Introduction

This essay aims to critically analyze the concept of a therapeutic relationship and its significance

in clinical settings. With the help of contemporary literature, the essay discusses the aspects of

the therapeutic relationship and their impact on nursing clinical practice. The clinical area

discussed in the paper is mental health nursing within an inpatient setting where the author has

experience in providing care for patients. Using the area of mental health nursing, the paper

analyzes the scope of issues faced by nurses in building boundaries within their therapeutic

relationships with the patients and argues the well-suited boundary managing style for this

clinical setting in contrast to other styles. Moreover, the paper also uses the Boundary Seesaw

model by Hamilton to support the use of the preferred boundary management style with

inpatients in a psychiatric unit.

The therapeutic relationship in a clinical setting is defined as a human exchange based on

effective interactions favouring the possibility for a clinician to help a person to improve their

mental health condition (Fullard, 2018). The basic pillars for nursing in clinical settings require

effective therapeutic alliance based on communication, understanding, authenticity, respect and

warmth. Mental health nurses seem to be aware and knowledgeable of the significance of

different aspects of a therapeutic relationship while working within inpatient units (Valente,

2017). The ongoing nature of treatment demands trust and rapport between the nurse and the

patient to avoid any risk and improve therapeutic goals (Hampton, 2019). Nurses recognize the

significance of their actions and words and the way they can impact the relationship and

ultimately the care given to the patient and therefore, work towards providing a supportive

clinical environment (Townsend & Morgan, 2017).

The establishment of a therapeutic relationship between a nurse and a patient has always been

considered in nursing (Valente, 2017). However, in mental health settings, it is the core of

practice involving interpersonal interactions making it the essence of the care being provided

(Fullard, 2018). The success of a number of psychological and medical interventions rely on the

foundation of a therapeutic relationship involving medication compliance, building insight,

facilitating problem-solving, achieving therapeutic goals and outcomes and increasing the quality

of life (Townsend & Morgan, 2017). According to the literature, a number of attributes and

aspects are required to compose an effective therapeutic alliance (Hampton, 2019). It requires

empathy, having unconditional regard for the patient, accepting their individuality, genuineness

in caring and demonstrating respect. However, these aspects often bring a number of challenges

in building strong and effective professional boundaries (Valente, 2017).

The ability to establish effective therapeutic relationships and maintain clear boundaries is

considered one of the important competencies in clinical settings (Hartley et al., 2020). It is due

to this establishment of professional boundaries that create a relational space where the nurse and

the patients come together to explore treatment options with safety and comfort (Hampton,

2019). Although well-established boundaries often go unnoticed, most individuals are able to

recognize any violation in their experiences. People experience interpersonal interactions

differently; one person’s feeling of being invaded, intruded upon or violated in any way could be

subjective and different from the other (Hartley et al., 2020). Yet some of the invasive

components of communication or acts can be viewed commonly as black and white (Zugai et al.,

2015). The trust that develops between a nurse and a patient, coupled with familiarity and often

seductive pull of helping and often a lack of understanding of challenges leading to crossing a

boundary, threatens the integrity and significance of therapeutic relationships (Fullard, 2018).
In relation to mental health nursing, both patients and nurses must be willing to form a

partnership for ongoing care. The process of getting to understand the patient is fundamental to

building an interpersonal connection (Tolosa‐Merlos et al., 2021). Literature finds a few

characteristics and qualities of these interactions which are necessary for the alliance such as

building hope and honesty (Townsend & Morgan, 2017). As this relationship facilitates growth

and change, nurses need to instill hope in patients with sensitivity and genuineness shown to

them both verbally and nonverbally. Literature suggests that therapeutic alliance leads to self-

awareness and reflection in the consumers who actively start collaborating with the nurses. On

the other hand, a therapeutic relationship must be built using professional values and boundaries

(Hartley et al., 2020). For nurses, no matter how the consumer may behave, it is their

responsibility to understand the professional behaviour continuum and manage their own actions.

According to the research, both over-involvement and under-involvement could jeopardize the

quality of care and relationship with the patient (Valente, 2017). Over-involvement may hinder

self-growth and sense of self in the patient and could lead to boundary crossing and violation.

Whereas, under-involvement may suggest disinterest, neglect and despair for the patient and

eventually lead to poor patient outcomes (Tolosa‐Merlos et al., 2023). Some of the other issues

identified in therapeutic relationships within contemporary literature include special patient

treatment, undue self-disclosure, super nurse behaviour (knowing better than anyone what is best

for the patient), and any secretive behaviours. Regardless of these concerns, the therapeutic

relationship and professional boundaries are rendered the most useful tools in providing care and

support to the patients, more so, when managed properly (Zugai et al., 2015).

Boundaries are limits that define the level of comfort for the patients and nurses while interacting

with each other (Park & Shin, 2018). In a clinical setting, it is the way nurse-patient interaction
creates, maintains and interprets these limits to facilitate recovery. According to Hamilton’s

boundary seesaw model (2010), there are three boundary management styles that are noted in

clinical practices. The controller or often known as the security guard style of boundary

management holds a negative attitude about bonding with the patient and about his treatment. In

the relationship, a nurse with this management style for boundary management shows

inflexibility and fixed limits (Lambert et al., 2019). According to this style, a relationship can

only be effective when underpinned by judgment, control and emotional distance (Hamilton &

Bacon, 2021). The patient may feel vulnerable, judged and neglected which may force the

psychiatric patient to push to regain a sense of control. This could most likely result in a vicious

cycle of negotiation, emotional deprivation and control and eventually poor patient outcomes. On

the other hand, Hamilton (2010), identified a second boundary management style i.e. pacifiers.

During this style, the clinician can be overly accepting, indulging, self-sacrificing and having

quite flexible limits. Within mental health nursing, it can cause several ethical and moral issues

relating to the patient (Park & Shin, 2018). The nurse may feel the need to rescue the patient and

may go out of her way to facilitate healing which is found to be associated with boundary

crossing. According to the literature, this humanistic approach to relationship building can be

useful however, with the complex manifestation of clinical diagnoses, it can lead to manipulation

and dependence from the patients (Lambert et al., 2019). Pacifiers may loosen the boundaries to

meet the need of their patients which over time leads to placating trap where boundaries become

confused and enmeshed (Davidson, 2019).

In mental health service users, both the controller and pacifier boundary management styles are

somewhat applicable with the latter more strongly advocated for (Park & Shin, 2018). However,

the applicability of these management styles in building boundaries and the therapeutic
relationship is questionable. For instance, a narcissist or psychopathic patient in a ward setting

may target pacifiers to get what they want and cross the boundaries to emotionally use the nurse

(Hamilton, 2010). Similarly, a sexual offender or psychopathic patient may comply with the

limits set by the controller only due to powerlessness which makes it hard to distinguish between

genuine treatment effect and compliance effect (Davidson, 2019). Henceforth, the third boundary

management style provided by Hamilton i.e. the negotiator is considered the most suitable to

enact within the chosen clinical environment i.e. inpatient settings (Lambert et al., 2019).

The negotiator style represents the synthesis of balance between the controller and the pacifier

and is reviewed as the most efficient way to manage boundaries in psychiatric units. The

negotiator is open, balanced, respectful, and responsive to the patient’s needs (Park & Shin,

2018). They do have some explicitly rigid boundaries yet maintain an openness to manage

patients’ wishes and needs. The rationale for the negotiators to be well-suited in the clinical

setting is the collaborative nature of the relationship where the nurses’ roles and involvements

are neither too distant nor too close. Nurses stay in tune with the process and use their critical

judgment to establish the relationship (Hamilton & Bacon, 2021). This style allows patients to

exert independence within a controlled setting of the ward and influence a sense of

empowerment. Therefore, to build an effective therapeutic alliance with psychiatric patients,

mental health nurses need to establish professional boundaries and adopt the role of negotiators

while managing these boundaries to facilitate recovery and treatment (Davidson, 2019).

Conclusion

The paper critically discussed the significance of therapeutic relationships within the psychiatric

inpatient unit where mental health nurses use different skills and aspects of communication to

establish a good alliance. The role of the therapeutic relationship in facilitating patient outcomes
and treatment/recovery has been discussed as well as the three boundary management styles in a

clinical context. Based on critical analysis and the review of the literature, the paper found the

negotiator style of managing boundaries to be most efficient with inpatients and building a

therapeutic relationship.
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