Describe and discuss an example of the provision of care in relation to a client you have been working directly with during your placement experience. Demonstrate in the light of the evidence how well the care, met the clients expressed and assessed needs
Describe and discuss an example of the provision of care in relation to a client you have been working directly with during your placement experience. Demonstrate in the light of the evidence how well the care, met the clients expressed and assessed needs
The focus of this assignment is for me to demonstrate my knowledge about social anxiety disorder (SAD), also known as social phobia and the psychotherapeutic interventions employed in the of care of a patient during my clinical placement. My aim is to explain what social phobia is, analyse and evaluate the care my patient has/is receiving and how far it meets his needs. In essence this assignment looks at the nursing process in the care, in community, of a patient suffering from social phobia.
Confidentiality has been maintained at all times in deference to the nursing and midwifery council (NMC, 2002), by giving the patient a fictitious name, Bob. Bob was on my caseload during my placement at a local care in the community resource centre, for psychiatric clients.
Definition of Social phobia
The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (American psychiatric association, 2000), defines social phobia as clinically significant anxiety provoked by exposure to certain social performance situations, often leading to avoidance behaviour. The central feature of this disorder is an underlying fear of being negatively evaluated or judged by others. SAD typically begins during childhood with a mean age at onset between 14 and 16 years (Pollack, 2001, Robins and Regier, 1991) and there is some evidence that genetic factors are involved (Kendler, Walters and Truett, 1995). Women and men are equally likely to develop social phobia (Margolin and Gordis, 2000; Bourdon, Boyd and Rae, 1988).
Patient Profile
Bob,27- year old, single, male lives in a van in his parents' garden. He feels safe in the van and becomes anxious on leaving it. He suffered depression in 1998 which he has not recovered from. He first came into contact with community psychiatric nursing (CPN) services in 1998. He disappeared into the woodwork until early this year, 2005.
Bob presented for treatment with complaints of anxiety and panic in the following one-to-one situations at work, in public areas and on public transport. When in these situations, he feared that he would exhibit symptoms of anxiety and would thus be humialiated and embrassed. Because of this fear he has avoided these situations by remaining in his van for over three years. Bob was diagnosed with suffering from social phobia with agoraphobia and an element of depression.
Bob had a history of bullying in high school of which he did not tell anyone. His problems began when "a friend turned on him" following which he dropped out of college. During this time Bob stopped going out with his friends and started to socially isolate himself. Social phobia can severely disrupt normal life, interfering with school, work, or social relationships (Narrow, Rae and Regier, 1998). Bob's presentation is consistent with social phobia.
Problem formulation and needs assessment
On the basis of Bob's presentation his needs were formulated as:
i) Raise his mood levels
ii) Lower anxiety levels.
iii) Stop paranoid ideas
iv) Raise self estemm
v) Improve socialisation
vi) Enable Bob to verbalise his ideas
The problem formulation resulted in a care plan drawn up with Bob's full involvement. The aims and objectives of Bob's care plan was to:
i) engage in 1:1 sessions with the key worker
ii) monitor mood levels, in particular, response to medication and side effects
iii) look at ways to ...
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On the basis of Bob's presentation his needs were formulated as:
i) Raise his mood levels
ii) Lower anxiety levels.
iii) Stop paranoid ideas
iv) Raise self estemm
v) Improve socialisation
vi) Enable Bob to verbalise his ideas
The problem formulation resulted in a care plan drawn up with Bob's full involvement. The aims and objectives of Bob's care plan was to:
i) engage in 1:1 sessions with the key worker
ii) monitor mood levels, in particular, response to medication and side effects
iii) look at ways to encourage social interactions
iv) refer to depression , anxiety and assertioin management; relaxation techniques
Treatment of Anxiety Disorders
Using core nursing skills and in collaboration with Bob I was able to gather information relating to his current psychosocial status. The benefit of this was that I managed to develop a shared understanding of Bob's problems. It helped me identify how these affect his thought processes, behaviour, feelings and daily functioning.
Effective treatments for each of the anxiety disorders have been developed through research (Hyman and Rudorfer, cited in Dale and Federman, 2000). In general, two types of treatment are available for an anxiety disorder-medication and specific types of psychotherapy. For example, treatment of social phobia with agoraphobia will usually involve medication, cognitive-behavioural therapy (CBT) or a combination of the two (Heimberg, 2001;Joshua et al, 1999). It is generally understood that CBT is the most effective psychotherapeutic treatment modality for social phobia with agoraphobia, and it can be used effectively in combination with pharmacological therapy (Saeed and Bruce, 1998). Medications used include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, benzodiazepines and monoamine oxidase inhibitors (den Boer, 1997:,Saeed and Bruce, 1998). Bob is currently on 100 milligrams (mg) of sertraline, an SSRI, for his depression and SAD, to help maintain his mental balance.
Cognitive-behavioural therapies may include relaxation, breathing retraining with or without the use of physiological monitoring, exposure therapy, and cognitive restructuring. The goals of most psychotherapy relationships fall into six categories: crisis stabilization, symptom reduction, long-term pattern change, maintenance of change, stabilization, prevention of relapse and self-exploration (Beitman, 1997). In the past decade, research from randomised clinical trials has produced strong and consistent evidence showing that CBT can play an important role in reducing social phobia, separation anxiety and generalized anxiety disorder in children and adolescents (Silverman, 2001).
CBT is a combination of any and all methods, strategies, and techniques that work to help people successfully overcome their particular emotional problems (Roth and Fonagy, 1996). The author, under the supervision of the mentor, engaged Bob in 1:1 sessions aimed at the reduction of his fear of negative evaluation by others, anxiety provoking situations to aid his recovery, through graded exposure therapy. One of the main goals of CBT is to encourage patients to confront their anxieties. For the cognitive part of Bob's therapy I referred to the day hospital for relaxation and anxiety management. He has also commenced sessions in the gym to boost his self-esteem and self-image. The purpose of this aspect of the therapy is to teach Bob methods of lessening his anxiety levels in interpersonal relations and for him to begin to control his own emotions. Feedback from him is positive and he is benefiting from this therapy.
The author was personally involved in the behavioural component of CBT. Traditional exposure therapy meant exposing people with social anxiety to situations that they fear, so that they will habituate the feared situations (Rogers and Gournay, 2001). This technique has been shown to be counter-productive for people with SAD (Minardi and Hayes, 2003). From my experiences with Bob, this approach causes damage and keeps the person in the vicious cycle of anxiety, irritation, frustration, anger and depression. To avoid the above pitfalls we engaged Bob in a gradual, step-by-step process, graded exposure behavioural activities. This involved Bob's participation in active structured therapy. A formal behavioural analysis of a patient's problem is typically followed by individually tailored application of techniques to change behaviour. A change in behaviour is viewed as paramount both as a therapeutic aim in its own right and in mediating other symptomatic improvement (Bruce and Saeed, 1999).
For the past three (3) years Bob has never been on any form of public transport. To confront this aspect of his SAD and agoraphobia, we agreed on practical activities that were mildly anxiety causing, and proceeded in a flexible, steady and scheduled manner. The activities I chose with Bob were escorted bus rides, walkabouts in Worcester, having meals/drinks in pubs and restaurants. The objective here was to seek to change Bob's reactions to anxiety-provoking situations by systematically confronting the things he feared.
The escorted rides helped Bob to cope with the resultant anxiety. Initially, these were short bus rides in and around Worcester, at various times. We increased the frequency of Bob's rides to twice weekly with the aim that eventually, after these exercises had been repeated a number of times, anxiety levels will be diminished. As Bob's self confidence grew and his anxiety levels lessened we organised bus rides from Bob's home to Worcester, a distance of 12 miles. Initially the author trailed the bus Bob was on. The plan was that Bob was free to disembark from the bus at anytime he felt that his anxiety levels were unbearable. Bob managed to ride the full trip on at the first attempt. Over the past weeks Bob has now managed to catch the bus on his own from home to Worcester and back for our sessions in Worcester.
When in Worcester we engaged in other graded exposure exercises, by encouraging Bob to spend time in feared social situations without giving in to the temptation to flee. This involved spending time in eateries, pubs, walkabouts in the city and shopping. In all these situations I would encourage Bob to engage in social transactions like ordering drinks, asking people for directions and/or time. Through talking to Bob whilst he did these exercises I would ask Bob to observe other people's reactions. During our post session feedbacks Bob verbalised that other people's reactions were not as harsh as he expected. His social anxiety has begun to fade as he is exposed to his anxiety provoking environments.
Conclusion
My experience with Bob has been enough evidence that the personal qualities of the therapist contribute to the formation of the therapeutic alliance are at least as important, if not more important, than the specific method of psychotherapy used.
The author is not qualified to give a judgement on the efficacy and effectiveness of interventions for social phobia. However, on the basis of the work I have carried out with Bob I can report on earliest signs of progress in therapy manifested as increasing awareness of the various ways in which he is "stuck." At my first encounter Bob recognised patterns or habits of thinking, feeling and behaving without necessarily being able to change them immediately. After the sessions with him for the last nine weeks watching these habits at work and discussing with him the causes and effects of these habits, Bob is starting to make changes and let go of old patterns.
On the basis of progress of Bob's treatment it is safe for me to conclude that the combination of psychotherapeutic and pharmacological interventions synergise each other and produce a better outcome for treatment of Bob's social phobia and agarophobia. Large scale studies on CBT for SAD conclude that patients receiving CBT show significantly greater improvement than those awaiting treatment (Heimberg, 2001).
Reference
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