Let’s explore Peplau’s theory of interpersonal relations. These stages encompass the entire process of a therapeutic relationship in a hospital setting, from initiation to termination. Understanding and applying Peplau’s theory of interpersonal relations can enhance the level of therapeutic interaction. Although this concept is particularly emphasized in psychiatric nursing, it is applicable to all nurses and therapists in their interactions with patients.
1. Mother of Psychiatric Nursing – Hildegard Peplau
Hildegard Peplau (1909-1999) was a prominent American nurse and scholar, known for her development of the four stages of therapeutic interpersonal relations (Peplau’s theory of interpersonal relations).
Her theory, introduced in her 1952 publication, has become a fundamental framework in nursing, focusing on the dynamics of the nurse-patient relationship across all fields of nursing.
Peplau is often referred to as the “Mother of Psychiatric Nursing” due to her significant contributions to this area.
2. Peplau’s theory of interpersonal relations
We will delve into the specifics of Peplau’s theory of interpersonal relations, which outline the progression of interactions from before the first meeting through to the resolution of the therapeutic relationship.
1) Pre-interaction phase
The first stage of Peplau’s theory of interpersonal relations is the Pre-interaction Phase.
This stage involves preparation for the first encounter with the patient, where the nurse gathers information from medical records, guardians, and other healthcare team members.
During this phase, the nurse becomes aware of their own feelings, which might include anxiety or fear, and considers any potential biases that could affect their interactions.
2) Orientation phase
The first stage of Peplau’s theory of interpersonal relations is the Orientation phase.
During the first meeting, the nurse strives to establish trust and rapport by assessing the patient’s condition and setting realistic goals and plans for treatment.
This phase is critical for building a foundation for future nursing interventions and understanding each other’s expectations and feelings.
3) Working phase
The first stage of Peplau’s theory of interpersonal relations is the Working phase.
This stage involves actively working towards the goals set during the orientation phase. The nurse maintains the rapport and trust established earlier and engages in interventions to help the patient gain insights and overcome resistance.
This phase is where most of the therapeutic work occurs, including dealing with transference and countertransference issues.
4) Termination phase
The first stage of Peplau’s theory of interpersonal relations is the Termination phase.
The final stage marks the conclusion of the therapeutic relationship, often aligned with the achievement of the goals or the patient’s discharge.
It involves preparing for the end of the relationship, evaluating the progress made, and dealing with any emotions related to termination.
3. Transference and Countertransference
During the working phase in Peplau’s theory of interpersonal relations, both transference and countertransference can frequently occur, potentially disrupting the therapeutic process.
1) Transference
Transference occurs when a patient unconsciously transfers feelings they had towards someone in the past onto the nurse. This typically stems from the nurse’s appearance, personality, or behavior, which can trigger memories of another person.
Transference can be positive (warmth, trust, respect) or negative (aggression, anger, distrust), and both can disrupt the therapeutic relationship.
Anger towards the nurse (negative transference) can manifest as non-cooperation and resistance, while excessive dependence or affection (positive transference) can lead to unrealistic expectations and resentment if these expectations are not met.
2) Dealing with Transference
When transference occurs, it is not always necessary to end the relationship unless it seriously impedes therapy or safety. It is important to help the patient recognize that they are repeating past patterns.
By acknowledging the transference, the nurse can help reform the nurse-patient relationship into a new and appropriate context, based on the present rather than the past.
This helps the patient take responsibility for their actions, feelings, and thoughts, grounded in the current reality.
3) Countertransference
Countertransference is the opposite of transference; it occurs when a nurse unconsciously experiences feelings and reactions towards a patient that are connected to unresolved feelings about someone from their past. It can also arise as a response to the patient’s transference.
Both positive (excessive caring, protective desires, fondness) and negative (displeasure, anger, indifference) countertransference can occur, potentially hindering the therapeutic process.
Typical scenarios include a nurse feeling angry when a patient is continuously defiant, becoming overly pleased when a patient shows affection or interest, or feeling omnipotent when a patient is overly dependent. These emotions can be challenging to control.
Examples of behaviors driven by nurse countertransference)
– Forming social or personal relationships with patients
– Attempting to counsel or rescue patients
– Encouraging and fostering dependence in patients
– Feeling disgust or anger towards patients
– Feeling anxious or uncomfortable in the presence of a patient
– Experiencing boredom and apathy during consultations
– Finding it difficult to set limits with a patient’s behavior
– Defending a patient’s behavior to colleagues
4) Managing Countertransference
The presence of countertransference does not necessarily mean that the relationship must end. Therapists experiencing countertransference should seek help from colleagues to understand and recognize their feelings and behaviors in the situation.
After consultations with a patient, therapists should have evaluation sessions with fellow nurses to discuss and reflect on these interactions.
4. Professional Boundaries
Maintaining appropriate professional boundaries is critical in Peplau’s theory. These include managing personal disclosures, gifts, physical contact, and the nature of the relationship to ensure it remains therapeutic and not personal.
1) Self-disclosure
When a nurse’s information can be therapeutically beneficial to a patient, self-disclosure may be appropriate. It should not be used to meet the nurse’s own needs.
Self-disclosure can humanize the caregiver, helping the patient see the nurse as a distinct individual and can alter the patient’s perceptions and emotions. However, disclosing overly personal information is unnecessary.
2) Gifts
In the therapeutic process, the exchange of gifts can be therapeutic or non-therapeutic depending on cultural norms. Patients who have received care may feel indebted and might offer gifts to the nurse. Whether to accept these gifts can depend on cultural beliefs and values.
3) Physical Contact
Touching or hugging can be helpful when it’s done with therapeutic intent and with the patient’s consent. It is essential to ensure that the contact is appropriate, supportive, and willingly received by the patient. Awareness of personal boundaries is crucial, as patients with high anxiety or paranoid or psychotic behaviors might interpret touch as an aggression.
4) Friendship or Affectionate Relationships
As nurses get to know their patients, the relationship should progress from a personal to a professional one. Failing to maintain this professional boundary can jeopardize the nurse-patient relationship, and personal relationships should be avoided.
5) Warning Signs of Professional Boundary Issues
- Preferring to care for one patient over others
- Sharing secrets with a patient
- Dressing up specifically for a particular patient
- Changing assignments to care for a particular patient
- Showing special attention and treatment to a certain patient
- Spending time with a patient outside of work hours
- Frequently thinking about a patient after work
- Sharing personal information or work-related concerns with a patient
- Receiving gifts from a patient or continuing contact after the end of the clinical relationship
I have worked for over ten years in the psychiatric ward of a major university hospital in Korea, studying cognitive-behavioral therapy, schema therapy, mindfulness meditation, and Jungian dream analysis. These experiences have shown me that the emotions arising in the relationships between caregivers and patients are often deeply connected to oneself.
Transference and countertransference can occur not only between therapists and patients but in any relationship. To understand these unconscious emotions, I recommend familiarizing oneself with the concepts of schemas and schema modes in schema therapy.
5. Conclusion and Q&A
We have explored Peplau’s theory of interpersonal relations, focusing on the various stages of interaction between the caregiver and the recipient.
Peplau’s theory of interpersonal relations is particularly beneficial for psychiatric nurses as they navigate the process of meeting and parting with patients, setting a therapeutic direction.
Let’s address some frequently asked questions and key points about Peplau’s four stages of therapeutic interpersonal relations:
1) What ㅑ Peplau’s theory of interpersonal relations?
Peplau’s theory of interpersonal relations outlines the four stages of interaction between a nurse and a patient : pre-interaction, initial interaction, ongoing interaction, and termination.
This model is especially useful for psychiatric nurses as it provides a structured approach to managing therapeutic relationships.
2) What should be considered carefully in Peplau’s theory of interpersonal relations?
It is crucial to be aware of transference and countertransference that can occur within the therapeutic relationship.
Both transference and countertransference involve intense positive or negative emotions that can arise between the patient and the caregiver. Understanding both oneself and the patient is essential for effectively managing these dynamics.
For those interested in further exploring therapeutic communication or the theory of proxemics, which deals with the use of space in communication, please refer to the following link.
► References and Further Reading
– [Book] “Psychiatric Nursing 9th edition” – Part on Therapeutic Relationship Formation by Mary C. Townsend and Karyn I. Morgan, published by Hakjisa Medical
– [Interview] Insights from a psychiatric nurse at OO University Hospital
– Be the Titan Brain
