Why is trust the most important component to promote development of a therapeutic nurse-client relationship?

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Before beginning psychotherapy, most patients wonder, "Will this counseling really help me with my problems?" Research shows that many factors affect whether treatment is successful, including the severity of the problem(s) being treated, the patient's belief that the counseling will work and the skill level of the therapist.

However, research over the past fifty years has demonstrated that one factor — more than any other — is associated with successful treatment: the quality of the relationship between the therapist and the patient.

In 1913, Sigmund Freud hypothesized that the relationship between the therapist and patient was a key component of successful treatment. Since that time, research has shown that the quality of this relationship (the "therapeutic alliance," as it is called) is the strongest predictor of whether or not therapy is successful.

Strikingly, the quality of the therapeutic relationship appears critical to treatment success no matter what type of treatment is studied. Large studies have been conducted of individual, couple and family therapy, using a variety of assessment methods to measure the quality of the relationship (i.e. patient or therapist reports or observational ratings). These studies, which used diverse patient groups (children and adults, in-patients and out-patients) treated for all types of problems (i.e. depression, anxiety, drug abuse, work and social problems), all show the importance of the therapeutic relationship on treatment outcome.

"A little over half of the beneficial effects of therapy accounted for [in previous research] are linked to the quality of the alliance," according to Dr. Adam Horvath, a professor at Simon Frasier University and a leading expert in research on the patient-therapist relationship. Interestingly enough, patients and therapists often (but not always) agree on the quality of their relationship. However, it is the patient's perception of the quality of the relationship that is the strongest predictor of treatment success. Patients' ratings of their relationship with the therapist, even very early in the treatment — after the first session or two — predict their improvement over the course of treatment. However, patients who report poor relationships with their therapists are more likely to drop out of treatment early.

What exactly is a "good" therapeutic relationship?

Since the relationship between the therapist and patient appears so crucial to treatment success, experts have tried to define a "good relationship." One pioneering expert, Dr. Edward Bordin, defined a good therapeutic relationship as consisting of three essential qualities: an emotional bond of trust, caring, and respect; agreement on the goals of therapy; and collaboration on the "work" or tasks of the treatment.

Qualities of a good therapeutic relationship:

• Mutual trust, respect, and caring
• General agreement on the goals and tasks of the therapy
• Shared decision-making
• Mutual engagement in "the work" of the treatment
• The ability to talk about the "here-and-now" aspects of the relationship with each other
• The freedom to share any negative emotional responses with each other
• The ability to correct any problems or difficulties that may arise in the relationship

A shared sense of ownership for the treatment also appears essential. Do the therapist and patient trust that the other is working hard to contribute to the treatment's success? Do they collaborate together on decisions that need to be made about the way the treatment is being conducted and what intervention strategies are used?

Every close relationship has problems, difficulties or misunderstandings, and the relationship between the therapist and patient is no exception. However, the manner in which the therapist and patient handle these difficulties together is another crucial component of the success of the relationship. When difficulties arise, can the therapist and patient share any negative feelings, hurt or anger that may have resulted? And, can they work together to resolve any problems that may occur in their work together?

The importance of an expanded conceptualization of the "therapeutic relationship"

Historically, study of the therapeutic relationship has focused solely on the patient's relationship with the therapist. However, research conducted at The Family Institute at Northwestern University by myself and Dr. William Pinsof demonstrates the importance of expanding this definition to include the influence of significant other people in the patient's life. For example, in individual therapy, support of the treatment by the patient's significant others (family members, spouse, close friends) was associated with successful outcome. In couple therapy, the extent to which the couple agreed with each other on treatment tasks, goals and bonds predicted whether therapy would be successful.

What do therapists do to establish a good therapeutic relationship?

Research shows that the ability to form good relationships with patients is not simply a function of therapist training or experience level. Many beginning therapists are as skilled as their more experienced counterparts at forming good therapeutic relationships. However, studies show that experienced therapists are better at forming relationships with those patients who have struggled in past relationships. In addition, experienced therapists are better than novices at identifying and resolving problems in the therapeutic relationship.

Therapists make important contributions to the establishment of a good therapeutic relationship. The therapist's ability to communicate empathy and understanding to the patient is very important. Another essential component is the therapist's openness, flexibility and willingness to adapt the treatment to the patient's needs. Skilled therapists actively solicit patients' input about the goals and methods of treatment, in order to facilitate collaboration.

What helps patients establish a good therapeutic relationship?

Research shows that patients are more likely to establish a good therapeutic relationship when they have good interpersonal and communication skills. For example, patients are more likely to form good relationships with their therapists when they are open and honest about their needs.

What should I do to try to improve my relationship with my therapist?

If you are having difficulties with your therapist, it is important to talk about that directly with your therapist. If you have questions or concerns about any part of the treatment, do not hesitate to discuss them with your therapist. Open, honest communication is a very healthy strategy for resolving difficulties. In fact, studies show that engaging in this kind of "talking about the relationship" is a very effective therapy strategy for improving the relationship, thus improving your chances of treatment success.

Taking care of patients can be rewarding and fulfilling. However, sometimes it can also be emotionally and physically draining. Nurses work in patient care, but also in customer service. Maintaining a professional, courteous interpersonal relationship can be challenging. However, it can be critical in a patient's overall health and well-being.

Establishing a healthy nurse-patient relationship is vital. Nurses should greet the patient by name, make eye contact, and display confidence and professionalism. They should explain everything they will be doing and review the plan of care, making sure to involve them in decision making. Maintaining patient privacy is also essential. For some patients, touch is a way to demonstrate compassion and caring, but nurses should be aware of personal boundaries, as some patients prefer not to be touched. Remaining culturally sensitive as well is vital; providing handouts and patient information in a patient's primary language should be offered, as well as an interpreter if needed. These essential items help to develop trust and open the lines of communication.

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So how does trust and communication help patients? When patients seek health care services or are hospitalized, many are not familiar with the process or what to expect. They may be apprehensive about what's to come, and not understand the medical jargon being spoken. For some, being spoken to using medical terminology is like a foreign language. Imagine being in a foreign country with people speaking to you and you have no idea what is being said. One can feel helpless and out of control, which may lead to anger or resistance to learning. If a healthy nurse-patient relationship is established from the get-go, the nurses can help the patient feel more at ease in their situation and encourage questions and participate in their care.

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Nurses must get buy-in from patients when it comes to their care. As any nurse will tell you, it's nearly impossible to work with a non-compliant patient. Little to no improvement is made. Encouraging participation and educating patients is paramount. As stated earlier, establishing a healthy nurse-patient relationship is essential as the first step to open the lines of communication. Communication must be ongoing and involve patient education. For example, a non-compliant diabetic may believe that skipping meals helps to lower blood sugar. A nurse can take the opportunity to explain the importance of regular meals and snacks and explain what happens physiologically when meals are skipped in diabetic patients. The patient may just not know. Education can lead to better compliance and patient engagement and therefore improved patient care outcomes. In this example, improved blood sugar and A1C levels.

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Nurses are on the front lines of health care. They become experts at establishing relationships with patients and can do so without a second thought. A healthy nurse-patient relationship built on trust and respect goes a long way in improving a patient's overall health.

Amanda Bucceri Androus, RN, BSN

Amanda Bucceri Androus is a Registered Nurse from Sacramento, California. She graduated from California State University, Sacramento in 2000 with a bachelor's degree in nursing. She began her career working night shifts on a pediatric/ med-surg unit for six years, later transferring to a telemetry unit where she worked for four more years. She currently works as a charge nurse in a busy outpatient primary care department. In her spare time she likes to read, travel, write, and spend time with her husband and two children.

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