Therapeutic Relationships Within the Medical

Therapeutic Relationships

Within the medical field, be it hospital, hospice, nursing home, or mental health, one of the most cherished and important relationships is that between the caregiver and patient. This is known as the therapeutic relationship, or helping alliance, and is the core locus between a healthcare professional and a client. It is the means by which a medical professional engages, affects change, and hopefully assists the patient to a road of personal responsibility within their own care paradigm (Gelso and Samstag, 2010, 49).

Much of the early research on the subject was, of course, conducted in the psychotherapy and mental health areas, but after the mid-20th century, nursing theories, such as those of Jean Watson and Hildegard Peplau, accentuate the positive outcomes from a more interpersonal relationship-based approach to patient care. Hildegard Peplau (1909-1999) was a nursing theorist whose most famous contribution to nursing literature was with her 1952 publication Relations in Nursing. In this text, Peplau focused on the client-nurse relationship as the basis for any foundation within the professional nursing template. While this seems logical today, the idea of compromise and advocacy of patients post-World War II was seen as both reactionary and upsetting of the hierarchical nature of patient-medical theory. Peplau believed that the partnership relationship between nurse and patient was essential to any means that would contribute to patient healing. The nurse, she said, should do far more than simply listen to the doctor and carry out medical orders. Instead, the nurse should develop a relationship with the patient in which the nurse actively listens to the needs and issues of the patient, communicates those needs up the chain of command, and acts as an advocate for patient well-being. The ratio of patients to doctors, reasoned Peplau, was such that the professional nurse had a critical responsibility in performing this advocacy role (Peplau, 2004, 7). Jean Watson views nursing as an art and a science, which has the goal of preserving the worth of humankind through the process of caring. Caring is the essence of nursing and a moral ideal: Caring...has to become a will, an intention, a commitment, and a conscious judgment that manifests itself in concrete acts. Human care, as a moral ideal, also transcends the act and goes beyond the act of an individual nurse and produces collective acts of the nursing professions that have important consequences for human civilization (Watson, 1997).

Within the generalized therapeutic relationship, there are three major sections that form the relationship between caregiver and client:

The Working Alliance -- This is the joining of the client's needs and personal style and needs with the caregiver's. This consists of three parts: tasks, goals and bond. The task section focuses on what is needed to increase the health of the client; goals are self-explanatory and individually unique to the situation, and the bond is the mutual emotional bond that needs to occur between client and therapist in order to meet the goal. The goals are what the client hopes will happen because of the care needed -- and the bond the specifics that need to be met in order to meet those goals (Widdowson, 2010, 83).

The Transference/Countertransference Section -- Within this section of the therapeutic relationship, transference and countertransference are phenomenons in which feelings between the client and caregiver are directed and redirected to one another. This has been part of clinical psychology since Jung, and may be both harmful or positive. Within the caregiver model, it is usually heightened empathy for the patient, with the client, a feeling of greater emotional bonding to the caregiver than that of a professional relationship (Wiener, 2009).

The Real Relationship -- This is the ideal outcome, the real or personal relationship between client and caregiver. It may, of course, include deception on the part of the caregiver or therapist depending on the actuality of the illness or the prognosis for the patient; but it transcends the dancing around and dishonesty that sometimes is indicative in new healthcare relationships because of the client's need to appear special on one hand, very needy on the other. The real relationship is often goal oriented as well, and allows both parties to develop a more positive and genuine way of dealing with the issues at hand (Gelso, 2010).