Sahreen Malik Bhanji*
The Aga Khan University School of Nursing and Midwifery, Pakistan
Received date: April 28, 2013; Accepted date: June 17, 2013; Published date: June 20, 2013
Citation: Bhanji SM (2013) Respect and Unconditional Positive Regard as Mental Health Promotion Practice. J Clin Res Bioeth 4:147. doi: 10.4172/2155-9627.1000147
Copyright: © 2013 Bhanji SM. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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The client whose case I am about to discuss is a 50 years old female, schizophrenic and experienced auditory hallucinations. She was an active lady, did all her work on her own. When I encountered her, she confessed that the intensity of auditory hallucinations had decreased to a greater extent. The only thing that worried her was her facial droop which was because of a disease she had suffered from in her childhood because of this reason and hearing loss, she was hesitant enough to get along with others. She felt disrespected sitting in groups when she was isolated as nobody talked to her or gave her importance as she could not hear which augmented her stress further.
The incident that urged me to write on this topic was, when I had the conversation with this client for the first time. The conversation started with the greeting and my next question was “Kaisi ho tum?”. I was taken aback with her response. She replied “please ap mujhe tum na kahain, may ap say umer may kafi Bari hun”, this was an eye opener for me. I was not expecting this reply, but at that very moment I realized that I was wrong. I quickly sought an apology for this. In response to my apology, she was kind enough to pat my shoulders and say “koi bat nahi beta ainda zaror khayal rakhna”. I quickly gathered my thoughts again to converse further but what had happened later opened a lot of dimensions for me to ponder upon. I had never realized that my conversation would miss an important element of respect. How could I ever think that I would build a therapeutic relationship without respecting my client?
The purpose if this scholarly paper is to explore different dimensions of respect and unconditional positive regard and impact of both the practices on mental health promotion. The paper is directed to the healthcare professionals to recognize respect and unconditional positive regard as mental health promotion practice.
Merriam-Webster Online Dictionary (2009) defines respect as “the quality or state of being esteemed”. College of nurses of Ontario, practice standard (2006) defines respect as “recognition of the inherent dignity, worth and uniqueness of every individual, regardless of socio-economic status, personal attributes and the nature of the health problem”. Mohr  and College of nurses of Ontario , practice standard (2006) describes six key components of therapeutic relationship. They are (1) Trust (2) Professional intimacy (3) respect (4) Caring (5) partnership and (6) power. These components in combination form a therapeutic milieu which is necessary for mental health promotion and mental illness prevention. In my paper to follow I will be talking about one of the components of therapeutic relationship i.e., Respect and its impact on mental health promotion.
Many authors have used words like caring, liking, valuing and prizing as synonyms for respect. During the literature search, I came across a few articles and books that talked about unconditional positive regard along with respect. Both these terms are interchangeable and as a practice, they are used widely in mental health settings to uphold the dignity and self esteem of the clients. They defined unconditional positive regard as accepting and respecting the clients without regard to their behavior or flaws. This means that clients should be regarded as a human being, as a unique individual and a person of worth and accepted as who they are and as they are despite their behavior or conduct. In the context of mental health this seems to be quite controversial but Stuart  clarifies this concept by stating that “acceptance means viewing the patient’s actions as coping behaviors that will change as the patient becomes less threatened and learns more adaptive ways”. Unconditional positive regard gives clients an opportunity to communicate their feelings and thoughts without fear of being stigmatized or disrespected.
Respect and unconditional positive regard can be communicated through attitude as well as activities or actions. In mental health setting, the attitude which includes verbal and nonverbal communication and feelings play a key role and guide our actions towards the patient. They suggest several ways of communicating respect towards the client. These include providing silence to a crying patient, genuine laughter or gesture of happiness at certain event, accepting a patient’s request of keeping a secret or experience, apologizing for the unintentional hurt caused by a phrase, being open to the anger or hurt caused by the patient and not taking patients behavior or words personally. If I recall my own experience mentioned above, I can relate these ways of communicating respect to my client. I apologized her for the unintentional hurt I caused her by calling her “tum” instead of “aap”. This intervention helped me build a strong therapeutic working relationship and remove all the misunderstandings and build a strong reputation with the client. Later throughout my clinical I also applied most of the interventions mentioned above and the impact of these interventions was such that my client developed self confidence, her self-esteem was improved, she developed trust in me and could confide every single detail of her life events without hesitation. She felt that she was respected and given importance. Boyer et al.  cited a qualitative study in which interviewed 77 psychiatric inpatients who emphasized mostly on empathetic qualities of nurses of being caring, respecting patients devoting time to patients and providing them a safe environment, whereas, the physical routine care was of least priority for those patients. This study reflects the importance of behaviors like respect and unconditional positive regard to psychiatric patients’ mental health promotion.
College of nurses of Ontario, practice standard has provided a comprehensive tool named as “Decision Tree”. It is a useful tool which can be used for self assessment and as a reflective practice to guide our interventions in the mental health settings. The tool follows certain steps guided by several questions to be answered as yes or no to finally decide whether the strategy or intervention would further enhance nurse patient relationship. I did not use this tool but I reflected over my words in the above presented scenario and realized that my words were quite disrespecting for my client. She was an elderly lady and I should have modified my words. Later I sought an apology and remained careful in my actions and communication so as to prevent further incidences of disrespect and promote mental health of my client. Moreover, in the rest of the clinical weeks, I tried my best to plan such strategies and activities which could give my client to be felt important. For e.g. she was fond of reading books and digests so I bought her three books which she read to me and was very happy and felt empowered and dignified. Furthermore, with every encounter I reflected on my communication pattern and also sought her views about it.
This was an overview of respect as a health promotion practice and a tool to implement this practice in mental healthcare settings. Let us now consider some of the strategies to carry out this practice to promote mental health. Strategies to promote respect and unconditional positive regard need not to be designed as such but both these aspects should be an important element in all the interventions that need to be carried out in a mental healthcare setting. Nurses are considered as backbone of the health care institution and are meant to cure rather than treat the diseases. Chiovitti  gave the theory of protective empowerment. According to this theory, the nurses described care as a protective component and their major focus was to empower patients to resume the activities of daily life. When the nurses were interviewed, they defined respect as “the basis of the relationship with the patient and trying to develop a trusting relationship, so that the patient can better interact in the community”. Moreover, the author has explained two actions that are necessary to the action of “caring” to be carried out. These include respecting the patient and not taking the patient’s behavior personally. To accomplish respect, the author gave four categories of interventions which were 1) acknowledging the patient’s suffering and distress; (2) being non-judgmental to the patient; (3) not over-powering the patient and (4) viewing the patient as knowledgeable. These interventions can be integrated within the daily practices of healthcare professional or practiced at individual, institutional and society level. At an individual level, a healthcare professional may it be a doctor or a nurse or any other staff, should accept the client as it is. Freeth  states that one barrier in practicing unconditional positive regard is the preconceived notion of people judging others through their behaviors rather than as a person. This is a very important point which should be considered by all the mental health care professionals to accept the behaviors of the patient keeping in mind that they would change as the patient learns more adaptive ways of coping. If I relate theses interventions with the scenario, after that incident, rather than taking her comment personally I took it as a learning point. I became very cautious during my conversation, I reassured and inquired about my communication pattern, I listened to and respected her concerns, acknowledged them and planned strategies with her. Since she was quite stable in the course of her disease, she was the only patient in the rehabilitation centre who cooked her food herself, always remained well groomed and did everything by her own. Yet she lacked confidence to face people as she thought they might make fun of her drooped face and hearing loss. To overcome this fear I always acknowledged her efforts, made her feel different from others in a positive sense for e.g. I made her realize that she was the only client in the rehabilitation centre who did all her work on her own independently, which gave a boost to her self confidence and self esteem. As cited in Kitson  viewed the concept of caring within nursing as “interpersonal activities and related attitudes, predominantly the moral attitude of respect for persons”. One day when I took her for the occupational therapy, she taught me how to do embroidery on a piece of cloth. I respected her knowledge and efforts by showing keen interest towards her initiative. This simple intervention made her empowered and she felt respected and cared for. At an institutional level, the healthcare setting should follow a set of rules or “mental health act” so as to govern the practices of the staff towards their clients. It is important that mental healthcare professionals respect their patients or clients by respecting their rights. It is very important for the society to participate towards the well being of the people with mental illness. It is an utmost duty of health professionals and especially nurses to educate and create awareness among the families as well as common public and provide correct information about mental illness. Moreover, families need to be educated about the negative impact of their attitude and practices of disrespecting and calling their ill family members as “insane”, “crack” or “worthless”. Furthermore, families need to be taught that the client should be accepted as a respectable human being and should be treated in accordance with the mental health laws. This would lead to the mental health promotion and early recovery along with psycho pharmacotheraphy .
Karim et al.  found that introduction of community mental health program and school mental health program in Pakistan have led to a decrease in stigmatization of people with mental illness and increase awareness of mental illness. Moreover, the implementation of National Mental Health Policy and Mental Health Act in 2001, have led to the provision of culturally appropriate care integrated with respect and dignity in mental health settings. The study gives us a picture of mental health care provision in Pakistan. Yet there are drawbacks in the systems in few areas. The need for reinforcement to practice these laws and constant education of healthcare professionals, community awareness especially family members of the client with mental illness to respect them in all the ways they can, is necessary in order to bring a change and improvement in this arena.
This scholarly paper was a great learning opportunity for me.It opened several new dimensions of Respect for me. Previously I considered respect as only an element of therapeutic relationship but through literature search I was able to discover the other side of the picture. I explored a new dimension of respect and positive regard as health promotion practice. It also enabled me to develop and design strategies to implement this practice in my client’s case and evaluate its outcomes. Finally my greatest learning was that even our simple interventions of giving respect can do wonders and a minute mistake can spoil the nurse - patient relationship. Most important of all it was a lifelong learning for me to remember that as a nurse it is the utmost duty to respect our patients but in mental health settings it is even more important and should not be overlooked in any case.
In conclusion, Respect is a basic human right and no human being posses this right. The importance of this right is augmented when uniqueness of an individual is concerned. As a mental healthcare professional, it is our duty to accept our client as they and treat them with respect, not only because they are also human beings, but also because they are in a vulnerable situation. It is also important to plan and implement strategies like mental health laws which promote respect and unconditional positive regard towards their clients in organizations providing mental healthcare facilities. Our efforts and small interventions integrated with the element of respect can do wonders for the clients seeking mental healthcare and can play an important part in their mental health promotion .