The aim was to relax the clients while confronting her with her fear and then build up gradually so she could take a taxi to her father's flat and take other public transport.
When the client reached the stage where she became comfortable with the walking distances we arranged a public transport ride. During the days prior to the journey we adopted visualisation where the client would imagine what would happen in the bus. We would also discuss how she would deal with the situation if she were to suffer an epileptic fit while in a bus or out walking.
This technique is a form of behaviour therapy called graded exposure (Atkinson 1993) it is all very well facilitating the person to understand why she is phobic but this does not mean the person will be cured of her phobia (Manville 1991).
The aim of behaviour therapy is to change the clients' behaviour. It works on the principle that the behaviour has been learnt, but this did not cause her to change her behaviour.
The basic approach of graded exposure is to relax the phobia and then introduce her gradually to the object or situation she fears. The nurse can either do this with the client through visualisation or actual exposure (Atkinson 1993).
This client was exposed using visualisation but the technique used the most was direct exposure to the situation.
The ideas to take the clients' smallest fear and confront this first working up to their largest fear. This is called the graded hierarchy. The clients' smallest fear was to go out of her front door and her largest was to be able to travel on public transport at will. Working towards the clients' largest goal gradually is most effective.
“Clients' may lose their fears more readily if they actually expose themselves to anxiety provoking situations in a sequence of graduate steps.
(Sherman 1972 cited in Atkinson 1993 page 678).
Another technique we use to help clients' manage her agoraphobia was relaxation techniques.
The clients' experienced various unpleasant anxiety symptoms usually just before and during the exposure. The client would feel agitated at the prospect of experiencing anxiety while outside. She would suffer from many physical symptoms. She would have increased pulse rate, pounding heart, nausea and a dry mouth. She would also sweat and complain of butterflies in her stomach or churning.
As part of my assignment of the clients' anxiety I needed to be able to have observe these feelings and symptoms in the client. Then together we could deal with them and ease her uncomfortable state. I asked questions to myself such as “Is she sweating?” “Is her body language suggestive of anxiety”? This would mean shaking or agitated moments.
During times when the client was anxious she found it difficult to concentrate and think rationally or logically. She found it difficult to name her feelings. These are normal reactions. (Wilson and Kneisl 1996).
Emotionally the client described herself as “tense”, “nervy”, “anxious” and “like I’m going to die”. The clients' would also have negative thoughts about herself. She would say she was “silly” and “useless”. So anxiety affected her physical state and cognitions.
This anxiety was causing the client to become increasingly isolated in her flat and also affected her self-esteem because she felt the anxiety controlled her. She recognised the need to control her anxiety, and she wanted to control it and therefore needed to be educated about anxiety and then hopefully she feels more competent to deal with her feelings.
The client and I engaged in teaching about anxiety. It was explained that anxiety symptoms occur when our brains interpret a given situation as anxiety provoking. (Baker 1995). The subject of our body involved in the responses in these responses is the autonomic nervous system, which is divided into two components; the Sympathetic and the Parasympathetic systems. The Sympathetic system causes the individual responses to speed up and the Parasympathetic causes the responses to slow down.
So when a person encounters an anxiety-provoking situation, for example, a person approaches someone with a knife, does that person run away or stay and fight? This is termed to fight or flight Syndrome and is dependent on the individuals or biological response to the stressor.
These responses to stress are quite normal and we need them to protect us from danger. Anxiety becomes a problem when a person perceives a situation as a stressor even when it is not. The person will find it difficult to relax and calm down. The interpretation of their anxiety and unpleasant feelings will in turn reinforce more anxiety. Severe anxiety and panic will interfere with the person's role of functioning and daily living as it did with this client. She could not do any of her own shopping or engage in any of her hobbies due to lack of concentration and also could not engage in employment. A consistently sensitised body will eventually become mentally and physically exhausted which prevents activity and decreases esteem (Weekes 1995).
It was important for the client to be taught the facts because then the client can begin to recognise when she feels anxious and also can realise that it is a normal reaction to stress (Wilson and Kneisl 1996).
The client and myself would sit in comfortable chairs and think of a place we associated with being relaxed and peaceful environment, for example, in the farm or beach, then we would imagine ourselves in the peaceful surroundings again.
This technique is based on the rationale that muscle tension is the body's response to anxiety. Muscular tension increases the feeling of anxiety and reinforces it. Deep muscle relaxation decreases the tension and blocks the anxiety. It aims to decrease the pulse rate and respiratory rate, blood pressure and perspiration, which are both heightened in anxiety. (Wilson and Kneisl 1996). As the client experienced those feelings the technique seemed relevant to attempt to alleviate the uncomfortable feelings.
So graded exposure and relaxation techniques are highly effective when combined together to alleviate fears and phobias. The principles of the treatment are to substitute a response that is incompatible with anxiety, that is, relaxation. It is difficult to be anxious and relaxed all the same time. (Atkinson 1993).
Before we begin the exposure and relaxation, the client could not even make it as far as the front step outside her front door. By the time the exposure therapy was undergoing she began to gradually improve until more comfortable with going outside. She was far from cured but she was gradually becoming more confident when been exposed.
Current research on behaviour therapy supports it as a treatment for agoraphobia. For example; “Behavioural treatment based on exposure and can provide lasting relief to the majority of patients. (Giovanne et al 1995 p 87).
The education I engaged in with a client regarding relaxation techniques and the biology of anxiety could be said but to be health prolonging. We were trying to work together to empower the clients to make her own decisions about her treatment based on the knowledge of her illness. Once she understood her illness she could begin to make health choices. This education may affect her perception of her illness. Perceived health stresses play a role in the frequency of health promotion behaviour (Pencle 1987). Before we began the therapies the client had a very negative opinion of herself and her abilities, this affected her self-esteem and therefore her experiences of well being. Therefore this affected her perceptions of her illness. Through education, knowledge and practice the client began to fill more positive and began making more decisions about her health and treatment. These examples of decision-making could then be reinforced to her to emphasise the value of good health. (Pender 1987).
For example;
“Making health choices and carrying them out can bring benefits… increase self-esteem from the feeling of taking active control are part of life such as being in control of the smoking habit rather than the cigarettes being in control. (Ewles and Simnett 1992 page 19).
In the clients case by making his own decisions in a self empowered manner he could then perceive that he was in control of their anxiety not that the anxiety controlled him.
Another example of the client improving his decision-making was when the taxi exposure began. When the taxi arrived for the first time the client was sweating and was very anxious. I deliberately stepped back and allowed the client to cope with it. He took control, he explained to the taxi driver where to go and why we were not going far. This shows that the technique was working as the client began to take control again.
In addition to these techniques another important theory which mental health nurses need to develop all the time in order to work efficiently with clients is interpersonal skills.
With anxious clients communication is vital this is because during an anxiety or panic attack the clients' perceptual field and personality are disturbed to such an extent that the client cannot solve problems of function effectively or discuss how they are feeling. (Wilson and Kneisl 1996). Through communication and body language nursing interventions can reduce the clients' anxiety to a more manageable level.
An example of this situation occurred with the client frequently during graded exposure so it was important that I knew how to help him. The client would begin to quicken his pace while walking and he would find it difficult to control his mobility. He would trip up and nearly fall to the ground repeatedly he would talk rapidly and make no eye contact. His speech would be incoherent and he will stumble over his words.
Physically he would sweat and has difficulty breathing. It is important to observe a client for anxiety symptoms such as these because nurses can begin to help the client to recognise his anxiety (Peplau 1962).
I would ask the client how he was feeling. I would comment you don't look very comfortable at the moment, how do you feel?
Through asking this it would help the client acknowledge his anxiety. Once he acknowledged his symptoms he could begin to learn to control them.
The client would say, “I feel sweaty and I don't feel like I’m breathing”. I suggested we could stop for a few minutes and sit down in a quieter area. It is important to attempt to move an anxious client away from stimulation if they fare panicking. (Wilson and Kneisl 1996)
Once we were sitting on the bench or away from their anxiety-producing situation I would encourage the client to deep breathe, which he had identified as a behaviour, which gave him relief. Adopting relief behaviour is important because it decreases the anxiety and helps the client feel more in control. (Peplau 1962).
I wouldn't sit too close to the client and I spoke in a calm manner. Anxious clients' senses are heightened during panic and if I raised my voice or invaded his body space he would probably become more anxious. (Weekes 1995).
The client would inhale through his nose and exhale out of his mouth. He would concentrate on his breathing; this helped him refocus his feelings away from the anxiety.
Once he had calmed down we would discuss briefly what he thought triggered the anxiety. The reason we would discuss the situation in brief is because short, simple sentences are more effective with anxious clients because the ability to concentrate is decreased. Lengthy discussion would only have served to make the client more anxious (Wilson and Kneisl 1996).
It is important to discuss the trigger for the anxiety because the client can begin to understand when the anxiety occurs. (Peplau 1962 see Appendix 5 for a model of how to deal with anxious clients).
Another issue where using interpersonal skills with anxious clients is vital is because those clients often have very worrying and negative thoughts. They way a person thinks effects the way a person feels which in turn affects their behaviour. Negative thoughts cause negative behaviour and so it is important to be able to work with the client to decrease its negative thoughts. The client believed he was silly and useless he would often say, I wish I could just get out of here and walk but I know I can't.
For example;
Client “I know that I should take but it step by step, and say, OK Paul this is good, but I'm thinking in my mind, Good?”
Student “have you considered that maybe you feel this way because you have the experience before the epilepsy began of leading a fully independent life”?
Client “Yeah…. But its hard…..”
Together a climber explored the reasons why he felt the way he did it and looked at some other positive behaviour he had achieved and how he had improved.
When I first began working with the clients' he could hardly walk to the end of his block of flats and by this stage he was walking around a whole block do and taking taxis in exposure sessions.
The client gradually became aware as time passed that he did have positive thoughts but the negative ones override them;
Client “I think it's like ….I've got two sides to my brain thinking…. one side that is thinking you know ……what I should be doing………… and the other side battling against it saying, no you can't do that”
Student “Try to block your negative thoughts with positive ones, but instead of thinking I can't do that, try…., I can do that if I want to.”
I was trying to facilitate the client to encourage and positively. Then he may feel more able to engage in positive behaviour.
Another example would be that the client would often get up in the morning and say, “I’m going to go out”, and then he would think, “but I know I’m not going to”.
We identified that these were negative thoughts and I suggested maybe the next time to he woke up and felt like that he should try and go out. This way he would be replacing his negative conditions with positive behaviour. In the long run this may have increased his self-esteem.
Positive self talks such as “I can do this” “I will go out” “ I am able to do this” is very constructive and will reinforce positive behaviour. (Wilson and Kneisl 1996)
Finely the client and I also used rationalisation and logic to cope with his fears. For example the client would think I want to go out, but I can't go out, I feel really unwell and I am scared of having a fit.
This fear of having a fit was quite realistic but the client did recognise that his fear did prevent him from going out at all. We discuss rationally how in all that time we had engaged in exposure in the three months I worked with him he had not had a fit outside. However we explored the possibility of him having a fit and how he might cope with it if it happened. If the client had a plan of how he might cope he would hopefully make him feel safer. It is important to help the client explore the options;
“You can help clients face the reality of this situation by encouraging them to explore the ways they can change to deal with it more effectively”. (Wilson and Kneisl 1996 page 82)
Conclusion
On reflection of the care the client received, firstly it appears the client did greatly improve. It was commented earlier that when we first began work with the client he would not be able to reach his front doorstep whereas towards the termination of our relationship he was really making his own decisions and become a more confident in increasing the distance. He also became more able to cope with his anxiety and panic through the relaxation techniques, and he learned from the occupational therapist and myself.
The client was verbalising more positive thoughts and these affected his decision-making and actions. He himself perceived that he had more of a handle on the situation and although he still had a lot of work to do he realised he could achieve more. He was significantly improving gradually. Through taking small steps and succeeded he was building up his self-esteem to tackle his larger goals. In addition to this he accepted he had to be realistic because of his mobility. He knew he could improve his quality of life because the graded exposure reinforced his belief in himself.
In addition to this we can use the importance of the theory learnt during the course in application to nursing practice. It gives us knowledge to work with clients as individuals. The client may not have responded well to graded exposure in which case we could have tried a number of different techniques learned during the course to cope with agoraphobia. For example flooding or possible imagery. Nurses need to be able to adapt their knowledge and to the clients individual needs. Having varied knowledge but gives the client and us more options more options to care.
Another important aspect that improve this clients' quality of care or supervision both the occupational therapist and myself engaged in.
This would involve the clients' programme of care, whether it was benefiting him in our perception and the clients' other options we could use and how we felt.
For example I often felt drained after my sessions because the client would ruminate for lengthy periods on his problems. With supervision I gained some knowledge of how to focus the client.
One-way of doing this was that I wrote down at comprehensive list of the clients and its topics for discussion before each session. I then used his list as a reference when the client began to ramble.
If supervision had not been used we could have become stressed through interpretation and lack of reflection.
Supervision is important because it enhances nurses' education, orientation, support and facilities and nurses to think about how to use of self. (Hinchcliffe 1994).
Therefore, the nurses are constantly learning and gaining insight, which impresses clients'. Quality of cares and protects nurses.
So we can see from this essay that all the care subjects we have gained knowledge of in the course can greatly improve the clients' care it and our ability to care for them.
We are constantly learning in practice and need to use knowledge, but supervision, reflection and other disciplines to improve our standard of care.
