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The Therapeutic Relationship

Enhancing Referrals

Coyle, Mary Kathleen, PhD, RN, PMHCNS-BC1

doi: 10.1097/rnj.0000000000000160

Purpose This article focuses on the ways rehabilitation nurses use the therapeutic relationship to lessen barriers some veterans experience when a referral to mental health treatment is recommended.

Design Veterans presenting with posttraumatic stress symptoms are discussed, and possible interventions within the therapeutic relationship are proposed.

Method Veterans’ perception of mental health stigma, building a collaborative therapeutic relationship, recommending a referral and assessments of stress responses, posttraumatic stress symptoms, suicide risk, and intervention strategies are proposed.

Findings When changes in functioning and suicidality occur in veterans with posttraumatic stress disorder symptoms, it is important to screen and engage veterans at risk.

Conclusions and Clinical Relevance When veterans in the rehabilitation process present with a need for mental health referral, barriers to treatment may include the stigma of mental health treatment. Rehabilitation nurses using the therapeutic relationship act as change agents to assist veterans in overcoming these barriers to treatment. The therapeutic relationship provides nurses with a foundation to provide opportunities for veterans to be supported and to seek treatment.

1 Department of Nursing, Shepherd University, Shepherdstown, WV, USA.

Correspondence: Mary Kathleen Coyle, PhD, RN, PMHCNS-BC, Department of Nursing, Shepherd University, P.O. Box 5000, Shepherdstown, WV 25443. E-mail:

Accepted February 15, 2018

Cite this article as: Coyle, M.K. (2018). The therapeutic relationship: enhancing referrals. Rehabilitation Nursing, 43(6), E18–E24. doi: 10.1097/rnj.0000000000000160

Since September 11, 2001 (9/11), more than 2 million American service members have been deployed to Operations Enduring Freedom and Iraqi Freedom (OEF/OIF; Lang, Veazey-Morris, Berlin, & Andrasik, 2016). Within this group, “returning veterans describe self-reported health problems” (Morin, 2011), which impact rehabilitation outcomes. Because many veterans choose to visit healthcare providers, rehabilitation nurses working in clinical agencies other than Veterans Administration need to recognize clinical features and health risks associated with service in Iraq and/or Afghanistan. Veterans’ mental health needs influenced by service in Afghanistan OEF, Iraq OIF, and/or Operation New Dawn increase relational to time served, individual experiences, and present when they return home (Hoge et al., 2014). Recent veterans have different types of injuries than previous veterans due to improvised bombs, use of body armor, and effective battlefield treatments. Also, more wounded soldiers survive their service injuries resulting in their return to the United States and need for physical and mental health care (Wolf, Bebarta, Bonnett, Pons, & Cantrill, 2009).

Military members exposed to trauma are at higher-than-average risk for mental health problems but may not seek the necessary mental health care (Tanielian & Jaycox, 2008). One approach to this current clinical issue is to address mental health treatment by exploring ways in which therapeutic relationships enhance the referral process for veterans. This article focuses on how rehabilitation nurses use the therapeutic relationship to lessen barriers some veterans experience when referral to mental health treatment is recommended.

Clinical signs and symptoms of posttraumatic stress disorder (PTSD) and accompanying suicidal risk must be identified so nurses may make referrals for a veterans’ mental health treatment. Also, by detecting subtle symptom changes, veterans with PTSD symptoms and suicidal risk factors can be identified. Nurses in clinical settings are equipped with skills, which include health promotion, providing patient education, support, and coaching within a therapeutic relationship (Clarke, 2012). As a foundation of nursing practice, a therapeutic relationship addresses patient problems by creating a partnership between each nurse and patient using therapeutic communication and empathy (Clarke, 2012). An accurate assessment of veterans assists in developing an understanding of how to diminish stigma, build rapport, and develop a collaborative therapeutic relationship with the veteran and his or her family (Cozza, Goldenberg, & Ursano, 2014). Nurses must first identify and examine their values and attitudes before attempting to understand the meaning of the veterans’ experiences. Being aware of one’s values allows the “nurse to be honest and accept perceived patient differences especially those veterans from diverse/unfamiliar backgrounds” (Stuart, 2013, p. 16). This is critical because veterans are often not asking healthcare providers for help due to shame, stigmatization of receiving care, and healthcare providers not understanding veterans’ experiences. As such, it is important for nurses to be broadly educated on mental health issues of veterans.

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Veteran Mental Health and Stigma

Since 9/11, combat veterans have experienced PTSD (49%), family life strain (48%), and readjustment difficulties (44%; Morin, 2011). They have also dealt with PTSD and higher-than-normal rates of depression, suicide, and substance abuse (impacting 12%–23% of those deployed; Wells et al., 2011). Operations Enduring Freedom and Iraqi Freedom veterans experiencing subthreshold PTSD symptoms, but not the full diagnosis of PTSD, were three times more likely to report hopelessness or suicidal ideation than those without PTSD symptoms (Jakupcak et al., 2011). In addition, OEF/OIF veterans with PTSD symptoms and pain are at risk for physical and mental health problems and an increased utilization of medical services (Lang et al., 2016). Evidence-based treatments available to persons with PTSD include trauma-focused therapy (Nash &Watson, 2012), cognitive processing therapy, and prolonged exposure. Although these treatments are available, veterans’ beliefs that mental health issues should not be acknowledged or that they are associated with weakness and shame may exist (Hoge, 2010).

A stigma surrounding mental health treatment pervades OIF/OEF combat veterans experiencing PTSD (SAMHSA, 2014). Mental health symptoms often go underreported on postdeployment health screenings due to perceived stigma (Hoge et al., 2014). People may refuse to admit to depressive or PTSD symptoms for fear they will be seen as unfit to function or simply be perceived as weak (counterintuitive to the very training that soldiers receive to prepare for engagement; Hoge et al., 2014). Moreover, significant associations were found between regional suicide rates and the intention to seek informal help, self-stigma, and shame (Sharp et al., 2015). The perceived stigma of mental illness also impacts veterans’ perceptions of treatment effectiveness (Koblinski, Leslie, & Cook, 2014).

The quality of the therapeutic relationship is essential to remove barriers of mental health stigma surrounding treatment of veterans. This relationship encourages hope that a veteran’s functioning will improve. Nurses address a veteran’s reluctance to ask for assistance by providing support and encouragement while engaging the patient in the therapeutic relationship. This engagement/support helps veterans identify and address (and hopefully minimize) risk-taking behaviors (Adler & Castro, 2012). It is also important to examine military culture as rehabilitation nurses become knowledgeable and skilled in working with veterans in need of referral for mental health problems.

Military culture is a “source of strength and resilience when it assists veterans to engage resources and supports and promotes hope” (Westphal & Convoy, 2015, p. 4). An understanding of military culture’s impact on the beliefs and practices of military members (Westphal & Convoy, 2015) will determine the need for mental health referrals. For instance, veterans often put others first, commit to a mission, and protect others from enduring hardships (Westphal & Convoy, 2015). “Military culture can be defined as knowledge, beliefs, customs, habits, and capabilities acquired by service members and their families through membership in military organizations” (Center for Deployment Psychology, 2014, p. 4). To develop competencies to care for military members and veterans, a military culture training course created by the American Nurses Foundation (ANF) and the University of Pennsylvania School of Nursing is recommended as a component of the PTSD toolkit for nurses (ANF, 2014).

In order to build a therapeutic relationship, there are self-assessment questions for the nurse to ask herself or himself. These include “Do I have ideas about military culture and stereotypes about the military?” and “Do my values and beliefs interfere with caring for a veteran?” (Cozza et al., 2014, p. 16). Making decisions to obtain mental health treatment for PTSD symptoms if often difficult for veterans. Besides not being comfortable talking about their needs, veterans may not acknowledge the presence or severity of their PTSD symptoms or be aware that they can be treated (Stecker, Shiner, Watts, Jones, & Connor, 2013). As a natural defense mechanism, one PTSD symptom is the avoidance of thinking about the trauma that was experienced (American Psychiatric Association [APA], 2013). Many veterans believe that they can manage on their own without receiving mental health treatment. A recommended approach to reduce stigma is to focus on the veterans’ “experiences, skills and strengths and explain the biological basis of symptoms” (Cozza et al., 2014, p. 17).

By focusing on the veteran’s experiences, a therapeutic process moves away from a disease and negative functioning focus to a symptoms-related focus for veterans (D’Antonio, Beeber, Sills, & Naegle, 2014); understanding a veteran’s stories is critical to a successful therapeutic process (Delaney & Ferguson, 2014). As a foundation for success, the provider–client relationship increases in its level of collaboration when the veteran is engaged in the rehabilitation process (Tyrrell & Pryor, 2016).

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Building a Therapeutic Relationship

A prerequisite to achieving patient outcomes is a care provider’s ability to build trust (Delaney & Ferguson, 2014). Before successful interventions can occur, a sense of trust and care needs to be established between the nurse and the veteran. As a foundation of nursing practice, Peplau’s influential work on the therapeutic relationship ensures that patient needs are primary (D’Antonio et al., 2014). A therapeutic relationship is defined as “one in which the patient feels comfortable being open and honest with the nurse” (Dart, 2011, p. 16) and is linked to the development of positive patient outcomes (D’Antonio et al., 2014). As agents for change, nurses use the therapeutic relationship as a vehicle to help patients reach outcomes (Tyrrell & Pryor, 2016); it becomes a foundation for all coaching to guide self-efficacy interventions. Self-efficacy interventions coach and guide patients to build a sense of confidence that outcomes can be achieved (Bandura, 1997).

The therapeutic process begins with acknowledging the sacrifices and commitments of the veteran to the country and his or her fellow soldiers (Hoge et al., 2014). Nurses who assist veterans during the transition process need to identify open-ended questions regarding the veteran’s rank, responsibilities, and occupational strengths during military service (Adler & Castro, 2012).

Asking a veteran to tell his or her story in order to understand what the veteran has experienced within the context of his or her life is beneficial (Hoge, 2010).

Therapeutic relationships are fostered by employing listening and questioning techniques, along with providing information, giving support, and ensuring care is patient-centered (opposed to task-orientated; Bach & Grant, 2011). Listening actively, focusing attention to recognize verbal and nonverbal cues while eliciting information about the person is critical. Listening to veterans’ stories (Hall & Powell, 2011) and helping them “find answers themselves is also critical so they can navigate their own course of treatment, if the transition from combat is not going smoothly or if the veterans is experiencing high distress” (Hoge, 2010, p. 170).

To gain an appreciation of the veteran’s experiences, it is important to explore their symptoms and need for treatment. We must explore presenting symptoms within the context of the military culture and/or stigma of mental illness symptoms and screen for and explore the impact of these distressing symptoms on patients’ daily activities and quality of life (Lown, McIntosh, Gaines, McGuinn, & Hatem, 2016). As a therapeutic relationship is being established, nurses must begin to assess functioning, how veterans are managing daily routines, stress, commuting, and performing self-care behaviors, preparing meals, doing housework, maintaining family and social relationships, and managing job responsibilities (Schnurr & Lunney, 2016). Healthcare providers have an obligation to understand the perspective of the patient; the degree of compatibility between the veterans’ beliefs and the provider’s recommendations determines effective outcomes (Kleinman, 1988). For example, we must ask about a veteran’s expectations and understanding of what they are going through. This detail may be obtained by asking questions such as “How do you think things are going?” and “What are they most concerned about right now?” (Kleinman, 1988).

Hoge (2010) indicates that healthcare providers must be honest, direct, sincere, and accessible. “Using understandable language without jargon normalizes experiences helping veterans to understand he/she is not crazy and that their responses make sense in the context of their experiences” (Hoge, 2010, p. 187). Hoge recommends avoiding using sentences starting with “you need to” because it presumes healthcare providers know what is best for the veteran and takes control from them rather than helping the veteran discover answers themselves (Hoge, 2010). Skills also include being silent while maintaining a presence and focusing on the other person (Lown et al., 2016). By providing reflective comments and summarizing what a veteran has stated (reflective listening), the rehabilitation nurse gains an accurate understanding using language a veteran understands. This approach integrates thinking, feeling, and specific behaviors. “Veterans need validation and support for their experiences” (Delaney & Ferguson, 2014, p. 150) as well as education and referral, which occur within a therapeutic relationship (Shattell, Starr, & Thomas, 2007).

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Recommending a Referral

Nursing responsibilities include detecting symptom changes, anticipating veteran needs, and determining early adverse events impacting a veteran’s safety. If a veteran is experiencing distress with symptoms that impact daily functioning, consider the need to ask the veteran if he or she would consider a referral to mental health. Often objective feedback from a trusted healthcare provider assists veterans in taking the first steps to getting help. The following approaches are recommended when assisting veterans:

  • Be brief and clear when sharing information about your services.
  • Check in with a follow-up question, “I have shared information with you. Let me stop to check if you have any questions up to this point” (Lown et al., 2016).
  • Avoid premature reassurances; instead explore thoughts and feelings about the need for a mental health referral.
  • Support and allow patient to speak without interruption; use open-ended questions and allow the patient time to respond; use reflective listening to reflect what you observe or hear (Lown et al., 2016).
  • Summarize what was discussed; encourage the veteran to attend to his or her own well-being by offering support that they are not alone.
  • A statement such as, “This may be hard for you as you may not be thinking about yourself but you need to take care of yourself” may be helpful (Lown et al., 2016).

The goals of treatment of PTSD are for the veteran to be able to function productively and maintain healthy relationships (Lee, 2012). Rehabilitation nurses assist veterans to stay focused on the possibility of receiving a mental health evaluation and associated treatment. Veterans may be overwhelmed with difficulties from their personal lives, including families, work, finances, and physical health, which add stress and interfere with symptom relief. A history of previous treatment and ability to recognize that there is a problem may influence a veteran to obtain a mental health assessment. Exposure to mental health treatment in the past may have decreased their perceptions of mental health stigma. Nurses may challenge a veteran’s statements, such as “I should cope on my own,” and their beliefs that mental health treatment is a “sign of weakness” and/or that “no one can help” or that “these problems will just go away on their own over time” (Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury [DCoE], 2015). Prioritizing veterans’ health needs and taking action to address their concerns is critical for healthcare providers (DCoE, 2015).

Prior to making a referral, nursing actions include educating veterans on the benefits of treatment. Psychoeducation may be helpful for veterans who are unaware of the symptoms of mental health issues. Nurses should reinforce that seeking trauma-based treatment is part of recovery from life-threatening combat traumas and assists with daily functioning. Referrals for the veterans are a first step. During the initial interaction, it is important to assess for suicidality and substance abuse. A veteran’s readiness to change is identified at this stage (ANF, 2014). Veterans who are ready for a referral should be immediately referred to a mental health provider. Veterans with more ambiguous symptoms may want to see their primary care physician for consultation (ANF, 2014). The provider should give the patient a phone number for a mental health provider and literature on the diagnosis, and the provider should place a follow-up call to the veteran within 48 hours. Although it is normal to experience stress responses after a traumatic event, veterans need to be informed that they should seek help if symptoms last longer than 3 months, cause them great distress, and/or disrupt their work or home life. In order for nursing to place veterans’ experiences within the context of combat, a description of the stress response is necessary. Types of referrals include support groups, treatment centers specializing in trauma-related disorders, mental health professionals, and hot lines (ANF, 2014).

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Identifying Stress Responses

Stress responses are normal physiological and psychological responses considered to be expected and transient (Westphal & Convoy, 2015) in veterans. Stress responses include impaired sleep, cognitive responses (distorted perceptions such as negative thoughts), relationship issues, and drug use (SAMHSA, 2014). Difficulties also include concentrating and engaging in aggressive behaviors like reckless driving and alcohol, tobacco, and drug misuse/abuse/addiction (SAMHSA, 2014). Nurses first identify and teach normal stress response along with assessing veterans for stress responses that have progressed. Identifying behaviors of potential PTSD include persistent impairment of sleep, emotional responses such as increased irritability and verbal and/or physical aggression, cognitive responses of patterns of persistent negative thoughts, memory impairment, and personal safety issues (Nash & Watson, 2012).

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Assessing PTSD Symptoms

Up to 20% of the 2.6 million service members who deployed to OEF/OIF/Operation New Dawn have or may develop symptoms of PTSD (Epidemiology Program, 2015). Posttraumatic stress disorder is an anxiety disorder that may occur after someone has experienced a traumatic, life-threatening event such as combat, military exposure, sexual or physical abuse, terrorist attacks, and natural disasters (APA, 2013).

Because PTSD is associated with suicidal ideation (Lee, 2012) and linked to poor health outcomes, healthcare providers need to screen for PTSD symptoms and early suicide risk (Lee, 2012). Life-threatening events may have involved the deaths of others or threatened death or serious injury to oneself or others. A person’s response to these events often involves fear, helplessness, or horror (APA, 2013). Signs and symptoms of PTSD include intrusive avoidance; reexperiencing the traumatic event through flashbacks, nightmares, and intrusive thoughts about the event; efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; and diminished interest or participation in significant activities.

Other symptoms of PTSD include sleep difficulties, feelings of detachment from others, angry outbursts, and jumpiness/startling easily (The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition has a fuller description of PTSD; APA, 2013). Beside nightmares, the veteran may feel like they are going through the event again in the form of a flashback. Hearing, seeing, or smelling something that causes the veterans to relive the event is a trigger (APA, 2013). A news report and seeing an accident are also examples of triggers. The veteran may keep very busy or avoid seeking help because it keeps him or her from having to think or talk about the event (Hoge et al., 2014). Hyperarousal symptoms may include sleep impairment, problems concentrating, and being easily startled (Nash & Watson, 2012).

When PTSD symptoms occur months or years after the trauma or come and go over many years and cause distress, they must be addressed and managed with professional help (Nash & Watson, 2012). As a treatable disorder, evidence-based therapy and medications can reduce PTSD symptoms and diminish risk factors. Intensive case management can assist patients with housing, employment, or financial problems. Psychosocial treatments include exposure-based cognitive behavioral therapy. Pharmacological treatment includes selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors, mood stabilizers, and antipsychotics (VA/DOD, 2010). Military guidelines recommend cognitive behavioral therapy as the first-line treatment (VA/DOD, 2010). Educational resources for veterans and healthcare providers could include the PTSD Tool Kit for Nurses ( This resource for nurses aims at reducing the fear and shame of PTSD symptoms and normalizing experiences (ANF, 2014).

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Assessing Suicide Risk

In 2014, veterans accounted for 18% of all deaths by suicide among U.S. adults and constituted 8.5% of the U.S. adult population (ages 18+); about 65% of all veterans who died by suicide were age 50 or older (Kemp, 2014). As veterans with PTSD are diagnosed and treated, healthcare providers from nonmilitary agencies assume active screenings of veterans for early suicide risk, potential for harming self or others, and implement prevention interventions (Lee, 2012). The co-occurrence of polytrauma clinical triad of traumatic brain injury, PTSD, and chronic pain are associated with a significant increase in suicide ideation risk or attempt and ideation (Finley et al., 2015).

Rehabilitation nurses perform suicide assessments to assess presence of suicidal or homicidal ideation, the lethality of any plan for how they will harm self or others, a history of previous attempts, and medical/psychiatric comorbidities (Nash & Watson, 2012). In addition, the presence of psychiatric symptoms, such as hallucinations/delusions, is important to determine, as is the presence of perceived social support and the access to lethal means. Nursing then communicates the assessment of risk to the treatment team and appropriate persons (i.e., nursing supervisor, on duty MD) and accurately and thoroughly documents suicide risks along with the initial assessment (American Psychiatric Nursing Association, 2015). Documentation includes exactly what the veteran states about harming self, details of their plan to do so, and means of harming self. This documentation should also include actions the nurse has taken to contact others and keep the veteran safe.

An important priority at this point is to focus first on protecting the patient from self-harm and harming others. As healthcare providers collaborate by alerting the team, they should identify their concern for the patient and emphasize the need for follow-up, referring the veteran to an appropriate mental healthcare provider for a complete psychiatric evaluation with treatment recommendations (Nash & Watson, 2012). Healthcare providers sometimes assume that asking a veteran about suicide may precipitate suicidal thought—this is not true (Nash & Watson, 2012). Instead, asking about suicidal ideation shows caring and reduces a veteran’s sense of isolation and stigma. Assessment of dangerousness/propensity for harm to self or others includes asking the following questions:

  • “Have you had any concerns about possibly harming yourself or someone else because life doesn’t seem worth living right now? Have you ever thought about acting on these feelings? Are there times when you are afraid that you will act on these feelings?” (SAMHSA, 2014).
  • “Have you ever tried to act on feelings like this in the past? Do you have a plan for how you would harm yourself or someone else?”
  • “Do you have access to one or more weapons?”

The DCoE (2015) recommends that healthcare providers offer assurance that such feelings are not uncommon when individuals feel overwhelmed with loss. If mental health services are available, the provider should refer the patient immediately to the emergency room for evaluation or call 911 if appropriate. Providers may also access the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or visit for additional resources (SAMHSA, 2014).

Nurses must attempt to ensure that lethal means of injury are removed from the patient’s access. This may require asking family members or neighbors to intervene and remove lethal articles so they are not accessible to the patient. As stated, the provider may always refer veterans to other mental health resources as needed (SAMHSA, 2014).

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When veterans in the rehabilitation process present with a need for mental health referral, barriers to treatment may include the stigma of mental health treatment. Nurses use the therapeutic relationship to assist veterans in overcoming these barriers to treatment. When changes in functioning and suicidality occur in veterans with PTSD symptoms, it is important to screen and engage veterans at risk. The therapeutic relationship provides nurses with a foundation to provide opportunities for veterans to be supported and to seek treatment. Research is recommended to measure the therapeutic relationship within the rehabilitation process and to determine its impact on clinical outcomes.

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Posttraumatic stress symptoms; Referral; Therapeutic relationship

© 2018 Association of Rehabilitation Nurses.