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Counselling and psychotherapy in mental health nursing: Therapeutic encounters

Counselling and Psychotherapy in
Mental Health Nursing: Therapeutic
Learning Objectives
Understand the historical influences of counselling and psychotherapy to mental
health nursing practice.
Consider the practical issues of engaging with counselling and psychotherapy
with acute adult mental health patients.
Awareness of the processes and outcomes of engaging with counselling and
psychotherapy in mental health settings.
This chapter provides an overview of how counselling and psychotherapy have
influenced mental health nursing practice. We aim to inspire a renewed curios-
ity about the influence of counselling and psychotherapy in contemporary mental
health nursing practice. The idea of interpersonal mental health nursing, as at the
heart of a therapeutic encounter, is considered in how words are spoken, received
and constructed during the relationship that develops between a nurse and patient
(Altschul, 1958; Cormack, 1976; Nolan, 1999; Peplau, 1952;). We outline how
a nurse seeks to develop therapeutic interaction through all aspects of his or her
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communication, whether verbal or non-verbal. Yet this can often feel like navi-
gating through an ‘unimaginable storm ( Jackson and Williams, 1994) as there
is a challenge when aiming to meaningfully engage with patients to help them
express their distress in words rather than actions. The nurse requires effective use
of words when confusion, hurt and rage often reign paramount in the people he or
she interacts with.
Talking therapy at its most potent is about expressing meaning, articulating
thoughts and emotions through a considered therapeutic encounter. A mental
health nurse might need to sit for hours with a suicidal patient, in a cold silence
that can become deafening; or be in a high secure hospital unit, listening intently to
ramblings of an index offenderwhere truth is seemingly dead in the woods. At other
times in outpatients with a detox-reluctant patient, where hope hangs as threadbare
as his clothes. In such situations, it may be words that find the therapist and not
the other way around. Where there is an urge to spit, scratch, smash, to embrace
ideas of dying, feeling dead and buried, or to be so furious, murderous with rage;
words found to utter, to clearly articulate such intensity of feeling, can bring relief
in contrast to immense distress that evokes a silence of inadequate words. Words
can become containers, filters and conduits that can ‘hold’ emotions (Rey, 1994),
giving them an outlet, a release, as if the pressure valve of internalised angst silently
screams for verbal expression: speak to me please (Selima Hill: b.1945)
Counselling is something all nurses do?
Since the 1980s there has been a tradition of teaching Rogerian person-centred
principles in counselling training that has generally underpinned a humanistic
application of talking therapies across a range of mental health professions (Rogers,
1998). There are a number of broad interpersonal principles that all nurses are
introduced to in their education and probably try to adhere to in their daily practice
(Stein-Parbury, 1993). Even if the application of counselling and psychotherapy
principles are not clearly defined, they are for mental health nurses unanimously
applied. Burnard (1992) reports that all nurses counsel.
In the UK, the National Health Service is demanding as a workplace; physically,
psychologically and intellectually for any practitioner. To prepare practitioners with
information on a humane and well-meaning approach to the challenge of being
alongside patients in mental health care practice, without adequate consideration of
the powerful subversive influence of transference, counter-transference and result-
ant self-expression, is a recipe for disaster (Barnes, 1968; Bowers et al., 2010b).
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Many nurses remain detached from their patients (Cohler and Shapiro, 1964;
Henderson, 2001; Menzies-Lyth, 1960; Moyle, 2003; Remshardt, 2012;] Winship,
1995), whether as a conscious or unconscious decision. Many have studied the psy-
chological impact of being ‘hit’ by a patient (Wykes and Whittington, 1991), with
the implications of workplace stress (Hardy et al., 1998) and need for effective
supervision as an ethical dimension of mental health nursing practice (Hardy and
Park, 1997; Milne and Reiser, 2012). Group therapy has become a key strategy
used in the toolkit of a mental health nurse, yet sufficient training for nurses run-
ning therapy groups remains poor (Burlingham et al., 2004; Garland et al., 2010;
Weisz et al., 2006). However, there is potential to reinvigorate interest and expecta-
tion around formal counselling and psychotherapy training, research evidence and
practice wisdom that can enhance the therapeutic environment (Mahoney et al.,
2012), patients’ level of engagement in their treatment (Hobbs, 2009), therapeutic
optimism/hope (Elsom and McCauley-Elsom, 2008) and well-being (Newnham
et al., 2010).
Historical developments
Active and exploratory psychotherapeutic approaches in mental health nursing
have been derived from the field of psychoanalysis, running deep foundations in
the formation of the modern profession of mental health nursing. Hildegard Peplau
(USA) and Annie Altschul (UK) from the 1950s developed an adapted psycho-
analytic procedure as a way of ensuring that mental health nurses could operate as
independent practitioners, applying the idea of talking therapy with novel possibili-
ties (Winship et al., 2009). There is much more that could be said about the com-
bination of feminism and anti-psychiatry that was refracted through the work of
Altschul and Peplau which not only pushed forward the establishment and author-
ity of mental health nursing in the latter part of the twentieth century, but also the
whole field of mental health. Derived in part from the radical libertarian ambitions
of psychoanalysis, not only as a means to therapeutic cure, but as a vehicle for social
reconstruction (Fromm, 1941, 1962; Marcuse, 1955), Altschul and Peplau learned
their trade under the wings of psychoanalysis (Winship et al., 2009).
There are notable parallels between the influence of Eileen Skellern (in the UK)
and Suzy Lego (in the USA), especially in shaping autonomous nursing practice,
with mental health nurses carrying clinical caseloads. Skellern worked in thera-
peutic communities (the Cassell and the Henderson clinics) informed by a com-
bination of psychoanalysis and social psychiatry. She had seen how politically alert
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therapeutic systems could enfranchise not only the patient, but also the staff. With
a therapeutic philosophy which challenged the hierarchical regimes of traditional
authority, Skellern and Lego were part of a wave of mental health nurses who were
able to reframe the patriarchal traditions of the medical model (Winship, 2008;
Winship et al., 2009). Skellern’s influence on UK government strategy in the 1970s
laid the foundations for annual nurse led awards and increased nurse autonomy
In the USA, Suzy Lego, having completed a further training as a psychoanalyst,
published numerous papers outlining the role of ‘one-to-one mental health nursing
practice’, defining a professional identity for the discipline of ‘nurse psychothera-
pist’ (Lego, 1974, 1987, 1993). As one of Peplau’s brightest students and a close
confidante, Suzy Lego carried forward Peplau’s vision for mental health nursing
into the 1980s and 1990s, advocating for a professional identity of a dually quali-
fied advanced mental health nurse who could enjoy parity with psychologists and
psychiatrists, whether in private practice or state institutions. Lego’s idea of inte-
grating the practice of psychotherapy and mental health nursing was embedded in
the journal Perspectives in Psychiatric Care, which carried the subtitle: ‘the Journal for
Nurse Psychotherapists’. The development in the role of nurse psychotherapists was
inspiring to a number of colleagues in the UK and though there were significant
problems with access to psychotherapy training outside London (McMahon, 1994
), still an increasing number of mental health nurses in the UK began to complete
formal analytical training, and for a time this resulted in a momentum to define the
role of nurse psychotherapists in the UK (Winship, 1996, 1998).
Lego’s death in 1999 (only a few months after Peplau’s) foreclosed what might
have been further significant contributions to a discourse on the role of the nurse
psychotherapist as an internationally regarded discipline. Mental health nursing
arguably remains the challenge of case management, control and restraint, medica-
tion adherence and so forth, where there may be less emphasis on the art of coun-
selling and psychotherapy. Even where there is general acceptance of the value of
talking therapy, the alliance between nursing and psychoanalysis, albeit with some
significant intellectual and institutional cornerstones, has been one that has rested
uneasily (Winship, 1995).
Rather than the more active ingredient of psychodynamic agency in mental
health nursing, the idea of psychotherapy has been generally applied in terms of
models of pastoral listening, reflection and befriending (Strang, 1981). Models of
recovery have also tended towards a frame of counselling as a friendly ear that can
support, advise and instil hope in clients on their journey to recovery (Repper and
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Perkins, 2003). The rise of cognitive behavioural therapy has been identified as an
essential talking therapy in the discourse of mental health nursing with resultant
positive patient outcomes (Layard, 2006). Bowers et al. (2010b) assert that knowing
how to talk to patients is a necessary, everyday, core contingent in the process of
mental health nursing. The publication of the Social Exclusion Unit report Mental
Health and Social Exclusion (2004) reclaimed a socially orientated reconstruction
of mental health, but also the centrality of talking therapy. The report argued that
health services needed to be less medically driven and more socially focused in their
orientation; ‘more than 80% of GPs admitted over-prescribing anti-depressants
such as Prozac and Seroxat to patients suffering from depression, anxiety or stress’
(Social Exclusion Unit, 2004: 36). The report emphasised the importance of talk-
ing therapy as not only a viable alternative to pharmaceuticals, but as a first choice
The fact that the UK government put aside money for the development of a
workforce of cognitive behavioural therapists demonstrated that the government
(Labour at the time) was to some extent willing to put its money where its rhetoric
was. However, the fit between CBT and social recovery might seem to be less viable
than other more socially focused counselling and psychotherapy approaches, such
as group therapy, interpersonal therapy or therapeutic community practice. CBT,
with a narrow individualist focus on mind and behaviour, might not vitalise the
relational dimensions of the therapeutic encounter that are the seeds of a recovery
process. Peplau’s (1952) first principle is that mental health nursing is essentially an
interpersonal process, and that the main agent of therapy is not a device, or a bio-
logical rebalancing act, nor is it derived from a manual that prescribes a particular
set of techniques that can correct the patient. Instead, Peplau asserts the main agent
of therapy is the nurses themselves.
Theory in practice
We learn to play with sound and forming words from the very start of life (Peddar,
2010; Winnicott, 1988). Although taken with the idea of psychotherapy as play,
many encounters in acute psychiatry with people deeply disturbed (as outlined pre-
viously) show that play is a long way from what is happening in the encounter. The
acutely disturbed or depressed patient may have lost capacity to play, or may not
have learned how to play at all. Instead, the therapeutic encounter can feel much
more like an altogether more backbreaking physical undertaking. The therapeutic
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alliance can be experienced as heavy duty. Counselling approaches for the men-
tal health nurse, at the sharp end of practice, may seem too passive, a game even.
Though the skills of listening are rightly credited, merely holding up a mirror and
reflecting back to patients (see the case example below) is not always enough to
bring about therapeutic gain.
A common mantra might be that words speak louder than actions for the ambi-
tion of all mental health practice. That is to say, helping patients find the words to
express their wish to self-harm or an urge to hurt others, or their need to express
what it feels like to be abused; these words might express feeling states that mean
future destructive acts can be lessened, more controlled, prevented even. Yet, a com-
mon concern for many nurses centres on not speaking of, or asking provocative
questions, or saying something that might provoke a violent reaction, encourage
delusions, persecutory thoughts, suicide even. Experience of working on an inpa-
tient unit has proven to me that continuous critical reflection, pertinent clinical
supervision and a willingness to feel, engage with and consider discomfort are all
important for the mental health nurse. The unit in question was influenced by
the psychodynamic psychotherapy principles of forming close working alliances
between nurse and patient ( Jackson and Crawley, 1992). We achieved this through
close supervision and a daily clinical evaluation system that incorporated all mem-
bers of the clinical team to come together to reflect and review their interpersonal
encounters. Learning from each other’s experiences enhanced the level of confi-
dence to express oneself within difficult and demanding situations.
I’ve lost my songbook
I had a two hundred year songbook
Tell me about your songbook
I don’t know where it is now – I lost it
That’s sad to hear
My feet are bad today
What’s happening with your feet?
My feet burn up, it’s when I did the test and walked on fire coals, I suffer
now and cannot get out of bed. I burnt my feet
Can you remember a time when your feet didn’t burn?
I’m preparing to do an Arab-spring at school, I’m standing in front of a
room full of people, getting ready. I feel nervous, but do it, I get really
excited, there’s a tingle down my spine
: What are you feeling now?
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My Dad used to hit me when I was smaller, I never let out a scream, I just
kept quiet. Even at school I never showed things, even in prison I learnt
to bottle it all up inside.
Now the pain is coming out in your feet?
I got the same excited feeling when robbing someone
Do you feel robbed of your past, having lost your songbook?
Can practitioners ever find the right words to soothe raw wounds like an oint-
ment or at other times, risk words that might cut deeply, like a surgeon’s scalpel?
Sometimes words need to be blunt, they can feel like using a mallet, resonating pain
without a physical touch. A patient spoke of wanting to throw himself in front of
a train, the nurse replied: ‘what about the driver, what about his family living with
him afterwards, could you do that to someone else’s children?’ The patient accused
the nurse of being insensitive. But he seemed literally stopped in his tracks, at least
for a moment. The words hit him, rather than the train. Words can also be sweet,
soothing or have to be swallowed, like a bitter pill. We all need to find the capacity
to speak out, find a voice, as clearly as we can. Of course there is a lineage here that
goes back to Freud’s development of the talking cure, from the moment that Anna
O discovered the idea that talking therapy is akin to chimney sweeping (Bruer and
Freud, 1895), where sense can be gleaned from experiences which otherwise seem
mad and incomprehensible.
Masson (1989) argued that a therapeutic encounter is only possible in a relation-
ship where there is no concern with power and hierarchy; yet for most, engaging
in a therapeutic relationship occurs between a patient and practitioner that will
initially offer a level of dependency on the therapist as carer/enabler. Breggin (1991)
recognised value in such a dependence, but qualified this by identifying the need for
consistency between the practitioner’s philosophy of care, and that of the patient.
Yet, there remain sizeable gaps in our knowledge about the finer tunings of talking
therapy. Bowers et al. (2010a, 2010b) completed a detailed analysis of the way in
which mental health nurses talk to acutely disturbed patients, showing that respect
and compassion are primary in the applied repertoire of the language of the nurses.
There is perhaps something unique in the everyday procedure of mental health
nursing in terms of the application of counselling and psychotherapy. Although
some nurses may indeed carry individual caseloads, and see clients for a traditional
sit-down face-to-face 50-minute therapy session, in mental health nursing prac-
tice there are otherwise manifold opportunities to apply counselling skills. Peplau
referred to this as the ‘other 23 hours’.
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As part of mental health nurse training at the Maudsley, during the 1980s to
1990s, a session was allocated where students could explore patients’ words, state-
ments, phrases that the student had found difficult to respond to, understand or
accept. For example, when patients said, ‘I don’t see the point of living’, or ‘my feet
are on fire’, finding the right words to respond in a therapeutic, engaged way –
rather than a more natural reaction of wanting to ignore, dismiss, laugh at or recoil
from – was considered central to a mental health nursing training experience. This
struggle to respond, reply, engage with the intensity of emotional distress is an
important part of the process required to understand and work alongside oth-
ers; understanding the chaos and uncertainty within which people exist. In fur-
ther developing educational approaches where practitioners can become versed in
therapeutic encounters, the use of experiential learning strategies whereby students
are exposed to therapeutic milieus (including free association in language and
articulation) is encouraged. For example, sessions where students develop narrative
group collages, where they might produce a collective sonnet/poem. In these ses-
sions students develop their own lines of thought around a particular topic before
cutting and pasting them together to form a longer collaboratively devised poem.
Students are encouraged to interrogate their own words, interactions, interconnec-
tions, reflecting on the nuances of their exchanges with patients, closely scrutinis-
ing the co-construction of meaning in verbal exchanges as part of the therapeutic
encounter between nurse and patient.
We advocate in this chapter for a revived interest in the importance of counsel-
ling and psychotherapy, as central theoretical principles in mental health nurses’
personal and professional advancemenrWe call for not just language acquisition as
a rational measure of competency in clinical practice, but the learning of fluency of
thought and accurate emotional reciprocity. This remains the challenge, where the
intensity of contact with a patient offers immeasurable opportunities to demon-
strate, through words, how nurses can reach the person, not just in the one-to-one
or group therapy sessions, but in all aspects of the ‘other 23 hours’. It is often said ‘a
picture can paint a thousand words’, but this overprivileges visual dexterity. Rather,
one word can paint a million pictures; some words like ‘love’ and ‘hate’ are infinite
in their complexity and meaning, experienced as different for each of us. When we
glance and gather words in our encounters with patients, the intricacies of meaning
suggest endless possibilities for therapeutic exploration.
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This chapter has provided an overview of how counselling and psychotherapy has
influenced mental health nursing practice. We have aimed to inspire curiosity and
interest in the position and influence of counselling and psychotherapy in contem-
porary mental health nursing practice. Nursing models have drawn from principles of
counselling and psychotherapy in notions of interpersonal skills, therapeutic nurse–
patient relationships, and these remain at the heart of a therapeutic encounter.
We have outlined how a nurse seeks to develop therapeutic interaction through all
aspects of their communication. Yet there is a challenge when aiming to meaning-
fully engage with patients to help them express their distress in words rather than
actions. The nurse interested in the effective use of words can gain much from fur-
ther study, training and ongoing critical evaluation/supervision of the personal and
professional aspects of a therapeutic encounter. We would encourage continuous
curiosity into the infinite riches of counselling and psychotherapy for contemporary
mental health practice.
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... It has been suggested that the interpersonal theories of psychiatric nursing have been inextricably linked to the theoretical positioning and understanding of psychology and psychotherapy; interwoven like a double helix, and to understand those relationships requires a consideration of their influence (Kirby, 2003;Winship and Hardy, 2013). Although it has been observed that whilst psychiatric nursing in its broadest sense, may have widely subscribed to the technical and relational skill sets of the various psychotherapies (Delaney and Handrup, 2011; Ryan and Hurley, 2018), contemporary acute psychiatric nursing has been observed to remain an outlier in that respect, and has not so freely engaged with the discourse of psychotherapy (Whittington and McLaughlin, 2000;Winship and Hardy, 2013). ...
... It has been suggested that the interpersonal theories of psychiatric nursing have been inextricably linked to the theoretical positioning and understanding of psychology and psychotherapy; interwoven like a double helix, and to understand those relationships requires a consideration of their influence (Kirby, 2003;Winship and Hardy, 2013). Although it has been observed that whilst psychiatric nursing in its broadest sense, may have widely subscribed to the technical and relational skill sets of the various psychotherapies (Delaney and Handrup, 2011; Ryan and Hurley, 2018), contemporary acute psychiatric nursing has been observed to remain an outlier in that respect, and has not so freely engaged with the discourse of psychotherapy (Whittington and McLaughlin, 2000;Winship and Hardy, 2013). Awty et al. (2010) observed that the psychotherapies seem to have had little representation or impact in the day-to-day work of the inpatient psychiatric nurse, and such technical endeavours are often seen as the responsibility of the visiting expert, rather than the domain of the acute psychiatric nurse themselves. ...
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This study has concerned itself with the therapeutic nature of the relationship between psychiatric nurses and the inpatients of acute psychiatric wards. In particular it sought the insights that those nurses held in relation to their strategic endeavour to form such a relationship. Existing theory was considered and a comprehensive review of the literature was undertaken; this identified a paucity of research and theory into how therapeutic relationships are formed between nurse and patient within a contemporary acute psychiatric ward. In order to answer the research question, this study adopted an interpretive phenomenological methodology. The convergent interview; with its inter-interview analytical process (Dick, 2017) was utilised as the method. The research was undertaken across four wards that make up the acute inpatient facilities of a single NHS site. A maximum variance sample was sought and seventeen interviews were conducted. Six major themes emerged from the responses of the participants: making a connection and relating to one another; the utilisation of values; appraising the situation and manoeuvring; using and working with boundaries; managing the challenges and pressures of acute psychiatric work; and work as a team. Themes were re-reviewed in the light of theory, literature and contemporary commentary and then conclusions and recommendations are made. The study concluded that the endeavour to form a therapeutic relationship is a boundaried, reflective, and altruistic driven social endeavour. One that utilises the opportunities that arise out of the relational intensity of sharing a living space, whilst one party experiences an episode of acute psychiatric illness. Such intensity requires nurses to engage in self-sustaining strategies, and to adopt a team approach if their endeavours are to be successful. The study made recommendations for recruitment practices that enable the identification of individuals with pre-existing social skill, altruistic values, an ability for personal reflection and a degree of personal resilience. Recommendations are also made for training that supports an examination of the relational impacts of power imbalances, psychiatric symptoms, professional boundaries and professional values. Additionally, the study presents it is the establishment of a relational bond alone, which most closely resembles acute psychiatric nurses’ understanding of therapeutic relationship. Hence a recommendation is made to rethink the framing of future research or measurement of the phenomena based on the tri-partite definition of bond, goal and task agreement that defines psychotherapy understandings of therapeutic relationship (Bordin, 1979). The study also makes recommendations for both further research and theoretical development.
... PD can often be understood and experienced by participants as a therapeutic endeavour, via the empowering and transformational aspects of PD. Such a loose distinction can lead to confu-sion when first introduced to mental health practitioners, who are familiar with person-centred principles of care delivery from a Rogerian perspective (Winship & Hardy 2013). Several authors have attempted to clarify PD intent as 'transformative'; although clearly identifying and working with individual values and beliefs can be experienced as highly supportive, personally challenging and cathartic. ...
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This paper examines the emergence of psychoanalytic ideas in nursing, tracing the history of these ideas, in particular the history of psychiatric nursing at the Maudsley Hospital since the 1950s. The development of psychoanalytically-informed nursing in the UK is compared with the developments in this field in the US. The future of psychoanalytically-informed psychiatric nursing is considered.
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Oral history and biographical research gathering previously unpublished material directly from Altschul and Peplau, and new commentaries on Eileen Skellern from colleagues, are triangulated to form a collective biography that accesses historical consciousness of times of great change in psychiatry. We can see core ideas about psychiatric nursing aggregated around the idea active therapeutic engagement. Peplau and Altschul were simultaneously working with innovative methods of community-based therapy during the Second World War in England with shell-shocked soldiers. Both developed founding ideologies in psychoanalysis and therapeutic community practice. A similar trajectory is apparent in the work of Eileen Skellern. User involvement and social inclusion, the corner stones of therapeutic community practice, remain intrinsic to the aspirations of psychiatry today.
This study investigates how people deal with the stress of being the victim of a violent assault at work. A consecutive sample of 24 employees of a psychiatric hospital were questioned over a three-week period following an assault by a patient. The ways in which these staff spontaneously attempted to cope with these assaults was used as a basis for a classification scheme. In addition their psychological difficulties were measured. Despite the restricted sample some interesting associations were found. Ignoring the incident by avoiding thinking about it and taking time away from work or work colleagues was associated with decreases in psychological difficulties over time. Although the causal link is still unclear, further studies using similar analyses may be able to tease this out.