The Idea of a Therapeutic Relationship
(Paper presented at the Tidal Model Conference, Making Waves, Totara Spings New Zealand, 30th June 2005, repeated with significant modification at Nurses Day, Christchurch, 10th May 2006.)
This paper begins with a story because a story has the potential to engage both the intellect and the imagination. Without imagination the intellect is a dry thing indeed. The intellect pulls together ideas in a way which seems to be coherent but the imagination engages us with its ability to enrich and embellish – to bring life. The story takes place in the acute admission ward of a large psychiatric hospital. The scene is a light, airy lounge room. Seated here on the floor is a young woman called Phillipa who has had several admissions. She has been diagnosed variously as depressed, borderline personality and bipolar. What is known is that her father who disappeared from the scene fairly early in the piece was a violent man not above abusing both his daughter and his wife and authoritarian in his demands for compliance. Currently Phillipa sits in the lounge and is somewhat morose. The time is 12.15pm
The nurse enters the lounge purposefully and energetically. She sees Phillipa and says ‘What are you doing here? You know that you should be in the dining room having lunch at this time. Go down to the dining room and have your lunch (the nurse turns and points indicating the way out of the lounge).’ Phillipa, not surprisingly, gives her the fingers with an appropriate rejecting grimace and a few suitable words. The nurse later records in the notes that Phillipa is surly, rude, uncooperative and that she continues to behave inappropriately.
Nursing literature is full of discussion about something called the therapeutic relationship. In much of this literature the nurse is seen as a tool in a process aimed at assisting the patient to develop and lead a satisfying life. I ask myself is the example given above an example of a therapeutic relationship? a relationship in which the nurse is the tool which will bring about the changes necessary for the person to lead a satisfying life. The interaction does, I think leave something to be desired. The picture is not especially pretty or uplifting. The dynamic of authoritarianism and rebellion are re enacted once more. Its ground hog day. The nurse is behaving like an authoritarian dictator and Phillipa responds in the role of ‘angry rejecter’ or ‘angry rebel’. This is a dynamic that has been played out in Phillipa’s life many, many times and it is repeated here once more. The sad truth is that more than likely it is a dynamic that has been played out many times in the nurse’s life. The difference is that the nurse by virtue of her career choice offers herself as a therapeutic agent.
In psychotherapy this dynamic would be called transference and counter-transference. Phillipa responds to authority figures in ways that were learned and enhanced in very different situations — probably with parents, school teachers and others. With the internal conflict over these earlier relationships unresolved, she perceives any person in authority as an authoritarian dictator and reacts accordingly. As the poet Mary Oliver so perfectly puts it in her poem about the great composer and pianist Robert Schumann who spent much of his life in a Mental Hospital
Hardly a day passes I don’t think of him
in the asylum: younger
than I am now, trudging the long road down
through madness towards death.
Everywhere in this world his music
explodes out of itself, as he
could not. And Now I understand
something so frightening and wonderful –
How the mind clings to the road it knows, rushing
through crossroads, sticking
like lint to the familiar…
The nurse for her part responds to challenges to her authority in ways that she has learned in her life. Her mind also ‘clings to the road it knows’.
It is not my intention here to hold up the nurse’s behaviour as either culpable or blameworthy but rather to highlight the dynamic which is enacted over and over again with Phillipa by many people in her life especially those who have ascribed authority in respect of her. It is ground hog day. There is nothing new or changing. The same dynamic is being enacted over and over again. Both are damaged through this process. Phillipa’s view of the world as a place full of authoritarianism is confirmed and her hostility reinforced. The nurse’s picture of the world in this moment as a place full of hostility is also confirmed and she responds from her position in the only way she knows how; that is to clamp down in a non compromising authoritarian fashion. Both leave the encounter further hardened in these views and this is tragic. But it is also a matter that requires some serious consideration. What is clear is that, if we consider therapeutic to mean healing in some way, then this is not a therapeutic interaction and the relationship is not therapeutic.
As I mentioned earlier dynamic psychotherapy has its own way of viewing this type of interaction. It would suggest that the roles enacted are transferential. That is Phillipa, simply because she is the patient is in a transference with the authority figure of the nurse and the nurse is in the counter-transference role which supports the transference. Here no real attempt has been made to understand the dynamic or to change it. There are many possible responses to a person who is in the lounge when she supposedly should be in the dining room. One might make an enquiry for example and enter into the person’s world for a little. But nurses are not psychotherapists you might argue. Well, that is true but if we want to be the therapeutic agent the literature would have us believe we are then perhaps there is a need to learn some of the insights that have been discovered through psychotherapy and to be constantly reflective about interactions such as that described above.
We all need this. We all have elements of our behaviour in relationships which are learned much earlier in our lives and then re-enacted day by day in a way that slowly kills us off and drains the life from us. Burn out of staff is not brought about by the constant interaction with distressed people. It is brought about by our own repeated and unchanging responses to these people. Having the same response every time we encounter a sullen rejecting person will ensure we burn out.
I would like now to say something about other ways of thinking about this situation and I want briefly to say something about a man called Jacob Moreno and his ideas.
In passing I would like to mention that Jacob Moreno’s influence on mental health nursing has been strong, although largely unacknowledged. According to the findings of an MA thesis by Wendy McIntosh ‘Until the introduction of Moreno’s work in psychodrama the role of the mental health nurse was custodial’.
Jacob Moreno, Role Theory and the Social Atom
Jacob Moreno had a different way of viewing these kinds of interactions. He said that they lack spontaneity. For him behaviour was generated in the social atom. The social atom is the network of significant relationships at any particular moment in our lives. So the original social atom is usually the family of origin. In these social atoms certain behaviours, certain roles and role relationships are learned. Moreno developed role theory so that it became a way of understanding personality and relationships. He described a role as ‘the functioning form the individual assumes in the specific moment he reacts to a specific situation in which other persons or objects are involved’. (Moreno 1946, 1961 p.vi) In other words it is a way of being in the world at any particular moment. Roles, in Moreno’s thinking, tended to be re-enacted in the various social atoms in which we are involved as we proceed through life. Eventually they become hardwired. Personality becomes fixed and somewhat rigid. Every time the nurse encounters angry rejection in a situation where she perceives herself to have authority she responds with dictatorial authoritarianism. The role system, authoritarian dictator, angry rejecter is hardwired and the mind ‘clings to the road it knows’.
Moreno referred to the roles learnt or re-enacted in the various social atoms we encounter in our lives as social atom behaviour. And beyond the early social atoms, such behaviour for the most part lacks spontaneity. It is simply a repeat or re-enactment of old behaviour. Spontaneity in Moreno’s terms refers to the ability to generate new responses to an old situation and adequate responses to a new situation. He described it as the ‘S’ factor. He said it cannot be conserved or stored. It is that spark that initiates creativity and indeed life. My daughter has informed me that creativity resides in a small corner of the soul simply waiting to be released and spontaneity is the spark that will release it. The poet David Whyte in a poem called ‘Out on the Ocean’ writes of being in a kayak five miles off shore, off a shore that he cannot see and in the midst of large swells. He describes what happens thus:
the blades flash
lifting veils of spray as the bow rears
terrified then falls
with five miles to go
of open ocean
the eyes pierce the horizon
the kayak pulls round
like a pony held by unseen reins
shying out of the ocean
and the spark behind fear
recognised as life
leaps into flame.
always this energy smoulders inside
when it remains unlit
the body fills with dense smoke.
He goes on to say that the smoke is expressed into the world as resentment, complaint, blame, self-justification and martyrdom; and I would add envy, self absorption, laziness, defensiveness and arrogance.
The behaviour in the story at the beginning of this paper is the behaviour of people whose bodies are filled with dense smoke. There is a critical lack of spontaneity in both the nurse and Phillipa. There is nothing new, it is just the same old same old repeated over and over again day after day. It is not therapeutic because it simply repeats the same old patterns and reinforces the same old responses. If anything we would have to argue that it is anti-therapeutic; it lacks spontaneity to the nth degree. There is nothing new; there is nothing created.
Let me just briefly look at another example so that you can see that this kind of thinking can be applied to any interaction. Often these are situations where the difficulty is much more subtle – much less obvious than the first example. Neil is an experienced psychiatric nurse with a small case load in an acute setting. One of his patients Patrick walks listlessly around the wards often depressed and unmotivated to change anything in his life. Neil is conscientious but in some ways rather dull. He approaches Patrick and asks him if he would like a game of table tennis. Patrick says ‘No thank you.’ Would he like a game of Scrabble. Patrick says ‘No thank you’. Neil thinks same ole, same ole and walks away not for a moment realising that his response is also same ole same ole. An examination of the file reveals that Patrick has been brought up in an immigrant family who have worked hard at creating some kind of living for themselves and never shown much interest in him at all. So long as he keeps out of trouble and does not fall foul of the police they let him go his own way and do his own thing. They visited him regularly, maybe once a month. They are not particularly interested in him neither is Neil. In other words the same dynamic of disinterest and giving up after a cursory interaction is re-enacted over and over again.
Is this a therapeutic relationship, I think not. My own thinking is that if we as nurses are to truly claim the territory of therapeutic relationship then we must begin to learn about the difference between a therapeutic relationship and a conserved re-enactment of earlier experiences. I propose that a therapeutic relationship is one in which earlier experiences are not re-enacted over and over again; is one in which the nurse, because they are the therapeutic agent takes the time and the trouble to figure out the nature of the dynamic which is being re-enacted and to introduce some spontaneity, some creativity, some new way of responding. Eg, in this case persisting beyond the immediate withdrawal in the face of Patrick’s negativity.
This is not an easy task. The responses of the nurse are often part of the problem. These responses emerge from the nurse’s own conserve of roles and role relationships. They are a function or even a feature of the nurse’s own personality. These responses were learned in the nurse’s own social atom(s). It is not easy to change. Conscious change requires sustained consideration and understanding of the difficulty, a recognition of its genesis, and an understanding of the dynamic. It requires a reduction of anxiety so that spontaneity can spark creative responses. It requires most of all a conscious effort to bring the interaction under scrutiny no matter how uncomfortable this may feel.
Many people, including nurses have never learned to recognise their own day by day anxiety let alone focusing in a sustained way on this low level fear of which they are largely unconscious. They shy away from it because every new thing we attempt in life carries with it an element of anxiety. We cannot predict the outcome, we cannot predict what will happen, we cannot predict what the consequences of our new behaviour will be simply because it is new and we haven’t tried it before and these things make us anxious, not supremely clinically anxious, but anxious enough with normal anxiety to prefer the old way, to prefer to live our lives in the conserved manner to which we have become accustomed. Social atom behaviour dominates many people’s lives and this is not different for nurses. In our work with the mentally distressed the task is to identify the social atom enactment, to reduce our anxiety and to trust our own spontaneity to come to the party. Throw up the possibilities into our conscious mind. Take what is there seriously and examine the possibility of its enactment with the person/patient.
Where do we do this? Well now, as many of you will know I am back to a pet subject and one to which I have devoted the last twenty years of my life. This is precisely the purpose of clinical supervision, to enable us to understand the dynamics in which we are entrapped and to allow the new to emerge and be enacted in the world. You may then begin to understand why these changes are so necessary and yet so difficult to enact in the system which often seems to be dominated by issues of power and control.
In a therapeutic relationship we give up our power and control and enter into the world naively recognising the old dynamics and letting them go so that the new can emerge and the ‘spark behind the fear’ leaps into flame. This is the spark of spontaneity. This is truly therapeutic because it brings about social atom repair. This is a relationship where the nurse does not re-enact over and over again the dynamics with which he or she feels safe and non anxious. This is a relationship where the nurse by introducing something new tolerates the anxiety and values the response of this other person. This is a relationship within which both nurse and this other person live in a new way; this is a relationship which gives this other person the opportunity to find within themselves a new response. This is a therapeutic relationship.
McIntosh, Wendy (1999) A Critical History of the Influence of Jacob L. Moreno’s
Concepts and Techniques on Nursing. Unpublished MA Thesis.
Moreno, J.L (1946) Psychodrama Vol.1. N.Y. Beacon House Inc., 6th Ed., 1980.
Oliver, Mary (1986) Dream Work. The Atlantic Monthly Press, New York.
Whyte, David (2002) The Heart Aroused: Poetry and the preservation of the Soul in
Corporate America. Doubleday, New York.