Posted on: March 5, 2021
Written by Cheryl Forchuk, Editor of From Therapeutic Relationships to Transitional Care.
Historically, mental health practices have been grounded in concepts related to establishing and maintaining therapeutic relationships. In modern mental health practice, there are many challenges and contexts that appear to push therapeutic relationships more to the background of care. For example, we have seen biological explanations for many mental illnesses and a reliance on medications as a primary intervention by numerous practitioners. In a much older article (Forchuk, 2001 10.1136/ebmh.4.2.39), I gave several examples in both nursing and broader mental health literature of how the biological understanding of mental illness was pitted against the interpersonal perspective – as if the two were mutually exclusive. More recent literature is increasingly reflecting the (somewhat obvious) understanding that we are whole people who have both biological and social needs and require multiple kinds of interventions.
With short lengths of stay in hospital programs, some mental health practitioners may question whether there is even time to focus on relationship issues when there are numerous tasks to be completed, and at times, basic safety issues that require more immediate attention. In the community, mental health practitioners are part of teams that have numerous members all claiming to have simultaneous therapeutic relationships with the client. In modernized hospital and community mental health settings we also need to understand the role of technology in the context of therapeutic relationships.
Photo by Greg Rosenke from Unsplash
Despite the obstacles and pragmatic concerns, I would argue that the therapeutic relationship continues to be the essence of our work. Recent research on relationship-based approaches continues to demonstrate their connection to positive client outcomes. For example, our recent work on the Transitional Discharge Model illustrates how attention to both traditional professional relationships and peer relationships that bridge the discharge process can literally save hospitals millions of (Canadian) dollars in hospital lengths of stay (Forchuk et al., 2019a), while also providing a welcome safety net of relationships for the client (Forchuk et al., 2019b; Forchuk et al., 2020).
We need to reflect on our understanding of the therapeutic relationship in the context of today’s practice arena. Therapeutic relationships are critical to effective client care, but we must acknowledge that not all of our relationships are therapeutic. Recognizing non-therapeutic relations is essential to providing effective client care. We must also recognize that we are not the only ones with therapeutic relationships (and non-therapeutic relationships). Assessing the constellation of relationships available to our clients and supporting the development of a network of supportive relationships can be an appropriate intervention, even during short lengths of stay and in the contexts of teams. Peers and family members should also be considered within these networks of relationships. The concept of “Therapeutic Alliance” was introduced in the literature as being almost synonymous with “therapeutic relationship”. However, this term can be useful to expanding our understanding of relationships in our work with groups and agencies. Organizational alliances at larger systems levels can assist us to provide a supportive context for the development of relationships at the individual level and also allow us to more systematically address issues of the broader determinants of health and promotion of community development. Our knowledge regarding processes at the individual and systems levels can also be used to assess and promote these other layers.
In current times, the therapeutic relationship still has precedence in treating the whole person. Educational programs and practice sites need to instill the importance of relationships with clients, their families, and peers and how these relationships can be cultivated. This approach can lead to improved outcomes in treatment and significant cost-savings for operations. On-site policies can be reviewed to allow practitioners to have more time and consistent assignments to develop therapeutic relationships - the foundation of healthcare. Professional development can also provide practitioners with opportunities to reflect on their practice and advance their skills in this important area.