The technique the client and I used to attempt to help her manage her agoraphobia was to expose her gradually to her fear of open spaces. We did this by going for walks increasing the distance each time as the clients’ anxiety levels decreased. We would not extend distancing until the client could reach a certain agreed point without feeling anxious. During the exposure the client and I would discuss how she was feeling and if she became very anxious we would stop and adopt relaxation techniques in the form of breathing. A fuller discussion of these techniques will be discussed later on.
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).