Therapeutic reciprocity poses significant practical difficulties and ethical hazards. For the use of this technique of self-disclosure to be considered ethical, the nurse must justify having a special relationship with the patient. To be considered practical, the interaction must help and not harm the patient or the patient's family members.

Both nurses and patients place high value on the "therapeutic use of self," which involves the nurse's positive regard for patients. Taking relationships with patients seriously means nurses must examine their own feelings and motives and how they affect their ability to practice ethically. Interactions with patients must be conducted in a way that's fair to all patients. For example, when nurses see similarities between patients' lives and their own, they aren't justified in giving those patients preferential treatment (as in the distribution of health care resources).

Such a similarity does not provide an ethical basis for a special relationship with the nurse. If it did, all patients would be entitled to be cared for by nurses who resemble them.

Empathy tends to occur between like people and with likable people. Nurses, like all people, are prone to having special feelings for others who are like them or who are endearing-or for patients who're "easy." It seems that the real ethical problem is not how to refine relations with patients whom nurses see as similar, but rather how to connect with patients whom they see as different or "difficult."

A nurse who perceives a special connection with a patient might be justified, even obligated, to use that connection for the patient's benefit as long as it doesn't interfere with other patients' care. A more potent danger occurs when a nurse's need to see similarities interferes with her or his ability to have a therapeutic nurse-patient relationship, such as if the nurse distorts understanding of a patient and the patient's problems in an effort to see the patient as more like herself or himself. Therapeutic connection is better served by developing the ability to understand, appreciate, and empathize with patients who differ significantly from the nurse, and to perceive the connection as broadly as possible, such as "I'm like you because of the experience of sadness" rather than "I'm like you because I lost my father, too."

There are also significant practical problems inherent to disclosing personal information therapeutically. For one, it's a difficult technique to master. Psychiatric nursing students, even those in master's programs, typically mistake disclosing personal information (such as "I cried like you when my father died"), which tends not to be therapeutic because the focus is on the nurse, for here-and-now personal feelings (such as "It makes me sad to see you watch your father die"), which are most likely to be therapeutic. The reciprocity that occurs in friendship is not the same as that which occurs between nurse and patient. In friendship, there is, appropriately, an expectation of reciprocity. In therapeutic relations, the clinician's positive regard of the patient must be unconditional. Also, friends may work toward equality in their relations, but in the clinical relationship power is not, cannot be, and should not be equal.

Countertransference-when the nurse's feelings toward the patient are in part based on personal experience and not directly related to the current situation-presents daunting practical challenges, especially when a nurse is attempting to judge whether disclosing personal information has therapeutic value. Nurses want to believe they're taking the right action, and they may want patients to tell them that they've done the right thing. And the patient may want to respond positively to the nurse-an ethically more concerning bias over which the nurse has no control. These sources of bias make it difficult for nurses to judge the therapeutic value of their own disclosures.

A nurse's disclosure of personal information to a patient can be beneficial, but as a technique therapeutic reciprocity is difficult to perform and teach, requiring more than compassion. It should not be taught to novice nurses, nor should it be widely promoted as part of standard practice.

The gratification nurses get from patients is what makes nursing a great vocation-contact with patients is fulfilling because nurses don't demand or expect anything in return. The ethical struggle is not in having compassion for patients who give back willingly and knowingly; it's in learning to feel that one has received something in return from the patient who rebuffs or is different from the nurse.

Douglas P. Olsen, PhD, RN

associate professor at the Yale University School of Nursing in New Haven, CT, and co-coordinator of Ethical Issues