r ‘I admire your determination to stay sober’
r ‘I know that asking for help is a big step for you’
r ‘You managed your anger very effectively in the meeting’
r ‘I really admire your positive attitude in spite of all the difficulties you have faced’
r ‘Well done for stating your needs in the group’
r ‘I admire your courage to be open with your family and friends about your experiences of being in hospital for mental health problems’
Source: Heron (2001)
r Informative – ‘One of the side effects of your medication is low blood pressure’
r Informative – ‘ECT stands for electro-convulsive therapy’
r Informative – ‘Sleep disturbance is a symptom of depression’
r Confronting – ‘It sounds like you were asked to leave the hostel because you were aggressive towards the other residents’
r Confronting – ‘Are you aware that you frighten other clients when you start shouting?’
r Confronting – ‘I notice that you find it difficult to ask for help’
In practice, balancing authoritative and facilitative interventions is about the appropriate use of power between the client and the mental health nurse (Heron, 2001) and includes the following forms of power:
r the mental health nurse’s power over the client, for example the nurse’s power in his/her capacity as a mental health professional
r the power shared between the mental health nurse and the client, for ex- ample, the nurse and client’s power to ask questions and to listen to each other
r the autonomous power within the client, for example the client’s power to make decisions about his/her life.
The above forms of power are interrelated, and will change according to the changing needs of the client throughout the therapeutic relationship. The following clinical scenario illustrates an interaction whereby the mental health nurse uses authoritative and facilitative interventions.
Clinical scenario
Adam, a third-year student, enjoys working in the Day Hospital for the Older Adult.
He has a good relationship with the clients, their families and carers. The staff nurse asked Adam to inform Mrs Black about the carers’ support group. Mrs Black has cared for her husband who has short-term memory impairment for over five years. They have no children. Mr Black attends the Day Hospital three days a week. The following illustrates the interaction that took place.
Adam: ‘How are you today?’ [Catalytic]
Mrs Black: ‘Fine thank you. I am so looking forward to my holiday in a few weeks.
I need a rest, I am so tired.’
Adam: ‘I am sorry to hear that. I thought you looked tired. What’s causing you to be so tired?’ [Supportive and Catalytic]
Mrs Black: ‘Oh it’s nothing; I just need a good rest.’
Adam: ‘How is your sleep these days?’ [Catalytic]
Mrs Black: ‘It’s OK.’
Adam: ‘OK?’ [Catalytic]
Mrs Black: ‘Oh I get a few hours.’
Adam: ‘Mrs Black, I might be wrong but I sense that you are not telling me something?’
[Confronting]
Mrs Black: [Starting to cry] ‘I am sorry I know you want to help but I am afraid to tell you what’s been happening as you will think I can’t cope.’
Adam: ‘From what I know of you, I think you cope very well caring for your husband.’
[Supportive]
Mrs Black: ‘My husband is waking up every night and wandering around the house, saying he wants to go to work. He only sleeps for three or four hours. I don’t know what to do, I have tried everything.’
Adam: ‘That must be very difficult for you. It is so important that you and your husband get adequate sleep. I think you should see the clinical nurse specialist and discuss how she can help you.’ [Supportive and Prescriptive]
Mrs Black: ‘Oh I don’t want to make a fuss.’
Adam: ‘You are not making a fuss. This is her area of expertise. I will contact her and arrange an appointment for you. I will also inform your husband’s doctor, he may review his medication.’ [Prescriptive]
Mrs Black: ‘Thank you Adam.’
Adam: ‘I also have information regarding the local carers’ group. Are you aware of this group?’ [Informative and Catalytic]
Mrs Black: ‘No I don’t know about it – what does it do?’
Adam: It is a support group, usually about eight to ten people who, like you, care for their partners or parents. It takes place every Tuesday at 2pm for an hour. They have a very good reputation. I have some leaflets about the group for you to read.
If you have any questions, please let me know.’ [Informative]
Overlapping of categories
All six categories are independent of one another and have a specific intention or purpose; there are also significant areas of overlap between the categories, for example informative interventions that are confronting, prescriptive inter- ventions that are catalytic, and others. When such overlap occurs, the inter- vention is then classified under the category, that covers its primary purpose, as illustrated in the following examples.
Informative intervention – confronting intervention
Nurse: ‘Your community mental health nurse told me that you did not attend the day centre.’
On its own, this intervention could be considered as an informative inter- vention whereby the mental health nurse is informing the client about what she/he knows. However, looking at the intervention within the following context, the intervention is identified according to its primary purpose or intention, which in this instance is to challenge the client in a supportive way; therefore, the same verbal intervention is a confronting intervention.
It is important to remember that the nurse’s body language will also be an influencing factor.
Client: ‘I don’t like going to the day centre, there’s nothing to do, and it’s boring.’
Nurse: ‘Your community mental health nurse told me that you did not attend the day centre.’
Client: ‘Well I went to a day centre years ago.’
Prescriptive intervention – catalytic intervention
Nurse: ‘Describe what it was like for you when you felt the urge to cut your- self.’
As it is, this intervention illustrates that the mental health nurse is directing the client to describe her recent experience of self-harm. Therefore, this intervention could be described as a prescriptive intervention; however, on examining the intervention within the following context and its primary purpose, which is to encourage the client to explore her experience of self- harm in greater depth, the verbal intervention is a catalytic intervention.
Client: ‘I tried to stop myself, but I couldn’t. I got the blades from my father’s razor.’
Nurse: ‘That must have been really difficult for you.’
Client: ‘It was. . .it was very difficult. I feel really bad now.’
Nurse: ‘Describe what it was like for you when you feel the urge to cut yourself.’
Client: ‘I feel numb inside, I need to cut myself to feel alive.’