Part Two: Report and Discussion of Therapeutic Intervention
Reflection on Feedback from Part 1
The discussion around the implementation of relaxation therapy in the chosen setting was quite detailed, because there were a number of people who raised issues which were important for managing the implementation. The first issue raised was the nature and type of the relaxation, which also related to a discussion of expertise in relation to providing relaxation of this type. Relaxation has been proven to be effective in a number of clinical scenarios (Hyman et al, 1989). However, questions were raised about the exact nature of the relaxations to be used – were these to be progressive muscle relaxations, guided visualisation, or free visualisation (Lehrer et al, 1988)? There are significant differences in the effects of different kinds of approaches to relaxation and visualisation (Galvin et al, 2006; Gerdner, 2000; Sellers, 2005). Questions were also raised about how well the intervention could be evaluated if there were different techniques being used.
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Therefore, one of the changes that was made was to devise a limited number of relaxation exercises and to only use these within the clinical setting. These were therefore limited to one progressive muscle relaxation exercise, and one guided visualisation, using very neutral imagery. There was no attempt at more complex therapeutic intervention. The issues raised about competence and expertise in providing these relaxation therapies were therefore addressed, and there was not need to seek out extra training or support in specific relaxation therapies. Further feedback identified a need to explore more evidence about relaxation therapies, particularly for this kind of client group, and in health interventions in particular. Therefore, a further search of the literature, extending back further chronologically as well as looking more widely, was carried out, and such literature reviewed as part of the process of evaluation of the intervention.
A clear framework, rationale and evidence base for the selected therapeutic intervention
Relaxation therapies have found a broad range of uses in healthcare practice.
In this client group, there is evidence to suggest that relaxation therapies would be beneficial, simply because they can help the older adult retain cognitive function and memory function (Galvin et al, 2006). Galvin et al (2006) describe the relaxation response in terms of a physiologic response that can counter the bio-chemical responses to anxiety which can affect the cognitive functions of the older adult. In order to achieve this Relaxation Response, a range of therapies can be used. “Numerous techniques, including progressive muscle relaxation, meditation, guided imagery, biofeedback, the pre-suggestion phase of hypnosis, deep breathing exercises, autogenic training, tai chi, Qi gong and yoga can elicit the relaxation response” (Galvin et al, 2006 p 187). Obviously, a number of these techniques would require specialist training and specialist provision, and most likely, a private, designated and appropriate place in which to carry out the intervention. However, Galvin et al’s (2006) research does suggest that progressive muscle relaxation and guided imagery are effective techniques for inducing the relaxation response. Improving memory function in older adults who mental illness might be particularly beneficial and might help to reduce anxiety.
Conrad and Roth (2007) discuss the use of progressive muscle relaxation in providing therapy for anxiety disorders. Conrad and Roth (2007) define muscle relaxation therapy as “an abbreviated therapy based on Jacobson’s original PMR, which included in its training procedure first tensing a muscle and then releasing that tension.” (p 244). They describe progressive muscle relaxation therapy as being based on the idea that tense, stressed, and anxious people can find some symptomatic and ongoing relief from their distress and the physiological responses which accompany it, by learning to reduce muscle tension within the body (Conrad and Roth, 2007).” A modern theoretical rationale for MRT is that an important element of psychological distress is elicitation of a generalized stress activation response, comprising multiple central and peripheral physiological systems … [and] learning to deactivate a single subsystem, the muscular system, will reduce activation in many other subsystems” (Conrad and Roth, 2007 p 244). Ost (1987) echoes these findings. Conrad and Roth’s (2007) review of the literature demonstrates clear physiological responses to muscle relaxation which have a number of health benefits, in reducing the effects of anxiety on the body and brain, and controlling the body’s response.
Yu et al (2007) show that relaxation therapy reduces physiologic distress in patients with cardiovascular disease, and has beneficial effects on recovery. It could be assumed, from these findings, that similar physiological responses to relaxation therapy would be beneficial to the ageing body systems as well as to the psychological state and wellbeing of the older adult. Gerdner (2000) addresses the issue of distress and agitation and confusion in the elderly patient with Alzheimer’s disease, and looks at relaxation music as a means of improving these symptoms. Gerdner (2000) found that individualised relaxation music (music of preference to the patient) was very effective in reducing agitation and confusion. It would be appropriate, therefore, to provide a range of music for the patients receiving the intervention here, and this was tailored to patient preferences over time, looking at responses from patients, and asking patients and their carers about preferences. Although this can be difficult to implement in a group setting, it was also a useful adjunct to the relaxation sessions and could be used by patients when they practised the techniques individually.
Murray (2008) found that relaxation techniques were of therapeutic benefit to patients with neurogenic disorders, including Parkinson’s disease. O’Conor et al (2008) found that this kind of behavioural treatment of psychologic disturbance in dementia was effective, but in the shorter term, and so the benefits were time-limited. Staal et al (2007) also found such behavioural interventions effective in dementia patients. However, this author believes that the therapies can continue to be of benefit to patients if they can learn to apply them independently, or if they are continued as a regular part of ongoing care. Other kinds of relaxation have been found to be particularly beneficial in elderly care, including animal-assisted therapy for dementia in the older adult (Filan and Llewellyn Jones, 2006; Sellers, 2005). All such interventions require is a dedicated practitioner to implement and evaluate them, and the facilities to carry them out. However, the literature is limited on the use of such therapeutic interventions in the kind of setting I planned to use them in.
A discussion of the process of the application and an evaluation of the outcome of the intervention in the practice area. This should include objective and subjective feedback from the person(s) involved
In line with the planning of this intervention, the author devised two relaxation protocols to take place in a 16 bedded functional ward for adults over the age of 65 who suffer from a range of mental health illnessess, such as bi polar disorder, shizophrenia, depression, anxiety and onset dementia. The first protocol was a progressive muscle relaxation exercise, with a duration of around 15 minutes, supported by music that was acceptable to the patients present during the intervention. The second intervention was a guided imagery relaxation exercise, in which the patients were taken through a progressive relaxation and then guided through a set sequence of visualising themselves in a comfortable place. The details of the visualisation were kept quite generic, in order to avoid, if possible, unwanted negative associations with particular imagery, such as, for example, using water in patients who are afraid of water. Therefore, the visualisation placed the patient in their favourite chair, in their favourite location, looking out of a window onto the sky and the landscape. They are guided to see blue skies, white clouds, rays of sunlight coming through the window, and to feel warm, relaxed and comfortable. A light breeze, warm and gentle, comes through the window. The patients are encouraged to feel very relaxed and comfortable, and to enjoy the sensations they are feeling.
The therapeutic relaxation was carried out with patients daily, and there was a mix of patients attending each day. The therapy was carried out in the day room, and only those patients who could mobilise to the day room were included, and obviously, those who wished to join in. The staff were informed about the intention to offer this therapy, and discussion with the lead nurses/key workers for each patient revealed their thoughts about the suitability of the intervention for their patient. Details about each patient that were relevant to the intervention were gathered from the clinical staff, and from the patients themselves and their carers/family members. Having carried out a more detailed literature review meant that I was able to provide a good rationale to staff, patients and carers, and also to discuss the measures I had taken in order to avoid any negative consequences.
There were a number of issues which made the implementation of the intervention challenging. The first was the fact that I had to carry this out within the day room that is provided for the patients as no other area is available. This was not exactly appropriate as the lighting is too bright even when the lights are off and the seating is not comfortable. To achieve a good state of relaxation, comfortable seating and subdued lighting is important. Although it was possible to play music, it was not sufficient to drown out other ward noise. Also some patients tended to wander in and out of the area, which couldn’t be helped, however it did disturb the group. Feedback from certain patients showed that they did enjoy the relaxation, but they found it hard to achieve deep relaxed states due to the environment in which the intervention was taking place, and due to the disturbances from patients (and staff at times) coming in and out, and from ward noises such as phones ringing. Some patients found the uncomfortable chairs worse than anything else. What this feedback shows, however, is that given the right environment, this intervention might be somewhat more effective.
Patient feedback around the effects of the intervention was mixed. Some patients said they enjoyed it, but did not feel very much different. However, these were patients who also found it difficult to carry on the intervention in their own time, and this lack of significant effect could be related to the interruptions and bad environment, and to their lack of commitment to continuing relaxation exercises on their own. Some patients found it very hard to achieve relaxation at first, but after successive sessions, were able to master the techniques. Two patients (and their carers) provided very positive feedback, stating that they were using progressive muscle relaxation regularly to manage feelings of anxiety, fear, and depression. The literature reflects this finding (Peasley Mikus and Vrana, 2000; Jorm et al, 2004; Knott et al, 1997). I found this to be a very positive result.
Feedback from the staff was similarly mixed. Staff were generally positive about the potential benefits of relaxation therapy, but were vocal and quite disparaging about the available facilities and location supporting this kind of intervention. Some expressed their doubts about patients being able to sit and apply the intervention, in certain cases. However, as stated, most were not opposed to the intervention. Feedback from staff, however, did not suggest that they viewed any particular benefit to patients, except in one case, where the patient’s key worker clearly stated that the relaxation techniques had helped with anxiety and depression symptoms. However, one of the negative issues that appeared in feedback from staff, patients and carers was the lack of belief in the ongoing usefulness of such therapies for certain patients, and the difficulty for certain patients, such as those with dementia, to follow the instructions and achieve a true state of relaxation. My evaluation of the intervention, however, would be that limiting it to two techniques was the right thing to do. The muscle relaxation alone was effective, but some patients did not tolerate the visualisation well. However, it is difficult to determine how beneficial these interventions might have been, because in my opinion, the negative effects of the poor environment, interruptions, noise and discomfort meant that it was difficult for them to achieve true relaxation. If I had had the facilities to measure physiological markers for a state of relaxation, I could have evaluated just how deep a state was achieved. In the circumstances, I do not believe that deep relaxation was achievable.
Reflection on Personal Learning Outcomes
My personal learning outcomes for this experience were very much related to my skills in communication with patients, staff and carers, my ability to develop a deeper understanding of a particular approach to supportive, therapeutic intervention in a clinical area, and the ability to apply principles of experiential learning and reflection to the experience in order to prepare for future practice.
In relation to the development of communication skills, implementing this intervention required a lot of different types of communication, including communicating the benefits of the interventions to different types of people, patients, some of whom had cognitive or mental health issues, carers, who were lay people without specialist knowledge, and staff, who did have specialist knowledge. This required adaptability to different levels of communication, and good listening and interaction skills to be able to answer their questions appropriately and take their opinions into account prior to the intervention.
In relation to the development of a detailed knowledge of a particular intervention, this was achieved through the detailed literature review, through talking to staff, and through carrying out the intervention. I gained a deeper understanding of the practicalities of this kind of intervention, and the environment and circumstances that are most conducive to achieving a state of relaxation. I also learned a lot about the kinds of things that assist in achieving a good state of relaxation, such as making sure everyone is ready, and that they have all been to the toilet and are not hungry or thirsty, and in the case of some patients, not in pain or emotionally distressed, or due to have a dose of medication. I only learned these things through attempting to implement the intervention.
In reflecting on the evaluation, the light of the feedback from staff, patients and carers, it was difficult to receive so much negative feedback, and also to understand the reasons for some of this. It was frustrating not to be able to provide an optimal environment for relaxation, and to realise that things might have been better if we could have had a better setting for the intervention. However, the fact that a small number of patients and carers, and one key worker, reported beneficial effects of the intervention, was reassuring. Ideally, for this kind of therapy to be effective, providing the appropriate setting, and support, and building the therapy into daily care activities, and care plans, is important. Providing information for patients and carers on the activity, perhaps in the form of a patient/carer leaflet, would also be useful.
Overall, I do believe that the intervention was a small success, and that in the future, with better forward planning and better facilities, it could present an opportunity for significant patient benefit for certain patients.
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Filan, S.L. and and Llewellyn-Jones, R.H. (2006). Animal-assisted therapy for dementia: a review of the literature. International Psychogeriatrics, 18 597-611.
Galvin, J.A., Benson, H., Deckro, G.R. et al (2006) The relaxation response: reducing stress and improving cognition in healthy aging adults. Complementary Therapies in Clinical Practice 12 186-191.
Gerdner, L.A. (2000). Effects of Individualized Versus Classical “Relaxation” Music on the Frequency of Agitation in Elderly Persons With Alzheimer’s Disease and Related Disorders. International Psychogeriatrics, 12 49-65
Hyman, R. B., Feldman, H. R., Harris, R. B., Levin, R. F., & Malloy, G. B. (1989). The effects of relaxation training on clinical symptoms: a meta-analysis. Nursing Research, 38(4), 216–220.
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