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Therapeutic Alliance and Mindfulness in Mental Health Assessments

Therapeutic Alliance and Mindfulness in Mental Hea
Photo: Therapeutic Alliance and Mindfulness in Mental Hea
As nurses how do we learn and teach therapeutic alliance? In fact can we teach it at all? It is such an important part of a “helping” relationship, it is difficult to get anywhere without it.

Carlat (2012) describes the therapeutic alliance as a feeling that you should create over the course of the diagnostic interview: a sense of rapport, trust and warmth. It is thought that creating rapport is an art and that it can be difficult to teach.

With the current trend of completing uniform assessments throughout the mental health industry, clinicians need to be mindful that it is important to be true to themselves so that their personality is able to show through. If this does not happen then they might appear to be rigid, wooden and lacking warmth, which could hinder the therapeutic alliance. So how does a nurse learn how to do this?

One way is learning from observation and then trialling your newfound skills. If you are fortunate enough to work with a variety of people you can observe behaviours and then decide if they promoted an alliance or if they were not helpful in establishing rapport. Recently I observed an experienced clinician who managed to take notes and have a meaningful interview with someone seeking assistance. I observed that the person was able to take notes but also managed to stop and listen to establish rapport before writing. They used an iPad and were thoughtful of all of their behaviours including keeping their fingers close to the keypad with no sound audible. They also had a pro forma on their iPad, which then only required them to write minimal information. This was a very timely and effective way of handling their workload and they had the written assessment complete and ready to be sent back to the referee immediately. Throughout the session they attentively listened to every response being sure to leave sufficient time for the person to respond. Without disruption they also managed to validate my presence by asking for my opinion and seeking my advice. I felt included and that I was an important contributor to this person’s health recovery plan. I also held information that may be critical to the success of the health plan and was given the opportunity to mention these things so they could be included in the SMART (short, measurable, achievable, realistic and time-bound) goals between the clinician and the person seeking assistance.

There are considerable differences between medical history taking and psychodynamic interviewing. This relates to diagnosis and treatment.  Gabbard (2014) explains that a physician evaluating a patient for appendicitis approaches the interview with a clear mindset: diagnosis precedes treatment. This can also be said for a nurse whose responsibility it is to assess the patient. The dynamic psychiatrist or mental health professional approaches the interview with the understanding that the manner in which the history is taken may in itself be therapeutic. There is undoubtedly some therapeutic action in listening and accepting the patient’s life story and validating that the patient’s life has meaning and value.

One very important fact to be considered by a clinician conducting an assessment is that they are serving as a witness who is recognizing and grasping the emotional impact of what has happened to the patient. The power of this alone cannot be underestimated as many people do not have someone to tell their story to or come from environments where listening is not something that is done well. McHugh and Slavney (1998) explain that every person has a story, and every story has the capacity to teach something about every one of us. There are as many stories as there are lives and there are many stories within each life. As a nurse you must be interested in people’s stories, not only the technical aspects of your role.

It is very important to be aware of one’s own feelings during an interview. They can give clues as to what reactions the person creates in others. In order to be able to do all of this well, the technique of mindfulness can not only be useful to teach others, but it can also help with developing a therapeutic alliance with others if you are the clinician.

Mindfulness as applied to mental health assessments requires ‘mindful listening’. Mindful listening requires that the health professional make a choice to understand and empathise with the patient. It is suggested that in mindful listening we put ourselves in the shoes of the person who is talking to us and try to see the world from their perspective. A strategy to help this is to pause before we speak. Ideally, we should take a few moments to pause and reflect on the question and on how we want to answer. I have observed this in prominent individuals who have to face the media regularly. They are careful to think before they speak which gives an impression of thoughtfulness..

As mental health professionals, we must continually strive to create a therapeutic alliance with our patients. Through self-evaluation, observation of others, and through mindful listening, we must work to develop and improve our rapport-building skills, as the clinical benefits of doing so, particularly in the mental health setting, have been well established.

References
Carlat, D., (2012) The Psychiatric interview. A Practical Guide. 3rd edn: Wolters Kluwer Lippincott Williams and Wilkins.
Gabbard, G.O. (2014) Psychodynamic Psychiatry in Clinical Practice. American Psychiatric Publishing, Inc.
McHugh, P.R., Slavney, P.R (1998) The Perspectives of Psychiatry. 2nd Edn. The John Hopkins University Press. Baltimore and London.
Tobler, A., Herrmann, S. (2014) The Rough Guide to Mindfulness. London: Rough Guides UK.
Black Dog Institute (2014). Available at: www.blackdoginstitute.org.au:  (Accessed 05/07/2014).

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