The therapeutic consultation

Over-emphasis on technology tends to overshadow therapeutic modalities that can have real significance. Nurses must recognise that they do not create change in people, rather they participate in the process of change to the extent that they bring knowledge to the situation and recognise that the healing process has the potential for healing beyond that which we recognise today. (Rogers, 1992, p. 61)

To help the patient make the most of their treatment, there is a fundamental need for health professionals to create effective opportunities for open communication within the context of the dermatology consultation. The consultation provides the key opportunity for effective education and support. It is paradoxical that within the discussion of evidence-based treatment in dermatology care, very little attention is paid to the quality of the consultation opportunity as a human interaction that can profoundly influence the patient’s behaviour, treatment plan and the final outcome of the care. Some attention has been paid to these issues in nursing in general (Ersser, 1997; Kinmouth et al., 1998; Watson, 1999), with limited attention in the dermatology nursing context (with some exceptions, e.g. Courtenay et al., 2009). General practice research has paid attention to consultation issues amongst GPs and nurses (Kinmouth et al., 1998); however, this remains a neglected area within the dermatological literature.

The quality of the consultation and its outcome is directly dependent on the quality of the practitioner–patient relationship and the ability to ensure that they optimise opportunities for education and support. Typically, nurses are well placed to do this should they allow time to assess and plan for patients’ support need, although it is also essential for the dermatologist– patient consultation when making crucial decisions about treatment plans. This may also apply to nurse–prescriber–patient consultations in some countries such as the UK.

The literature from the social psychology literature on therapeutic professional relationships reveals common features which apply to all therapeutic and helping relationships. There is also evidence of the exploration of the distinctive therapeutic opportunities that nurses may have through helping patients with everyday living activities as well as treatments (Ersser, 1997); these are summarised and exemplified in Table 7.3.

Table 7.3 Features of therapeutic-helping relationships.   Feature Illustrative supporting references   Self-awareness Freshwater (2002), Egan (1994), Peplau (1988), Krikoriam and Paulanka (1982)   Being genuine and authentic Jourard (1971), Truax et al. (1974), Mitchell et al. (1977)   Committed to patient participation in care Brearley (1990), Hays and Dimatteo (1984), Roberts et al. (1995)   Emotional involvement and closeness Jourard (1971), Strang (1982)   Empathy Morse et al. (1992), Truax et al. (1974), Mitchell et al. (1977)   Trust Watson (1985), Bernado (1984)   Unconditional positive regard/warmth/caring Geanellos (2005), Sellick (1991), Stickley and Freshwater (2002), Combs et al. (1971), Mitchell et al. (1977), Morse et al. (1992)

Central to all the features of therapeutic relationships is the capacity for self-awareness within the health professional, as a prerequisite for enhancing the therapeutic quality of the consultation (Ersser, 1997; Freshwater, 2002). These features help to create the opportunity for effective patient education and support described previously. Taking the example of the concordance process, this is much more likely to be effective when there is a commitment to patient involvement, empathy to their concerns and preferences, unconditional positive regard and self-awareness regarding the health professional’s own preferences and predispositions related to patient care. However, these features of therapeutic relationships cannot be taken for granted as being ever present; for example, Sellick (1991) found that nurses had a stronger desire to control relationships than other professionals, such as occupational therapists.

Through the nurse–patient relationship, the nurse has scope to meet the patient’s expectations for seeking help, including their need to receive support to develop their abilities and independence and play their part in managing their condition.


To achieve this, nurses may contribute as a resource and catalyst for the patient by raising mutual awareness of their needs on their journey from dependence to independence; this is achieved through the formation of an attachment, providing the patient with a basis for support (Ersser and Watkins, 2007). Attachment relationships are common in helping relationships and times of need (Ersser, 1997). Attachment theory is relevant to adults as well as children – and remains an important theory in the social psychology literature (Rholes and Simpson, 2006). It is concerned with adult attachment styles and the psychological underpinnings and how these make an impact on the outcomes of different attachment styles. Dependence and anxiety may be reduced and the patient can explore new coping mechanisms adapted to new awareness and diverted into positive control over the experience of symptoms/illness. McCluskey (2005, pp. 86–87) describes the consequences of an effective attachment as follows: ‘The care-seeker has the subjective experience of accessing competence. When this happens, the instinctive system for care-seeking will shut down and the exploratory system within the individual will have more energy to engage with the problems of living.’ The appropriate caregiver response to the patient’s (or parental carer) need is to put them in touch with their competence to act and reactivate their emotional, physical and intellectual capacity and resources applied to the individual (Ersser and Watkins, 2007).

There is evidence of distinctive therapeutic opportunities for education and support provided within nursing therapeutic or helping relationships. This may include meeting a range of patient needs through the provision of skilled bodily or intimate physical care such as washing and moisturising the skin Lawler, 1991; Ersser, 1997). Furthermore, there is evidence of a recognition of the integrated nature of care of mind and body, with an emphasis on maximising the therapeutic opportunities that exist within ordinary daily care, such as skin hygiene or helping to apply treatments events, which provide therapeutic opportunities to integrate the meeting of both physical and psychological needs (Chapman, 1986; Taylor, 1994).

Therefore, in conclusion, there is a need for the health professional to cultivate an accessible, effective consultation style, building on established psychological principles on therapeutic/ helping relationships, as a basis for helping or empowering the person to be able to engage actively in contributing to the management of their own health.