The Therapeutic Relationship and Issues of Power in Mental Health Nursing

Abstract

Objectives: The therapeutic relationship is an important concept to mental health nurses, and many believe it to be the essence of nursing practice. However, the nurse patient relationship is one of imbalanced power. This study, completed as a BSc dissertation project, forms a scoping review, utilising a systematic approach, to examine the research on the relationship between power and the therapeutic relationship, with relevance to mental health nursing.

Methods: Literature was found online through texts available in the university library catalogue using a variety of search strategies. Literature was searched for on Cumulative Index to Nursing and Allied Health Literature, PsychINFO, ProQuest hospital collection, British Nursing Index and ScienceDirect. Additional articles were found using an ancestry and decendancy approach.

Results: Existing research gives collaborating evidence that there is a relationship between power and the therapeutic relationship. Not only is coercion related to negative evaluations of the therapeutic relationship, but the main way in which professionals influence patients to make healthy choices is through the therapeutic relationship. The context in which mental health nursing takes place also influences this relationship.

Conclusions: As there appears to be a relationship between power and the therapeutic relationship, nurses who identify with the concept of the therapeutic relationship would benefit from considering power as a pertinent theory. Nursing academics need to direct more resources towards researching power as there appears to be a dearth of nursing literature on this topic, particularly in the United Kingdom. Professionals may benefit from reflecting upon power as a concept that affects their reciprocal relationships with patients.

Introduction

Although nursing is not generally considered a powerful profession (Barker 2009a), power dynamics frequently become apparent when thinking about relationships within nursing (Wilkinson and Miers 1999). Nowhere is this power more relevant than in the field of mental health, where legal powers are granted in order to detain persons who are deemed unwell and in need of assessment or treatment (The Stationary Office 2007).

Despite on-going criticism of psychiatry and its association with coercion, control and power (Szasz 2007; Foucault and Howard 1967; Goffman 1968), and continuing lack of evidence to demonstrate the effectiveness of compulsory treatment (Kisely and Campbell 2014), recent reports suggest coercive practices in the United Kingdom are increasing (Care Quality Commission 2015).

Resistance to the idea of coercion and control in psychiatry, may be found in the idea of empowerment, service user involvement and recovery, which have gained popularity in nursing literature (Barker 2001; Lloyd 2007; Caldwell et al. 2010) and in mental health policy (Department of Health 2011). However, the extent to which empowerment is possible, and its actual impact on service users true freedom and consent within a system that endorses detention and compliance, has been problematised (Grant 2009). This implies that it is important to think about empowerment in the context of the imbalanced power relationships that exist in mental health. That nurses endorse empowerment without appropriately considering the concept of power, may contribute towards ambiguity in terms of the approaches and definitions of empowerment within the nursing literature (Ryles 1999).

Perhaps the most pertinent theorist on power within mental health is Foucault due to his examination of madness (Foucault and Howard 1967), and of medical power (Foucault and Sheridan 1973). For Foucault, however, power is not something that can be held by certain groups or individuals, nor is it exclusive to intentional action. Power is essentially a positive force which permeates all levels of society and people are always simultaneously undergoing and exercising this power. Power, in this sense, is legitimised through knowledge ascertaining to what is considered true, or “discourse”. People are disciplined by discourses that work as normalising structures which guide people to understand the world and their bodies in certain ways (Foucault and Sheridan 1979). Although Foucault’s conceptualisation of power has been criticised as generalised to the extent that it loses any analytic force (McNay 1994), It also opens up ways of thinking about power differently, simultaneously avoiding specificity and reductionism.

The effects of power on relationships is pertinent to the role of mental health nurses as the “therapeutic relationship” is frequently cited as the core of nursing (Barker 2009b; Browne et al. 2012; Dziopa and Ahern 2008; O’Brien 1999).

The idea of therapeutic relationships were highlighted in nursing most notably by Peplau (1988, 16) who regarded nursing as ‘a significant, therapeutic, interpersonal process.’ This asserts the interpersonal nature of nursing, gives salience to nurse-patient relationships and highlights the need for these relationships to be therapeutic, promoting health and growth (Peplau 1988). Since Peplau, therapeutic relationships have been considered the core focus of mental health nursing (Barker 2009b; O’Brien 1999).

In order for a relationship to be therapeutic, though, it must function as more than an everyday relationship. It is a relationship in which the patient feels accepted as a person of worth, free to engage in self-expression without fear of rejection. Therapeutic relationships should involve communication that helps the nurse understand the needs and perceptions of the patient, enable the patient to learn about, or cope more effectively with their environment, and result in the reduction or resolution of the patients’ problems (Reynolds 2009).

The popularity of the therapeutic relationship in mental health nursing has not meant it is easily defined, however. In fact, it may have become more difficult to define now that it is tied into the mental health nurse’s identity (Browne et al. 2012). A literature review on what makes good quality therapeutic relationship identified nine overlapping constructs within the nurse-patient therapeutic relationship (See image 1), which require a complex interplay of skills dependent on the needs of both nurse and patient at a given time (Dziopa and Ahern 2008). Judicious use of power is implicated as one mechanism through which the development of a good quality therapeutic relationship is achieved, although the possibility of nurses abusing said power is also duly noted.

The impact of power on the therapeutic relationship has been alluded to (Dziopa and Ahern 2008; Wilkinson and Miers 1999). However, a review of the literature within this area may shed increasing insights into whether a relationship exists. This literature review, Inspired by my curiosity from practice, defines power as bi-directional, as something that can be used negatively (in coercion, compulsion, force and threat) and positively (through empowerment and legitimate authority or leadership). It also acknowledges that power can be overt (as in restraint or seclusion), or subtle (as in persuasion, approval and observation).

This literature review aims to highlight common themes in academic literature, and areas where more research is needed answering the question:

How does current primary research, with relevance to mental health nursing, explore issues of power within the therapeutic relationship?

There is potential for findings to help guide practice enabling nurses to be aware of the benefits and drawbacks of different facets of power and their use within the therapeutic relationship. It is also possible that the evidence found may confirm or deny whether these concepts are related.

Methodology

The research question was developed during the process of preliminary searching around the concept of power and the therapeutic relationship. This allowed me to gain a sense of what published research existed on my chosen topic, leading to the development of a question that could be answered by the research available without becoming over or under saturated aiming for between 10 and 20 articles (Aveyard 2014).

As power can be conceptualised in different ways (Scott 2001), which may result in the exploration of different perspectives, it is important to use the appropriate terms associated with those perspectives in order to find a breadth of literature. Some synonyms of power have been mentioned in the introduction – yet preliminary searching revealed more. Authority represents the legitimate use of power while Control, coercion, restraint and restriction represent more invasive uses of power (Scott 2001). In addition, Agency and empowerment could be seen as positive elements of power whereas influence and leverage are more subtle forms of power (Wilkinson and Miers 1999). These synonyms of power were utilised as unique search terms in my preliminary search strategy.

Observations from preliminary searching demonstrated a dearth of specifically nursing literature within this topic indicating my search strategy would need to be broad. A systematic approach was adopted for the primary search strategy in order to gain a sense of the literature that already exists on this subject. Four separate search sectors were developed to ensure specificity to nursing, mental health, power and the therapeutic relationship respectively. These search sectors were combined using the Boolean logic AND so all results returned were relevant to all the search sectors (Boagy et al. 2013).

Within the search sectors, additional search operators were used informed by literature specific to performing a literature search (Aveyard 2014; Boagy et al. 2013; Jesson et al. 2011).

The extent that the search was restricted by the generic search sectors was then considered. “Therapeutic relationship” was considered as a limiting search term that may be described in other ways, for example, “therapeutic alliance” is another term that could be used. Further exploration uncovered “helping alliance” and “working alliance” but these proved to be more relevant to counselling and psychotherapy than nursing and including them did not expand results. The term “relationship” on its own was also considered, which caused the search to become too broad with an unmanageable amount of results (n=1108) from just one database.

The following databases were accessed as considered the most relevant to nursing psychiatry and sociology: CINAHL, PsychINFO, ProQuest hospital collection, British Nursing Index and Science Direct.

It was then necessary to develop inclusion and exclusion criteria (Table 1) in order to define the scope of the review (Aveyard 2014) and answer the research question: how does current primary research, with relevance mental health nursing, explore issues of power within the therapeutic relationship?

Inclusion and exclusion criteria

• Only articles exploring power (and its synonyms) and the interpersonal relationship were included.
• Only articles that were relevant to nursing were included. This included articles that were interdisciplinary in nature but excluded articles that were exclusive to other professions such as physicians.
• Articles examining control and restraint as an intervention were excluded.
• Only primary research was included.
• Only research published after 2004 was included.
• Only research available in English was included.
• Research from all specialities of mental health was included.
• Research from all countries was included.

As it is possible that searching through online databases alone may not find all relevant research, snowball sampling was used to accent this initial approach (Aveyard 2014).

When the full texts of the final articles were read, 9 did not meet inclusion criteria, leaving 10

Although similarities between findings were apparent from an early stage and fit into themes, to aid in presentation of the findings, articles were instead split into themes according to the approach used to gather data, rather than their findings. Critical analyses of each article took place using a research appraisal framework by Caldwell et al. (2011) as it is appropriate for both quantitative and qualitative research, both of which were included in the review. Critical appraisal of the articles were presented in the appropriate themes and the impact of each article was considered and synthesized for discussion.

The relationship between perceived coercion and evaluations of the therapeutic relationship

Four of the studies found through the literature search were Quantitative studies measuring service users’ perceptions of coercive practices alongside their evaluations of the therapeutic relationship to see if there is an association between these concepts. The following articles result in a fairly narrow conceptualisation of power as coercion, which, despite being often measured on a continuum, does not allow for positive conceptualisations of power. Also, a variety of measures are used to describe the therapeutic relationship resulting in some conceptual discrepancies within this area too. Despite this, the articles demonstrate that a relationship does exist between these concepts, which is significant (p<0.05) in three out of the four studies.

Stanhope et al. (2009) acknowledge case managers use of pressure in assertive community treatment of vulnerable populations in Pennsylvania, USA and seek to examine consumer’s perspectives in relation to these pressures through use of surveys delivered through face to face interviews. They recognise that introductions with consumers had to be negotiated through case managers which may result in social desirability bias.

Findings show a modest relationship between consumer-provider relationship, and perceived coercion with small effect size but no relationship between case manager’s utilisation of coercive strategies (pressure), and perceptions of coercion. It is noted, however, that case managers utilised almost exclusively low-end coercive strategies, such as verbal guidance (Neale and Rosenheck 2000). Higher perceived coercion was also related to shorter service contacts with a small effect size; more years spent in services with a medium effect size and negative service evaluation with medium to large effect size.

Sheehan and Burns (2011), from a complimentary perspective, seek to test a hypothesized association between the therapeutic relationship and the experience of coercion. A cross sectional cohort study was conducted for a consecutive sample of admissions to five acute hospitals in Oxford, England. Sheehan and Burns (2011) report a similar response rate (75%) to other articles exploring perceived coercion, but acknowledge that patients who decline to participate in research may have different views to those who did participate. How the population used in this study differs from a UK population is noted with consequences for generalizability.

Sheehan and Burns (2011) show that positive evaluations of therapeutic relationship with admitting clinician (12% identified as nurses), were significantly associated with low levels of perceived coercion; low levels of negative pressure and high levels of procedural justice, as measured by the AES. Perceived coercion was higher in participants who had been involuntarily admitted and logistic regression analysis showed the therapeutic relationship as an important factor, explaining 6% of the variance in perceived coercion. Just 21% of the variance was explained through the collected data indicating that other factors also come into play, including relationships with other staff members.

Furthermore, Theodoridou et al. (2012) use a similar approach in their study utilising a survey delivered through face to face interviews to measure the relationship between perceived coercion and the therapeutic relationship.

Theodoridou et al. (2012) show that higher levels of perceived coercion were consistently related to worse evaluations of the therapeutic relationship. Furthermore, involuntary admission, history of involuntary admission diagnosis of schizophrenia were all associated with higher AES scores.

These three articles present corroborating evidence to demonstrate that higher ratings of the therapeutic relationship are linked to lower perceptions of coercion in inpatient psychiatric populations across England (Sheehan and Burns 2011) and Switzerland (Theodoridou et al. 2012) and Assertive Community Treatment populations in the USA (Stanhope et al. 2009).

Wolfe et al. (2013), examine the relationship between coercion, motivation and therapeutic alliance in community-based drug and alcohol treatment in New South Wales, Australia. The researchers show that coercion was significantly related to external motivation and that external motivation was partially related to lower therapeutic alliance. However, no significant relationship was found between coercion and therapeutic relationship, apart from for the variable “openness”.

Patients perceptions of power and the therapeutic relationship

Further to the quantitative articles discussed previously, four articles found in the literature search were qualitative studies examining service users’ perspectives of power in various forms. While none of these studies sought to examine the therapeutic relationship, relationships with professionals emerge as an important concept from their results.

The following qualitative articles should help expand on the reductionist nature of quantitative research, enhancing understanding of how the variables of power and the Therapeutic relationship relate to each other in certain situations, as understood by service users, giving some sense of the complexity of this relationship.

Thogersen et al. (2010) aim to explore whether patients perceive Assertive Community Treatment (ACT) to be a coercive service due to ongoing academic debate about coercive aspects of the assertive provision of care. Participants were recruited, using staff as gatekeepers, from two newly formed ACT teams in Copenhagen, Denmark.

Themes were revalidated through agreement among other researchers and participants.

Lack of active participation in treatment processes and a poor alliance with case managers; not being recognised as an autonomous person and crossing the line and intruding on privacy, were recognised by Thogersen et al. (2010), as themes enhancing perceptions of coercion. On the other hand, a collaborative and mutually trusting relationship with case managers; commitment, perseverance and availability and a recognition of the need for social support and assistance with everyday activities were experiences that counteract perceptions of coercion. These themes can easily link coercion with the therapeutic relationship but also indicate other important factors, including time spent with patients; providing support; intrusion on privacy and case managers’ attitude demonstrated towards the patient. The study also demonstrates that different services invoke different experiences that relate to perceptions of coercion. Namely, ACT was considered coercive in that it was intimidating and overwhelming, whereas experiences of coercion in other services were related to lack of autonomy, lack of alliance with staff and lack of influence on treatment.

Tveiten et al. (2011) seek service users’ views and experiences of empowerment utilising data from focus group interviews. They define the concept of empowerment, relating it to concepts of advocacy, service user involvement and participation, stating that user participation allows transcendence of the power hierarchy inherent in psychiatry. The population is selected from two inpatient units in Norway, each with different acuity, but similar in relation to the services offered.

The three main themes included possibilities and presuppositions for participation, influence of the system on the empowerment process, and collaboration along a continuum of power between empowerment and powerlessness. Interesting to note for this review is that, in the possibilities and presuppositions theme, participants spoke about real acknowledgement, rather than acknowledgement as a formal claim.

Laugharne et al. (2012) aim to examine the experiences and attitudes of patients with psychosis in relation to factors that enhance or undermine trust, choice and power utilising face to face interviews. They acknowledge that, while participants found it difficult to engage with the concept of power, two overarching themes emerged. First that patients feel the need for a shifting balance of power that moves over time and is dynamic according to circumstances. Crucial to this shifting of power is improving patients’ understanding by providing them with information. Within this theme it is also suggested that threats of coercion and neglect disable patients.

Second, patients saw a trusting relationship as vital in their care. Trusting relationships are portrayed as going beyond the recognised expertise gained through training and experience, to include attributes and behaviours of patients as well as staff. The value of a personal touch was also stressed through aspects of kindness, hopefulness, friendliness, conversations about shared interests and personal disclosure from staff. There was contradictory evidence from some participants who suggest that they thought patient views should take precedence over scientific evidence and that relying on scientific knowledge was disempowering for patients.

Maguire et al. (2014) used a purposive sampling of 12 nurses and 12 patients from a forensic hospital in Australia to explore the practice of limit setting – a potentially coercive intervention, from both nurses and patients perspectives – in order to propose principles to guide practice. Limit setting is frequently used in forensic settings and it focuses upon setting boundaries in the therapeutic relationship and limiting or preventing disruptive behaviour.

Maguire et al. (2014) propose three themes. First, limit-setting is valued by patients as it sets boundaries around what are acceptable or unacceptable behaviours, promoting safety structure and control in the unit. This is also proposed as development of a therapeutic milieu.

Second, engaging patients in an empathic manner indicates that patients don’t find limit-setting as coercive in itself, but this is mediated by elements of the relationship in which patients feel understood, and understand why the limits have been set. Experiences of humiliation and disrespect contribute to coercive experiences, whereas experiences of limit-setting in a caring way did not damage the relationship or lead to negative outcomes.

Thirdly, the authoritative, rather than authoritarian style of limit setting suggests that, from a patient perspective, an authoritarian style is experienced as intimidating, aggressive and disrespectful and damages the therapeutic relationship. Conversely an authoritative style involves the nurse being knowledgeable about the patient and setting limits in a fair, consistent and respectful manner.

Nurses perceptions of power and the therapeutic relationship

Some qualitative articles found through the literature search considered power and the therapeutic relationship from a professional perspective. The professional perspectives explored appear to be more varied than the patient perspectives, some posing as a challenge to the use of power while others accepting the necessity of using power (or influence) to encourage healthy behaviours.

Maguire et al. (2014), explore nurses’ perceptions of limit setting, alongside previously mentioned patient perspectives, in forensic services. Many of the nursing perceptions are similar to patients’ perceptions, with nurses giving stories of observed poor practice resulting in aggressive responses or poor outcomes. However, separate to patients’ views, many nurses were uncomfortable with the term limit-setting as they believed it implied exerting control over patients as a coercive intervention.

Other nursing staff confirmed patient views, that limit setting was important for safety and maintenance of the therapeutic milieu. Having an understanding of the patient, and being fair, respectful and consistent was crucial to patients responding positively to limit-setting.

Cutcliffe and Happell (2009) highlight that interpersonal relationships, which are fundamental to nursing practice, are replete with issues of power. Despite discussions about empowerment being popular in the literature, Cutcliffe and Happell (2009) point out that there is a dearth of nursing literature examining power as it may be a difficult or uncomfortable subject for nurses. The study utilises examples from practice, with consideration for confidentiality, to illustrate health professionals’ use of power over consumers. Examples from practice enable naturalistic generalisations where readers gain insight through recognition of similarities in case study details and find descriptions that resonate with their own experiences.

Cutcliffe and Happell (2009) argue that these examples are tied to the use of invisible power through the dominant discourse of bio-psychiatry. They illuminate the recovery discourse as a viable alternative to this in which nurses can reconnect with Peplau’s theory of mental health nursing or, in other words, re-value the therapeutic relationship. However, this article paints an exclusively negative picture which taken alone may overemphasize the prevalence of the use of invisible power in current mental health practice.

In contrast, Gardner (2010) reports on a preliminary theory of how mental health nurses establish therapeutic relationships and maintain professional boundaries. The theory portrays the establishment of the therapeutic relationship as a gradual process, which begins with “therapeutic friendliness”, and develops through stages of “therapeutic engagement”, until a “therapeutic relationship” is developed and deepens over time.

Similar to Laugharne et al. (2012) who indicate that patients appreciate personal disclosure and conversations about shared interests, this study indicates that therapeutic engagement begins with a process of being friendly, which is not based on professional roles, but rather on getting to know each other. This is demonstrated to be particularly important in order to counteract the previous negative experiences many mental health clients have had in services before, supporting results suggesting that previous experiences of coercion might result in a higher likelihood of perceiving coercion in future (Laugharne et al. 2012; Theodoridou et al. 2012; Thogersen et al. 2010).

As a relationship progresses through the different levels of engagement it finally becomes a “Therapeutic Alliance” in which nurses can use “Therapeutic Leverage” as a form of influence that helps the client make the best decisions regarding their illness and health. It is important to recognise that “Therapeutic leverage” is different from coercion or manipulation, which would jeopardise the therapeutic relationship making it more difficult to manage. The level of influence a nurse has through their “therapeutic relationship” with a client can also be compromised when professional boundaries become blurred, resulting in confusion from the client as to whether the relationship is a friendship or a professional one, highlighting significant complexities within this framework.

Rugkåsa et al. (2014) highlight contemporary professional roles that are both empowering and controlling in light of recent changes in mental health where professionals utilise a range of “influencing behaviours”. The use of existing groups promoted discussion of professional perspectives on the use of “influencing behaviours”, to which real cases and existing relationships could be referred.

The quality of their relationships emerged as the central way in which professionals influenced patients, highlighting the need for trust within these relationships to be built over time. Honesty, curiosity, fairness, empathy, consistency and reliability were considered important to demonstrate within the therapeutic relationship, which in turn promoted engagement from patients. Providing something outside of patient expectations, such as going for coffee, or helping with practical tasks, helped to create reciprocal obligations, similar to findings by Laugharne et al. (2012) which suggest that patients also appreciate conversations about shared interests and staff personal disclosure, which is traditionally considered beyond professional boundaries. Emphasising the reciprocity of relationships, the authors describe “negotiating agreements” as another mechanism for influence. The final way of exerting influence was indicated as “asserting authority”, noting professionals’ power to compel, mainly through the use of the mental health act. This was seen as an inferior approach to others as, although it is a useful way of ensuring patient safety, it also had the potential to undermine relationships. The authors describe the difficulty navigating patients’ expectations about coercion that arrise from them having experienced coercion before. In fact, the very context of having the Mental Health Act to fall back on can be experienced as coercive in itself.

Strengths and limitations of study

As a novice researcher at undergraduate level, this review is hindered by inexperience and limitations placed by financial and time restrictions (Aveyard 2014). Publication bias may be an issue for this review as literature was only found on electronic databases which could be improved if efforts were made to search for grey literature (Polit and Beck 2014). Single author reviews might also increase the potential for subjectivity and bias, although I have consulted with my dissertation tutor, which will hopefully have helped limit my own biases where evident. I have also acknowledged my own views at the beginning of this research so that it would be evident to others if my own views did influence the results.

In contrast, I consider the broad approach to this research a strength, as it demonstrates the complexity of power relations instead of focusing on a single area. Although most articles are not exclusively relevant to nursing they acknowledge the interdisciplinary nature of working within mental health and nurses’ core role within the interdisciplinary team. Recommendations may be found as relevant to other professions working in settings alongside nurses but may also lack specificity to nursing.

Discussion

Power is a complex phenomenon that may need to be broken down into other elements in order to be better understood and researched. This review was able to observe some of the current trends in research relevant to mental health nursing as to the way in which power is conceptualised.

The findings of this review mainly converge upon 4 areas: Legitimate use of power by professionals, the adverse impact of coercion, force and neglect, how are balance and reciprocity important to both power and the therapeutic relationship, and the influence of the system upon these perceptions. Mental health nurses are clearly in a position of power in comparison to service users and this review proposes that this is not inherently bad. There are examples of where professionals use their power legitimately and this is beneficial. This relies upon having a good Therapeutic relationship. However, the potential for coercion if this power is misused is apparent and perceptions of coercion are related to poor evaluations of the therapeutic relationship. Professionals should be aware that balance and reciprocity may be important concepts when thinking about building relationships in the context of unbalanced power relations and might also want to acknowledge that structural and environmental factors can influence how patients perceive actions as either legitimate or coercive.

There were only three articles exclusive to nursing (Gardner 2010; Maguire et al. 2014; Cutcliffe and Happell 2009) although two further articles had nurses involved as part of the research (Thogersen et al. 2010; Tveiten et al. 2011). The extent to which nurses can accurately reflect on and engage with the concept of power, when it has been indicated as something which they are uncomfortable discussing (Cutcliffe and Happell 2009), is highlighted by the lack of articles exclusive to nursing and the language used to signify power within those articles, such as leverage (Gardner 2010) and limit setting (Maguire et al. 2014).

It has been noted elsewhere that there is a dearth of nursing literature regarding coercion which is surprising considering that nurses are involved, directly and indirectly, in many coercive interventions (Galon and Wineman 2010). Although this review is exclusive to nursing, it was difficult to find exclusively nursing-related literature. Additionally, patients may be uncomfortable with the idea of power due to its negative connotations as noticed in certain studies exploring patients’ perspectives (Tveiten et al. 2011; Laugharne et al. 2012).

Although three studies were of UK origin (Rugkåsa et al. 2014; Laugharne et al. 2012; Sheehan and Burns 2011) none of these included a nurse in the research process. This is an important limitation as the unique culture of the UK may provide unique challenges and perspectives. Future research in the UK, including nurses in the process, would enable more specific recommendations to UK nurses in various settings and may highlight areas of power explicitly relevant to nursing. The EUNOMIA study highlights differences in coercive practices across European countries (Raboch et al. 2010), further cementing the difficulty in generalising this review between countries. Interestingly, the only centre where nurses order coercive measures more frequently than physicians was the United Kingdom (Raboch et al. 2010). The need for nurses to be involved in research about coercion in the UK, when they are the ones most frequently ordering it, is evident. However, as results in this review appear to conform across cultures and are supported by an article of international approach (Cutcliffe and Happell 2009), some implications of this review should not be discounted From a UK perspective.

Recommendations and implications for practice and research

Despite consensus in this review that many relationships might exist between power and the therapeutic relationship, further research is needed due to the quality of the current quantitative research and the tendency to focus on a single element of power: coercion. In regard to the relationship between perceived coercion and evaluations of the therapeutic relationship, longitudinal studies may help determine whether this is a causal relationship and experimental studies may be appropriate if an intervention specifically targeted at building a therapeutic relationship can be developed. Studies should continue to use face to face interviews to collect data for surveys as, although this is more time consuming, it results in a more complete data set and higher response rate. Directions in research to date appear to be interdisciplinary, reflecting the increasing interdisciplinary nature of mental health care. However, an increased nursing emphasis needs to be applied to research in order to relate findings specifically to nursing. The articles in this review were all written in what are considered high income countries (The World Bank Group 2015) reflecting the higher number of mental health professionals employed as a proportion of the population in these countries (World Health Organisation 2011).

The current research is difficult to generalise to UK culture and more research is needed in order to assess whether these findings can be generalizable across cultures, and whether unique cultures have unique differences. However, the homogenous nature of high income countries mean it would be more reasonable to generalise the findings of this review to the UK than to developing economies who do not have such a developed mental health workforce. Ethnographic studies involving participant observation may also be helpful in future in order to see if there is a difference between attitudes as gathered by interviews, and actions as seen through observation (Gobo 2011). Future research needs to make efforts to attempt to gain the views of individuals who for various reasons did not want to participate in current research. This will obviously pose practical and ethical challenges, although involving service users as part of the research team may provide new perspectives due to the potential for people to change their responses in relation to who is asking the questions. This also highlights the importance of increased nursing involvement in these research teams, which are currently overrepresented by medical staff.

Nurses may benefit from acknowledging power as a relevant concept within their practice, which appears to be strongly related to evaluations of the quality of the therapeutic relationship. Power may be an uncomfortable topic to reflect on as it may be seen as equating to coercion, but not all power is perceived as coercive and may be perceived legitimately. Relationships are clearly indicated as a factor in which perceptions of power may change. Some of the important aspects in these relationships to ensure they are empowering and not coercive are fairness, reciprocity, authenticity and a personal touch. Sharing of power involves the sharing of information and needs to be balanced appropriately throughout the relationship in order to avoid feelings of either coercion or neglect.

The need to reflect upon power has been demonstrated and there is potential for (ab)use of power to damage the therapeutic relationship. Coercion is also remembered by service users and impacts their perceptions of future encounters within services. The coercive context of mental health services may make service users more sensitive to issues of power and more prone to perceptions of coercion – and the threat of coercion through the mental health act itself may cause formation of therapeutic relationships to be more difficult. It may not be a coincidence that mental health nurses ascribe such value to the therapeutic relationship if you consider how difficult it is to build relationships in a culture where coercion is so prevalent. The influence of the system should not be ignored when thinking about power and current models of practice should be evaluated to determine their benefits and disadvantages in relation to the power relationships they can produce and, in turn, the effect this has on building trusting therapeutic relationships. In particular, the allocation of time should be considered as an important aspect of whether our relationships with service users are coercive or therapeutic.

Neil Molkenthin. Mental Health Nursing, BSc (Hons) Nursing Student

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