Recognizing, understanding, and responding to familiar responses: the importance of a relationship history for therapeutic effectiveness.

PROBLEM: To describe aspects of therapeutic effectiveness, including the importance of an ongoing relationship. METHODS. A phenomenological study (n = 14) involving nurse psychotherapists (n = 6) and clients (n = 8). FINDINGS. Participants recognized dense meanings and familiar, shorthand communications evolving from their relationship history. This ability to read another's responses with sensitivity and attunement contributed to a sense of comfort and openness during therapy sessions. CONCLUSIONS. Students should be taught how a relationship history contributes to sensitivity to nuances of meaning and development of an individualized approach. Reimbursement structures must be developed that acknowledge the situated nature of change and the significance of an ongoing relationship. Key words: Nurse-patient relations, nurse psychotherapist, psychiatric nursing, qualitative studies, treatment outcomes Although the importance of an relationship history between clients and therapists has not been discussed to a great extent within the literature on therapeutic effectiveness, several authors within the disciplines of nursing (Heifner, 1993), philosophy (Merleau-Ponty, 1964; Taylor, 1991), and mother-child relationships (Symons & Morgan, 1987) have addressed the significance of a relationship on understanding and effectively responding to another person. In philosophy, Merleau-Ponty explained, "Former acts of expression establish between speaking subjects a common world ... a keyboard of acquired meanings" (p. 186). Communication becomes finely tuned, agile, responsive, and well suited to the exchange of nuances of meaning when people have spent significant amounts of time together. Merleau-Ponty elaborated: When I chat with friend whom I know well, each of his remarks and each of mine contains, in addition to the meaning it carries for everybody else, a host of references to the main dimensions of his character and mine, without our needing to recall previous conversation with each other. These acquired worlds confer upon my experience its secondary meaning. There is no need for re-synthesis, we simply understand one another based upon shared history. (p. 130) MacIntyre (1981), another philosopher, described ways life histories and relationship histories evolve in a narrative fashion: "I am what I may justifiably be taken by others to be in the course of living out a story that runs from my birth to my death. My life is not a series of unconnected episodes--it is a narrative" (p. 217). As Bauman (1995) explained, relationships are whole and continuous, not fragmentary, not episodic in character even if the structure of the meetings is such that their continuous nature develops from weekly contact over time. Knowing another through years of contact or periods of intense interaction allows one to grasp their narrative. Understanding another's narrative is based on having a shared world of references and repertoire of common meanings developed by knowing and talking to each other over a period of time (Taylor, 1991). Developing ongoing relationships with clients is more than remembering what they have told you and understanding more quickly or deeply, based on having heard some of the story before. Developing a relationship and a history with a client has to do with establishing a climate of trust. It has to do with how you are with someone each time you are together. As Bauman reflected, a lasting legacy is fashioned each time two people interact. The nature of the relationship and the way two people are together in each therapy session is a heritage that affects how they will respond to each other in future sessions. Within nursing, Martinsen (1996) described the ethical importance of an "aware listening to" and "looking into" (p. 12) associated with presence and sustained involvement with another person. Tanner, Benner, Chesla, and Gordon (1993) explained that knowing patients involves experiencing them as people, noticing their typical pattern of behavior, and anticipating the most likely trajectory for recovery based on their past responses to treatment. …