee (1966, 1969). Unquestionably, Peplau‘s work has been most influential.
Across five decades, the preponderance of published work on the nurse–patient relationship has been based on
the theoretical concepts of Peplau (Horsfall et al. 2001). Nurses across the globe are familiar with the phases of
the nurse–patient relationship outlined by Peplau (1952, 1997). She was a fierce advocate for humane and
respectful treatment of hospitalized patients and was known to have physically blocked seclusion room doors
(Horsfall et al. 2001). Her interpersonal relations theory included Sullivan‘s (1953) concepts such as ‗security
operations‘ and ‗parataxic distortion‘, as well as concepts of her own, such as ‗empathic linkages‘, or the ability
to feel the emotions being experienced by the patient (Peplau 1997; p. 163). Her guidance to clinicians is
straightforward and succinct. For example, when discussing the collaborative working phase of the therapeutic
relation-ship, she advised: ‗The general principle is to struggle with the problem and not with the patient‘
(Peplau 1997; p. 164).
In her last paper, Peplau (1997) acknowledged that the trend towards shorter hospital stays and brief psycho-
therapies challenged the relevance of her theory.
However, other writers have noted its continuing relevance. Beeber et al. (1990) pointed out that every inter-
action with a client can have educative potential. Moreover, the phases of the nurse–patient relationship are ‗not
time-anchored and can occur over brief or lengthy relationships‘ (Beeber et al. 1990; p. 6). Reed (1996)
contends that Peplau‘s theory can bridge nursing‘s modernist past with current postmodern trends. Hrabe (2005)
even proposes that Peplau‘s theory is applicable to computer-mediated communication.
Perhaps because Travelbee died at age 47, her theoretical work is not well known. Travelbee (1966, 1969)
critically examined unwritten laws about ‗appropriate‘ nurse behaviour, disputing the old admonition to eschew
emotional involvement with service recipients. The tenets of her theory of one-to-one relationships include: (i) a
relationship with a patient is deliberately and consciously planned for by the nurse; (ii) emotional involvement
is necessary if the nurse is to establish a relationship; and (iii) complete objectivity is not possible (objectivity is
a barrier to a meaningful relationship). Travelbee was particularly insightful in helping patients find meaning in
suffering and in dealing with problematic aspects of the nurse–patient relationship.
LITERATURE REVIEW
Service recipients‘ perceptions of the therapeutic relationship have been highlighted in several studies of
therapist–client relationships (Bedi 2006; Bedi et al. 2005; Littauer et al. 2005). According to these studies,
clients desire therapists to be warm, calm and responsive, and prepared for each session. They want therapists
to: listen attentively; show acceptance, confidence, and understanding; and balance specific questions and
comments with listening (Littauer et al. 2005). Service recipients also want validation of their experiences,
emotional support and care, and appropriate education and referrals. Honesty in the therapist is important, as are
positive non-verbal gestures and personal presentation (Bedi 2006; Bedi et al. 2005).
Service recipients and nurse perspectives on the factors influencing the nurse–client relationship have also been
reported (Horberg et al. 2004; Hostick & McClelland 2002; Lowenberg 2003). The studies report that clients
and nurses deem trust, being comfortable with each other, being sensitive to ‗vibes‘, and respect as important to
the relationship (Hostick & McClelland 2002). Compassion, caring, empathy, concern, sensitivity, and support
are important, as well as confidence or trust in the nurse‘s competence, confidentiality, and non-
judgementalism (Lowenberg 2003). Horberg et al. (2004) report that clients see security, trust, and genuineness
in the relationship as important. Companionship, including friendship, mutual understanding and confirmation,
feeling respected, and being understood, is also reported as important (Horberg et al. 2004).
Empirical testing of Hildegard Peplau‘s interpersonal theory of nursing (1952) has been reported by Forchuk
(1994) and Forchuk et al. (1998), who looked at factors influencing the orientation phase of the relationship.
Because this initial phase is predictive of the outcome of psychotherapy with clients with chronic mental
illnesses, they wanted to see what was related to the positive development of the orientation phase of the
relationship. Pre-conceptions of both nurses and clients were found to be strongly related to the development of
the therapeutic relationship.
Forchuk et al. (1998, 2000) also looked at factors involved in the progress of the therapeutic relationship from
orientation to the working phase. Clients felt that availability, consistency, and trust in the nurse facilitated the
progression of the relationship. They frequently mentioned needs for mutual trust and respect, which were met
through listening, consistency, and follow-through. Nurses identified consistency, pacing (slow approach, at
clients‘ pace), and listening as factors encouraging progress from the orientation phase to the working phase.
They mentioned initial impressions (preconceptions), comfort, and control and client factors.
Positive outcomes of interventions and interactions in the therapeutic relationship have been reported by Beeber
(1989) and Beeber and Charlie (1998) in their work with clients with depression. In 1989, Beeber used Peplau‘s
interpersonal model (1952) to demonstrate how theoretically driven corrective interpersonal experiences
successfully promoted growth and change in a depressed client. To quantify the effects of therapeutic
interpersonal interventions, Beeber and Charlie (1998) tested a depressive symptom screening and intervention
programme. Lower depression scores on the Beck Depression Inventory and an increase in efficacy self-esteem
were found, but no improvement was noted in social self-esteem or satisfaction with interpersonal relations.
The therapeutic relationship is foundational to the delivery of mental health nursing care (O‘Brien 1999).
However, understanding the service recipient‘s perspective on the therapeutic relationship is vital if appropriate
interventions are to be developed and implemented. Therefore, this study examined mental health service
recipients‘ experience of the therapeutic relationship.
MATERIALS AND METHODS
Design
The study was a secondary analysis of qualitative interviews (Szabo & Strang 1997) conducted with persons
with mental illness in a larger study of the experience of being understood. The larger study used an existential
phenomenological approach in the tradition of Husserl (1913/1931) and Merleau-Ponty (1962), as described by
Thomas and Pollio (2002). The sample in that study included 20 English-speaking individuals who self-
identified as having a mental illness and having experienced understanding by a health-care professional.
Participants were aged between 21 and 65 years (mean 39.6). Fifteen participants were Euro-American (75%), 4
African American (20%), and 1 Native American (5%). Eight patients were male (40%), and 12 female (60%).
One patient had less than a high school education (5%), 3 were high school graduates (15%), 6 reported some
college (35%), 6 were college graduates (30%), 3 had a master‘s degree (15%), and 1 held a doctoral degree
(5%). The number of previous psychiatric hospitalizations ranged from 0 to 33 (mode = 0; median = 0.5); the
majority of the sample (n = 11; 55%) had never been hospitalized for mental illness. Participants reported past
and present psychiatric diagnoses, including depression (n = 10), anxiety (n = 3), generalized anxiety disorder
(n = 1), bipolar disorder (n = 9), postpartum depression (n = 1), panic attacks (n = 1), post-traumatic stress
disorder (n = 1), attention deficit hyperactivity disorder (n = 1), antisocial personality disorder (n = 1),
schizoaffective disorder (n = 1), and schizophrenia (n = 1). Seven participants reported more than one
psychiatric diagnosis (mode = 2). Six (4 women and 2 men) were homeless at the time of the interview. Names
and references to places were changed to protect the identity of participants. Interviews, which were audiotaped
and transcribed verbatim, were conducted between February 2005 and April 2005. Individuals were
compensated $20 to participate in the study. The original study has been reported elsewhere (Shattell et al.
2006).
Secondary data analysis
This secondary analysis was conducted after approval by the university‘s institutional review board. Interview
transcripts were reread and re-analysed, and were examined for the experience of the therapeutic relationship.
The question we asked of the texts was ‗what is therapeutic about the therapeutic relationship?‘ The data were
analysed using the systematic method described by Thomas and Pollio (2002), facilitated by ATLAS.ti 5.0
(Scientific Software Development, Berlin, Germany), a qualitative data analysis software package. The
researchers analysed each transcript for meaning units. Transcripts also were read from the part (meaning units)
to the whole (entire transcript). Meaning units were eventually aggregated into themes (recurring patterns that
constituted important aspects of participants‘ descriptions of their experiences). The major outcome of these
readings was development of a thematic description for each transcript. Eight transcripts were analysed in an
interpretive research group; the remaining 12 were analysed individually, by the first and second authors. An
overall structure of the experience was then developed and presented to a research group to enhance rigour, and
interpretations from the group were considered, in addition to the rereading of all transcripts, to finalize the
thematic structure. This thematic structure was then presented to one participant for validation.
FINDINGS
In existential phenomenology, each phenomenal experience has a figure that is noticed or stands out and a
ground, that is, the context or background of the experience. In this study, the ground of the experience of the
therapeutic relationship was living with challenges. Individuals experienced therapeutic relationships against the
backdrop of living with a mental illness, domestic violence, substance abuse, and homelessness. This ground or
context of their experience, as described below, forms the basis for understanding the significance of the
therapeutic relationship from the perspective of those with mental illness.
Context
Participants in this study lived unique and challenging lives because of their mental illnesses. As one participant
said, ‗Well, depression and panic attacks are both unique things in themselves, until you‘ve been there you have
no idea what it is like ... most people don‘t realize how debilitating it can be‘. Another participant, who was
dealing with depression, substance abuse, attention deficit hyperactivity disorder, and the loss of her children,
described life like this: ‗I‘m screaming but nobody can hear me ... I don‘t feel worthy of love ... I‘m hurting all
the time‘. For these participants, dealing with common, everyday issues, superimposed upon living with a
mental illness, was a challenge.
Participants in the study lived with various psychiatric diagnoses, including addictions, affective disorders, and
anxiety disorders, as well as schizoaffective disorders.
Many had to deal with stigma-related behaviour from lay persons as well as health-care professionals. Stigmas
included a psychiatric diagnosis, homosexuality, race, ethnicity, education, and poverty. Being the recipient of
prejudicial behaviour was reported by one participant, Suzanne, who was a middle-aged college professor with
bipolar disorder. She had experienced stigma from health-care professionals as well as lay persons in regard to
her mental illness and her homosexuality. Suzanne reported that she had to provide her professional resume to
health-care professionals to prove she was educated and successful, while at the same time having a diagnosis
of a mental illness. She related this about not being seen as a whole person.
Everything about you starts being attributed either to the mental illness diagnosis that you have, even
though it‘s stabilized, or the medication that you‘re on for the mental illness. And you know, then other
things get ignored; you‘re not seen as a whole person.
A diagnosis of severe medical illness was delayed because Suzanne‘s symptoms were attributed to her
diagnosis of bipolar disorder. While hospitalized, support from her life partner was temporarily denied due to a
lack of understanding of the relationship by health-care professionals. She lived in fear of relapse with the
subsequent loss of time in her life and the inability to maintain her professional endeavours.
Many participants were dealing with issues of homelessness, abuse (physical, emotional, and sexual), rape,
divorce, loss of children, and estrangement from family. One participant, Mary, a 59-year-old disabled,
homeless, divorced woman with bipolar disorder and chronic obstructive pulmonary disease, reported being
abducted, brutally raped, losing her house in a fire, losing her husband when her children were preschool age,
and having her personal information stolen while in a shelter. She reported being a ‗rapid cycler‘ and described
manic states as, ‗It‘s almost like I was possessed by demons. That‘s frightening‘.
Interference with life experiences was related by some participants. Eric, a 56-year-old African American man
and college graduate, disabled with schizoaffective disorder and mania, reported interference with college plans.
He had had a psychotic break after his first 2 years of college and had to change his study major due to electro-
convulsive treatments that made him lose his ‗background‘. Another participant, Tim, had a master‘s degree but
had to stop medical school studies due to anxiety and panic attacks. Interference with interpersonal relation-
ships was described by Bob:
I‘ll have friends call and want to do something and I‘ll be in the beginning or middle of an attack and I
can‘t do it ... most of them don‘t understand that it‘s not that I don‘t want to spend time with them ...
panic and anxiety attacks almost immobilize me. It just seems like every-thing is spinning out of control
and I can‘t go out and have a good time when that‘s going on.