Counselling case study
Counselling Case Study
The following intervention analysis will utilise a planned verbal interaction, which occurred as part of ongoing care, during a 15-week placement on a Psychiatric Acute ward catering for Women aged 18-65. The client's informed consent was gained verbally, to use this conversation within my assignment. The client will be referred to as Carol. These measures are in accordance with the UKCC (1998) guidelines regarding consent and confidentiality. A client centred approach is to be employed as an aid to critical analysis of the intervention. It will firstly give a rationale for why this particular intervention was chosen and for the theoretical approach utilised. Biographical details of the client including events leading up to this point, previous conversations and incidents which are relevant to the chosen intervention, can be found in Appendix A. It will outline what a client centred approach involves. Firstly by defining its beliefs and essential core conditions, then by calling on the more practical micro-skills involved. The interaction will be analysed as each of these core conditions and skills are stated, thus helping in illustrating the helpful and not so helpful aspects of the interaction. Throughout the analysis, I will reflect upon how the intervention could have been more effective offering alternatives, which could have been more client-centred.
The interaction, which is the focus of this study, is a prime example, in which I feel the need to offer a solution, in order to solve the problem, as I saw it. It was obvious to me that I did not have all the answers. This left me wondering whether a more 'realistic' approach would help. My practice up to this point has always been more directives and prescriptive, so logically I searched for an alternative, as my current practice was not having the desired effect. Therefore I chose to utilise a client centred approach and selected this particular intervention because I hoped firstly, to make sense of it and secondly, it could be inspiring to use a client led approach, as the prescriptive methods widely used in hospitals today (Morrison & Burnard 1990) had not helped. Another contributing factor were, staff attitudes toward the client. These were mostly negative. One member of staff said, " Good luck with her, you will soon find out, she's beyond help". This influenced my perception of Carol, making me negative before the fact, which served to make the task of being client centred more complicated, consequently making me more determined to understand this accepting 'way of being' described by Rogers (1989).
What is a client centred approach?
Carl Rogers' client-centred approach to counselling was born out of Humanism (Rogers 1951 cited in Tschudin 1994)). Thorne (1990) states that Carl Rogers believed that what mattered, was the kind of relationship he offered to his client, nothing more, and nothing less. His approach, views the client as the expert. That is to say that, only they can really know what is good and bad for them. It stresses individuality, offers the client the opportunity to take control of their own life. The client centred-approach believes therefore, that the client is capable of finding their own way through their problems believing that in, everyone there is a potential for personal growth and change. Carol has been in the services for 20 years, only serving to deepen the layers of defences she has put in place to protect herself from harm, thus burying this ability to grow. He also holds strong belief in that counselling is not a way of modifying behaviour (Burnard 1999). The question remains how do we create the correct environment? Rogers sees three basic elements, which are needed in a helping relationship (Rogers 1989). These are his core conditions.codd ddr seddddw ordd ddk indd fodd dd.
Congruency seems to be something that is gradually achieved. Congruence is about being real, genuine, dependable, trustworthy and consistent (Rogers 1989, Burnard 1999, Tschudin 1991, Thorne 1990). Rogers (1989) would advise that whatever feelings or attitudes I may be experiencing, I must try to be fully aware of them, in order to be congruent. He also states, that there is much research, which supports the concept that the congruency of the counselor is beneficial in creating a therapeutic relationship. In interactions 28 & 29 I was feeling frustrated and angry with Mrs. X. I recognized this at the time and expressed it through, reacting to her behavior, not by trying to understand the underlying feelings that were making her behave this way. Tschudin (1994) suggests that when feeling annoyance with another and not acknowledging or recognizing it, then the client will begin to see your verbal and non-verbal communication are not in harmony. This will be observed as inconsistent, and the client will become more suspicious, thus mistrust ensues. Rogers (1989) calls this 'transparency', or in my own words 'see through'. This is what it is to be incongruent. Maybe in 28 & 29 I could have been more honest with Mrs. X and said " I am feeling frustrated and angry because you are willing to walk away, without explanation". On reflection, my frustration was already established prior to the interaction, due to the content and outcome of other interventions, along with staff attitudes towards my attempts to help. I did not address these issues. Therefore I allowed myself to be incongruent. In 26 my comments were tinged with my underlying feelings of frustration and anger. I was beginning to become transparent. Maybe it was this factor, which played a part in making Mrs. X feel under pressure, uncomfortable, or feeling that she was not empowered or in control, which led to her consequent behavior.
This is the ability to understand the client's current situation from their point of view (Tschudin 1994). This requires the counselor to be not only able to listen effectively and gain an accurate perception of their world, but to also be able to communicate this to the client (Reynolds & Scott 1999). Rogers (1989) suggests that to understand it, the reader should view it as walking around another person's world, while communicating some understanding of it, of which the client may only be dimly aware. In 5 I missed the cues, which indicated her need to talk about her current feelings. If I had of been listening I would have recognized this and focused on those feelings instead of challenging her to search for a cause of these symptoms. If we had explored her feelings together, maybe the cause could have been found in her own way, and at her own pace. Again in 11 & 12 I missed what appear to be cues. She repeats the phrase 'at times' twice. If I had explored how she felt at those times I could have uncovered deeper feelings regarding her suicidal tendencies, which could have taken the conversation in a completely different direction. This writing from studentcentral.co.uk
Unconditional positive regard
The third condition is also called accepting or prizing the client. This means that I must view the client with dignity and value them as a human being (Rogers 1989, Burnard 1997, Tschudin 1991) in other words that I accept the person without fear or favor. On reflection I feel I didn't accept her, as I should have. Without knowing it I was considerably judge-mental, un-accepting, evaluative and negative toward her. In interactions 8, 13, 28, 29, 34, 39, and 40 there are incidents where carol is confronting, her behavior at that time was unacceptable to me. I perceived this lady as negative, old, unwilling to engage and awkward. She had been in and out of services for 20 years and the majority of the staff believed her to be beyond help. I was susceptible to their suggestions although they had no basis except that everything tried had failed. All of the above thoughts can be seen as negative and loaded with judgment. Did I accept the client? At times I didn't believe her, believing that she was exaggerating her symptoms in order to get her PRN medication. On reflection I feel I didn't understand her, as I should have. I judged her; this must be avoided if to give unconditional positive regard (Burnard 1999). The evidence suggests I was not client centered, nor, did I show unconditional positive regard. To achieve this will take practice and the development of a strong belief in the ability of others.
To allow for easier application, Burnard (1999) defines some micro-skills, which may help in the development of a client-centered approach. These include:coee eer seeeeew oree eek inee foee ee.
2. Reflection/Selective Reflection
3. Empathy buildingcoeb ebr seebebw oreb ebk ineb foeb eb.
4. Checking for understanding.
I will continue my analysis of the recorded intervention as these skills are stated, attempting through this, to gain some insight into whether my actions were client-centered or not.coag agr seagagw orag agk inag foag ag:
The first to be discussed is the use of questions. These can be open or closed, leading and confronting (Burnard 1997). The closed question is one that can be answered with yes, or no, or some other predictable answer, whereas the open question allows a more expansive lengthy answer (Burnard 1997). Littered throughout the interaction are questions, some open, some closed. I used these without any idea of the impact they might be having. In the opening of the conversation 1, 2 & 3 open questions were used. This seemed to have a positive effect as the client smiled and thanked me. I was expressing genuine concern for her well being. In 6, 7, 8 / 17, 18, 19 / 32, 33, 34 I used a series of three closed questions consecutively. On each occasion Carol reacted defensively. At the time I was totally unaware of why she was behaving this way and in particular that I may be influencing it. I felt that the problem was hers, that she was being awkward. These sentiments illustrate my lack of awareness in this situation. Burnard (1999) suggests that when closed questions are used this way, they can lead the conversation, making the client feel as though they are being interrogated, leaving Carol with little control over the direction of the conversation. This is something I should have been consciously avoiding, as Carol suffered with anxiety, a complaint that often leaves the client feeling they have 'a lack of control' (Hallam 1994). If my aim was to help Carol gain back some control over her life, then I should have not been undermining it this way. I had the opportunity to avoid this scenario. In 5 I could have said, " the churning is it painful, I noticed you rubbed your stomach" or " the noises and voices are distressing you today". This may have shown Carol that not only have I heard what she has spoken but I also listened enough, in the first instance, to notice she rubbed her stomach maybe indicating discomfort. Instead, I asked her to search for a reason as to why this was happening, rather than allowing carol to decide, which needs warranted further exploration. Within this, there is a degree of empathy being shown. Serving to help me stay with the patient's feelings.
As stated above closed questions do have their uses. They can help the counselor to clarify what is being said (Tschudin 1991). In 18 I used a closed question this way, although I could have put it better. For example, "am I right in thinking that...."? Rather than "So would you agree..." Altered in this way it would have served to clarify, thus being client-centered. I follow this in 19 with a leading question, one that contains an assumption, (Burnard 1999) placing Carol in an indefensible position, subsequently undermining what I had already tried to do. I tried to clarify again, in (33), this time the outcome was more preferable, as carol disclosed important information regarding the anxiety pack. This should have allowed me to explore these issues with her, yet instead of doing so in a client-centered way I attempted to offer solutions to her problems instead of going with her feelings by focusing on them. Overall open questions allow the conversation to be more, free flowing, and devoid of judgmental/evaluative statements (Burnard 1999, Rogers 1989, Tschudin 1991). I find it difficult at times to achieve this as I have a controlling nature; it seems easier for me to offer a solution based upon my interpretation and perception of the problem. Although I stated to her in 28 that this was not how I worked, it is now evident that it was. If carol realized my contradictions then it will have served to only make her suspicious of my agenda. There lies incongruence Not, as discussed ideal for a therapeutic relationship. from coursewrok work info
2. Reflection/Selective Reflection
Reflection is a talent that is sometimes referred to as 'echoing'. This is where the counselor reflects back the last few words said by the client, sometimes acting as a prompt. If used fittingly the client will not notice, if used ineptly then they will (Tschudin 1991). Selective reflection on the other hand is one in which the counselor echo's what has been said not at the end of the sentence but from the middle. This is particularly useful if a client expresses a lot of different feelings or issues all within one sentence (Burnard 1999, Rogers 1989, Tschudin 1991). This was an area in which I failed miserably. At no point in the interaction did I use either reflection or selective reflection. Although there were many occasions where I could have. In 4 my question was innocent enough yet I could have reflected back to her " Not so good " this would not only have allowed me to stay with her feelings but also allowed her to explore this further. Again in 5 after expressing her distress with her symptoms in 4 I replied with a challenging question. Maybe it would have been more productive to focus on carols feelings, through reflection and recognition of her nonverbal cues. In 7, 11, and 17 I could have used this same technique to elicit further information. For example in 7 I should have said, "you said it was all right, you seem unsure" I would hope that she would respond to this by elaborating on what she means. This, as well as being reflective is also an empathy building statement.
3. Empathy building
Burnard (1997) states that empathy building consists of making statements that show an understanding of the client's feelings. They should reflect what is implied as well as what is said overtly. Effectively this is an ability to read between the lines, allowing the client to disclose further as they see you understand them more. As seen above in 7 I could have been seen to be more empathic by noticing that although she implied it was okay, her non-verbal signals indicated otherwise. To notice this is a start but not enough, you need to state it within the conversation so that both parties are aware and the issue can be dealt with. To recognize this incongruence in a client can only help me, to recognize it in myself in the future. There was one point at which I attempted to be empathic. In 30 from her behavior I recognized her frustration with the situation, this seemed to appease Carol and consequently allowed us to continue. I feel that it would have been even more beneficial to have just said, "I sense your frustration, yet I'm confused at what it's with" again I see this statement as an aid to further exploration. Further illustration of my inability to build empathy is evident in 6 I lead the conversation to what I think is the root of the problem. If I am to be truly client centered here I would have to have faith in the fact that carol can lead herself to the root of her problem. Maybe following carols answer in 5 I should have returned to her feelings in expressed in 4 by stating "you say the noises and voices are bad" this would help focus on the carols feelings and show that I was listening.
4. Checking for understanding
This is self-explanatory. It involves asking the client if you have understood what they have said and secondly summarizing what has been said for the purpose of clarification (Burnard 1999). It can help focus a conversation and also serves to help the counselor to stay with the client's feelings (Tshcudin 1991). Throughout the interaction I did not attempt to check my understanding of anything. I had opportunities in 12 I could have checked what was being said. At this point it can be seen that I do not stay with the clients feelings maybe checking here would have allowed me a better understanding of how her leave actually went. I do not identify specifically what the problem was on leave, throughout the whole interaction. This is a simple measure that contributes to all other factors discussed. It links in with empathy as it allows better understanding. It allows me to be congruent while helping me stay with the clients feelings. All fundamental in this way of being.
If I am to be truly client centered I would have to have faith in the fact that carol can lead herself to the root of her problem. At the time this was not my mind-set. I have learned that a good counselor can't be phony. They must be able to relate to others honestly and sincerely. I realize I don't have to be perfect, but I must try to avoid being defensive when relating to the client. I must be able to put myself in the client's shoes, try to be genuine being able to understand them and communicate this to them. It seems that there is much to be learnt from the client, as they are the experts. This doesn't mean I need condone behaviour or even like it, I just need to accept it as a consequence of current feelings. This interaction is a prime example, in which I feel confused not by the verbal and non-verbal content of what is being said but by what I should now do with it. In undertaking this study I have developed new skills and insight, it appears that there are methods that have the client at the centre which allow me to overcome those periods where I am at a loss for what to say. Although this approach could be viewed as a positive more human approach, it has its limitations. It seems to rely on a degree of compliance on behalf of the client. A situation we are not always blessed with in acute psychiatric wards. It requires a deep person-to-person understanding, acceptance and awareness, something I sometimes don't have with those closest to me. There are always arguments for and against differing approaches yet I have learnt one way of being which is comfortable and natural.
Carol is a 63yr old lady, who first had contact with the mental health services in 1980 suffering from mild symptoms of depression including some suicidal ideation. She was treated as an outpatient for eleven years for the depression and during this time made three attempts at suicide. It is suggested that the trigger for these symptoms was the death of her mother, who died of cancer in 1979. Very little is documented in medical notes during this time, which does not allow me to identify any interventions, e.g. bereavement counselling, anxiety management etc. that may have been done at that time. Further problems occurred in 1991. At this time she was found to be suffering from bulimia. She continued to be seen as an outpatient at her request for a further two years in which her problems were managed jointly by the consultant psychiatrist and in the community. Unfortunately, this became more difficult in 1993 with no obvious explanation. She was admitted to an acute psychiatric ward for assessment and treatment. She spent an 8-month period on the ward in which time her husband left her and her son was sent to prison. These stressors could possibly explain her relapse. In 1996 the bulimia was reported to be under control. At this point, she had her first contact with Bradford Mental Health Services spending a four-month period on the acute ward for depression and anxiety. She acquired her own flat, for which she shows great affection. Since this time she has had several admissions presenting with an inability to cope, low mood and symptoms of anxiety.
On this admission Carol had been admitted for respite, expected to be no more than a week, as she was feeling low and suicidal, she also complained of noises and voices and a churning in her stomach. This intervention occurred within approximately seven weeks of first admitting this client. She had originally been under the care of another nurse, yet I requested the opportunity for me to approach her with the idea of changing her primary nurse. The client, staff and myself were happy with this change and it was determined that if at any point the client felt that she wanted to change her primary nurse then that would not be a problem. Our previous meetings consisted of setting some boundaries for both the client and myself. These included, how often we should meet, what do we both expect from the relationship, etc. From this we set realistic goals and agreed on ways to tackle them. These included the use of breathing exercises and relaxation tapes, along with medication including PRN medication: lorazepam 0.5mg QDS. I introduced the idea of an Anxiety self-help pack, to which the client was interested. We attempted to go through the self-help pack together but she became irritated and wanted to stop. I left the pack with her and assured her that if she did want to go over it again then I was more than happy to. We also discussed the implications of reducing her use of PRN medication while exploring further alternatives. We had agreed that there had to be effort on both sides if this relationship was to work to her benefit.
Three weeks prior to this intervention Carol had taken a serious overdose in response to her feelings of anxiety and her noises and voices, while she was on leave. She described the incident as if she was going to 'explode'. She had tried all the PRN medication, breathing exercises and relaxation tapes which did not help, she felt the only way to stop it was to "die".
Prior to the conversation starting the client was again made aware of the purpose of the interaction, to explore how she felt about her home leave. At the end of the last meeting a time, date, and purpose had been set.
TRANSCRIPT OF CONVERSATION
(1) NURSE: Hello Carol, (I smile) take a seat. (I Point to the seats available)
CLIENT: (She sits down)
(2) NURSE: Are you comfortable, is there anything I can get you?
CLIENT: No thanks; I'm fine (She smiles)
(3) NURSE: How are you today?
CLIENT: Not so good martin. (She shakes her head from side to side).
(4) NURSE: What's the problem?
CLIENT: My stomach is churning, and the noises and voices are bad today. (She rubs her stomach)
(5) NURSE: What do you think is causing it?
CLIENT: I don't know
(6) NURSE: Did your leave go well?
CLIENT: Yes, It was all right; I cleaned up the flat and saw my grandkids.
(7) NURSE: Was it nice to see the grandkids?
(8) NURSE: Overall do you feel it was better than the last time you went out?
CLIENT: No, it was the same. (She said this hurriedly) What's this got to do with anything?
(9) NURSE: I'm just interested
CLIENT: Oh (Tone of voice was dismissive and she shrugged her shoulders)
(10) NURSE: Did you feel safe this time; because the last time you had leave you took an overdose.
CLIENT: At times I thought about it
(11) NURSE: How seriously did you think about it?
CLIENT: Only at times, I wouldn't of done it
(12) NURSE: Then I would suggest that on that basis you could say your leave went much better
CLIENT: Not really, I still felt awful inside
(13) NURSE: Yes, but try to focus on the positive things that happened, and not just the negatives
CLIENT: That's easy for you to say
(14) NURSE: I understand that, but ask yourself what benefits you get from thinking so negatively
CLIENT: (Carol remains silent for a long period.... 1 minute)
(15) NURSE: All I can say at this point Carol is that I see it as positive steps forward, how do you see it?
CLIENT: I don't want to go out on leave again this weekend
(16) NURSE: That's your decision. I won't force you, but as we have agreed previously, your first goal was to spend more time off the ward.
CLIENT: Well I don't want to go, not this weekend. I just felt that something awful was going to happen
(17) NURSE: And did it?
CLIENT: Not really, I just felt panicky
(18) NURSE: So would you agree that although you felt that something terrible would happen, it didn't?
CLIENT: I suppose so
(19) NURSE: Isn't that a good thing?
CLIENT: Yes but it doesn't make me feel better now
(20) NURSE: How are you feeling now?
CLIENT: All churned up inside
(21) NURSE: Have you tried the techniques I showed you?
CLIENT: Yes I've tried the tape, and done my breathing exercises.
(22) NURSE: And has that helped?
CLIENT: A little. (Looks up at me and maintains good eye contact)
(23) NURSE: Good. (I nod my head in an attempt to emphasise that I was pleased for her)
CLIENT: Can't you give me some PRN please martin.
(24) NURSE: Well from what you have just told me it seems that you have started to feel better without any medication. Do you think you could control this yourself at the moment?
CLIENT: You don't understand. It's awful feeling like this. (She begins to cry)
(25) NURSE: (After about a 20-30 second break) Carol, I want to understand, talk to me about your feelings.
CLIENT: What's the point?
(26) NURSE: The point is that for you to begin to feel better, you need to take more control over your feelings of anxiety, and that means being prepared to talk to me or to someone you feel comfortable with about these feelings.
CLIENT: You do say the most stupid things sometimes martin.
(27) NURSE: What do you mean?
CLIENT: Well you're the nurse I'm the patient. You're the one who's supposed to get me better.
(28) NURSE: I'm afraid that's not how I work Carol. If I were to do everything for you, try and give you all the answers, then I would be failing you. It's not about how I would cope with these feeling's, it's about how you can best do that for yourself.
CLIENT: So what am I supposed to do, you always want to talk (Carol emphasises this word) about things, yet you never give me any ways of coping with these feelings. (Carol gets up out of her seat and begins to walk away without explanation). (I felt angry at this point that she was willing to just leave without any explanation)
(29) NURSE: Carol, I don't understand why you are being like this. I don't get up and walk out like this. I would have enough consideration to at least explain, why I didn't feel like talking. So I expect the same level of respect from you. I thought we were getting somewhere today.
CLIENT: (Carol continues to walk to the door)
(30) NURSE: You're obviously frustrated Carol, I can understand that, but walking away from it can't help, can it?
CLIENT: (Carol says nothing but stops near the door and turns towards me)
(31) NURSE: (There is a silence, which lasts for about 30 seconds) Please come back and at least set a time and date for the next meeting.
CLIENT: (Carol returns to her original seat, she remains silent for about 30 seconds) Nothing is helping.
(32) NURSE: (I remain silent, while maintaining good eye contact) the anxiety management pack I gave you, has it been useful or not?
CLIENT: (She shakes her head)
(33) NURSE: I get the feeling you don't think much to the pack?
CLIENT: I don't understand it. It goes on about physical things. I don't want to know that I just want a list of thing's that will cure it
(34) NURSE: Should we go through it together again, would that help?
CLIENT: I don't know (She is dismissive in her tone of voice)
(35) NURSE: Well, why don't you think about it and get back to me. I am more than happy to try alternatives.
CLIENT: Yeah okay
(36) NURSE: Do you have any ideas about what might help?
CLIENT: Don't know
(37) NURSE: There are other self-help packs around which you may find better, would you like me to get one of those for you?
CLIENT: I don't really want to talk about it at the moment.
(38) NURSE: Okay (I hold my hand up as to suggest that it is okay) shall we leave it there for now?
(39) NURSE: Why don't you think about what we've talked about today, try to look at the positives, think about whether we should try a different approach and we can talk about it the next time we meet.
CLIENT: There you go again talk, talk, talk, and talk. (Carol makes a gesture with
her hand as if it were talking)
(40) NURSE: I think maybe we should leave it there. When would you like to meet again?
(41) NURSE: Tomorrow?
(42) NURSE: Okay, tomorrow I'm on an early shift so about 10am?
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