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Jane
Jane
is a 43-year-old woman living in a small group home for people with learning
disabilities. She has a diagnosis
of moderate learning disabilities, paranoid schizophrenia, with current
physiological and emotional problems associated with the peri-menopause.
Jane
lived at home until she was 25 years old before moving into a long stay mental
hospital because her parents could not cope with her difficult behaviour.
When she was 38 she moved in to semi-supported living accommodation where
she remained until 3 years ago supported by the Community Mental Health Team.
A crisis occurred 3 years ago when Jane’s live-in boyfriend was
arrested and convicted of drug offences. It
transpired that he had been sexually abusing Jane and was using her for
prostitution. Jane was moved in to
her present home to share with 6 other residents, all of which have mild to
moderate learning disabilities. She
now has 24-hour care, attends a local Day Centre and regularly visits her
parents for shopping, outings and occasional overnight stays.
On
the surface, Jane can appear quite sociable with good verbal communication
skills. However, when one gets to
know her, it is evident that much of her conversation is echolaic with little
depth of understanding. She
confuses the memory of past events with the present and has little concept of
time. She also confuses delusions
with reality and will incorporate them into her conversations.
Jane suffers severe mood swings from mild depression to excitable hyperactivity, when her thoughts and conversation will become disjointed and sometimes bizarre. Some of the staff told me that they often thought that Jane’s moods and paranoid episodes were exacerbated during the week prior to menstruation, something that was difficult to predict due to the irregularity of her cycle and her peri-menopausal symptoms.
While
Jane was living with her boyfriend, she regarded physical and sexual abuse as
being normal and would passively comply. This
has resulted in inappropriate and uninhibited sexual behaviours at her present
home. I observed that her confused
sexual behaviour was often chastised by staff as being “naughty”.
I
was asked to consider treating Jane by her Key Worker because evenings were
particularly difficult for staff to deal with when Jane’s bizarre behaviour
seemed to worsen. She needed a
calming routine at bedtime and it was also hoped for me to introduce a
smell-memory programme for Jane to associate with feeling relaxed and safe
(often referred to as the ‘Proust effect’).
Jane’s
GP and Consultant had no objections to Jane trying aromatherapy, the Consultant
positively supporting the idea.
The Consultation
Before
meeting Jane, I talked with her Key Worker to find out their expectations of
treatment: staff were very interested in finding ways to help her during periods
of anxiety and to help her relax in the evenings.
I was able to go over her medication, mental health history, social and
emotional needs. Her Key Worker
outlined her difficult behaviours and I had the opportunity to read her
behaviour plans and care history. I
completed 2 consultation forms, one I use with all my clients, and the other I
designed for use specifically with people who have learning disabilities,
challenging behaviours and communication problems.
On
her arrival at her present home, Jane was severely medicated with anti-psychotic
medication and Benzodiazepines for anxiety and sedation.
Last year she had undergone significant de-medication, and at the time of
her initial consultation, Jane was still on Carbamazepine, which is an
anti-psychotic medication, a side effect of which is drowsiness.
Staff
described Jane as reasonably active and sociable, seeking out the company of
staff rather than the other residents. She
would however, protect her own personal space and would become agitated if other
people sat too close. She was
overweight although not obese, and I was told that she suffers from occasional
urinary infections, thrush and cold sores, the last episode being 2 months ago.
I was told that Jane has very irregular periods, which made it difficult
for staff to predict menstruation due to the irregularity.
However, some staff had observed with hindsight that some of her erratic
behaviour would heighten during the week prior to menstruation.
Also during this time she complains of night-sweats and staff suspect
peri-menopausal symptoms due to the early menopause of her mother.
When
I first met Jane, her body language suggested that she did not feel comfortable
with someone new encroaching on her own personal space. There was virtually no
eye contact and she would lean and turn away from me while she spoke.
I also got the impression that she was very insecure, with poor
self-esteem. She agreed to
have treatment but I was not sure whether she fully understood. Overall, I found
Jane to be passive, compliant, insecure and uncomfortable in the presence of
people she did not know. She found
it difficult to understand new or unfamiliar instructions and would appear
awkward and uncoordinated, suggesting a difficulty in processing thought into
action.
I
ended my first meeting/consultation with her by trying out a few essential oils
to see which fragrances she preferred. I
did not offer anything else at this stage because I felt she needed more time to
get to know me. Now I had met Jane,
I also needed time to go away and formulate ideas for her treatment.
My
main aims after the consultation meeting were to research appropriate essential
oils to address her complex physiological, emotional and behavioural problems;
to start to develop a relationship with Jane to help develop her confidence; to
introduce the therapeutic use of touch in a non-threatening/non-sexual way; and
to decide on a specific blend (cue-smell) to use with music for staff to use at
a later date as an aid to relaxation. I
had used the therapeutic use of touch with autistic clients previously as an aid
to developing interaction, but saw Jane’s aversion to physical contact more as
a result of the sexual abuse she had suffered rather than a symptom of her
learning disability. I was keen to
use massage therapy to help her as there is evidence that touch and massage can
help lessen the psychological effects of abuse (Field et al. 1997, p65-69).
Treatment 1
Prior to treatment 1, I had prepared blending charts from a variety of sources to use as a reference (see Blending profiles). I had also prepared a cue-smell blend already mixed. I wanted the cue-smell to be particularly calming, to address her hormonal needs and the obsessive psychosis associated with her schizophrenia (see Aromatherapy Treatment Record 1). I also particularly wanted to use lavendula angustifolia as I had read research on its use as a complement to the use of benzodiaphene medication (Hardy et al. 1995 p701). I used the Caddy Blending Calculator to check the composition of the cue-smell, which also helped me to formulate the proportions for the blend.
I
was concerned that one of my aims was to develop a blend for Jane to associate
with feeling calm, this would mean using the same blend each time in order for
it to be familiar - this would not allow any flexibility to alter the blend
according to client need. I talked
this over with staff and some colleagues at a Link Therapists Group, and decided
to try treating Jane according to her emotional and physical needs at the time,
but would then leave 3 drops of the ‘cue-smell’ in a dish of neutral
potpourri in her room. The
routine after each treatment was always a bath, followed by bed.
Although it was not an ideal situation for Jane to have a bath
immediately after treatment, I had to fit into the routine of the home.
The aim was for Jane to associate this feeling of being clean and relaxed
with the fragrance from the potpourri. A
long-term aim was for staff to be able to reinforce the cue-smell with the
cue-music played during each treatment to help her focus on relaxing in times of
anxiety.
On
my first visit I initiated the start of a menstrual diary to ascertain any link
between behaviour and menstrual cycle. I
offered a hand and arm massage with a blend at 1% dilution to prevent sensory
overload with the massage blend + cue-smell blend left overnight in her room.
I selected oils to address anxiety and hormonal imbalance associated with
peri-menopausal symptoms, leaving the specially prepared cue-smell to address
some of her more complex problems as a room fragrance overnight.
Jane
appeared very anxious and tense during the treatment, no eye contact was evident
and occasionally she would pull her hand away and talk about something bizarre
or unrelated. I sensed that
although compliant, she felt very uncomfortable being touched.
I persisted with the hand and arm massage taking cues from her when to
stop and talk, then attempting to bring her back to the activity.
We finished by smelling some more oils together, something she liked
doing at our last meeting. I asked
for another appointment in a weeks time to build on continuity of treatment.
Treatment 2
Jane
recognised me when I arrived and took me straight to her room for treatment.
I
decided to continue to use the same blend used in Treatment 1 and to concentrate
on developing my relationship with Jane.
I massaged her hands and arms for 20 minutes then followed her lead to
break from treatment and talk about some photographs she wanted to show to me.
I felt that this was a positive step forward in her feeling a little more
comfortable. We talked about what
she expected from the sessions and she told me that it was a “good idea to
help her relax”. I was not sure
whether Jane genuinely felt this or was repeating what staff had said to her.
During
our conversation, Jane talked about her ‘bad’ boyfriend, and the fact that
he was now dead (staff told me that her boyfriend was not dead and no longer had
contact with her). She also made
other references about Jane being dirty and being very ill. When her conversation became particularly bizarre she would
become more agitated, I found that it was easy to calm her by redirecting the
conversation to ordinary matters such as clothes and outings, but was aware that
I would occasionally have to gently pry into her psychosis in order to
understand her better.
I
asked her if she would like to try a foot massage next time and she agreed.
I did not feel it appropriate yet to suggest any sort of contact that
would involve Jane taking any clothes off in case Jane miss-interpreted this as
a sign of pending abuse.
After
the treatment Jane chose some music to play at each session and I showed her how
to pour 3 drops of the cue-smell blend onto the potpourri, the first steps in
her self-managing her own anxiety.
I
felt that the second treatment was positive in that Jane seemed to accept me
more, but I was beginning to realise that some of the issues surrounding her
mental illness and history of abuse were extremely complex.
Treatment 3
Before
treating Jane I ascertained that Jane was not menstruating yet but staff were
expecting her period to start at any time.
She seemed particularly hyperactive today and staff said they had had a
difficult time with her. Jane
kept getting up during the pre-treatment consultation to straighten things in
her room. She also appeared to be
sweating and felt hot to the touch. Staff
had already told me that she suffers from night sweats and would be seeing the
GP shortly about this. However, I
was not sure whether the sweating was a peri-menopausal symptom or as a result
of her hyperactivity.
I
chose relaxing oils to help with the hyperactivity including oils with balancing
properties as hyperactivity can often be a result of hormonal imbalance,
combined with oils reported as antipyretic for the sweating (which could also be
a result of hormonal imbalance). I
offered her a hand and arm massage followed by foot and lower leg.
When
massaging her feet I noticed a tinea pedis infection (athletes foot) between
most of her toes. After the foot
massage, I applied a solution of tea tree essential oil in calendula (macerated
in sunflower) between her toes removing some of the debris with a cotton wool
pad then reported the infection to the staff afterwards. Tea tree is supposed to be particularly effective against
tinea pedis (Tong 1992 p149; Olsen 2000 – no page) which is a common infection
with people who have learning disabilities as staff try to promote independence
in self hygiene - with foot care occasionally being neglected as a result.
My main aims of treatment were to continue developing my relationship
with Jane and I could already see a positive development through increased eye
contact. I asked Jane how she felt
after the treatment and she said that she felt “nice” and didn’t want to
wash the oil off in the bath.
Treatment 4
During
the week, the Home Manger had phoned me to say that there had been a major
confrontation with Jane after the last treatment because she had refused to have
her bath. I offered to visit Jane
later in the evening to give her time for a bath beforehand which would be much
more beneficial for her as it would give the oils more chance of being absorbed
into the body. I also took this as
positive indication that Jane was enjoying the sessions.
On
arrival, staff told me that Jane had started menstruating 3 days ago suggesting
a possible link between her behaviour, physical symptoms and hormone imbalance,
although the diary would have to be continues for a few more months to confirm
this. Jane appeared considerably
calmer than the week before and there was no evidence of excessive sweating.
I
had already decided to let Jane take the lead in dictating how sessions would go
as part of developing her confidence of being in control, and not having to do
anything she felt uncomfortable with. She
asked me to “do” her feet first.
Staff had been treating the tinea pedis infection with an anti-fungal
cream (Nystatin) so in order not to disturb this treatment, I decided not to
apply tea tree topically, but to offer a foot spa with a few drops of Tea tree
in the water. In order to give the
foot spa, I asked Jane if she minded taking her slacks off to which she did
straight away. I thought this would
be a good opportunity for her to undress without any sexual connotations and
reminders of her abuse.
While
Jane sat with her feet in the foot-spa, I massaged her lower legs with oils
selected to address hormonal imbalance along with calming and relaxing
properties. I positioned myself in
front of her and this gave much more opportunity for eye contact.
Jane was not turning away as much as when I first met her, and at time
would lean forwards towards me to say something.
After the treatment, I showed Jane how to dry her feet properly and
reapplied the Nystatin.
To
finish the session, I prompted Jane to put the cue-smell on to the potpourri and
she told me that this was her “magic medicine”.
She also said that she enjoyed having her legs “done”.
Treatment 5
When
I arrived for Jane’s 5th treatment I met her parents who had been
visiting. They told me that Jane
had talked about the sessions and they were keen for her to continue.
They offered to help pay for some of the treatments so I suggested for
Jane to have 2 long sessions a month with shorter sessions in between.
By making the sessions flexible, I hoped to coincide the long sessions
with the days when her behaviour was more difficult.
Jane’s
parents were present when I talked to her about trying a back massage.
With Jane’s parents encouraging her, she was reassured that it was not
a “bad” thing to do and hopefully would not feel threatened by the thought
of taking her top off and being touched by someone else.
Jane seemed in high spirits after
the visit from her parents. I
selected balancing oils again because it was probably only a few days before
expected menstruation. I noticed
Jane was suffering from dry skin so I added avocado oil to the carrier and
especially selected Sandalwood for the base of the blend as I have had good
results using this. I offered
a hand and arm massage with her favourite music to start with.
After a while she asked for her feet to be done and actually initiated it
by taking her shoes and socks off. There
was plenty of eye contact as I placed myself directly in front of her.
I then suggested a back massage to which she complied by taking her top
off – however, she did seem a bit more nervous and defensive.
I wanted to finish the session on a comfortable relaxing note so I
massaged her hands again after she had got dressed.
Jane seemed to relax more with the hand massage was part of a more
familiar routine she was used to. She
said that she enjoyed the session.
Treatment 6
Staff
told me that Jane was now taking Clonidine for her hot flushes and other
peri-menpausal symptoms. Clonidine
works by decreasing impulses from the brain, which have the effect of dampening
the sweating response. Unfortunately
a side effect is that it can dampen other neural functions, and like the
Carbamazepine she was already taking, it is a very powerful drug with
significant side effects, including drowsiness. I suspected that this was a desired effect in view of some of
her very difficult behaviour.
Although
Jane was pleased to see me, she appeared very confused and slow.
I noticed what liked like the start of a cold sore around Jane’s mouth,
Staff told me that she had been sleeping very well since taking the Clonidine
(not surprisingly) and had started menstruating 2 days ago with no obvious
affects on her behaviour. I tried using a blend with a high proportion of lavender to
act as a stimulant and selected oils to continue to treat her dry skin, to
address her hormonal imbalance and also to help boost her immune system -
particularly after her recent tinea pedis and current Herpes 1 infection.
I gave Jane a hand and arm massage followed by her back, neck and
shoulders. Afterwards I applied
Melissa officinalis (Melissa) 1% in a base of Aloe Vera topically to the
affected area around her mouth. I also showed Jane how to wash her hands properly after
touching the sore so as not to spread the virus.
I left the remaining cream for staff to apply 3 times a day and Jane put
3 drops of the cue-smell blend on to the potpourri as an overnight fragrance.
Treatment 7
The
staff would not let me treat Jane for the last 2 weeks due to a severe impetigo
infection. What I thought was a
Herpes infection had turned out to be the start of impetigo, which had spread
around her face and hands. She had
since been on oral antibiotics and had developed vaginal thrush as a result.
Jane appeared less drowsy today as her body was probably getting use to
the sedative action of her medication. Her
skin was clear of signs of infection so I selected oils to hep boost her immune
system in view of her recent impetigo and current thrush infection.
Jane eats a lot of sweets so I advised her not to do this until her
thrush had cleared up as Candida albicans enjoys a warm, moist sugar environment
to multiply.
I
offered Jane a stimulating upper body massage; she appeared very relaxed during
the session with lots of turning to look at me as she spoke.
I
now considered Jane ready to start using the cue-smell and cue-music
independently of treatment sessions. I
talked with Jane about leaving a bottle of the potpourri (“magic”) blend
with staff for her to ask to use in her room if she felt angry, upset, or
anxious about anything. I also
suggested that she could ask for a few drops to be put into her bath if she
wanted. I had also purchased Jane’s own copy of the CD we play
during treatment and I told her she could play this at bedtime to help her go to
sleep. Jane thought this was a good
idea; so before leaving, I left a programme plan for staff to use the cue-smell
as a room fragrance or bath additive, with instructions on how to best help Jane
use her music to relax. I labelled
the blend with client name, date, and instructions for storage and application.
I
decided not to leave a blend for staff to use in the bath for Jane’s thrush
infection, as this would be too much for staff to remember to do.
I
also made a note for my own development to look into ways to help positively
identify the differences between early Impetigo and the Herpes simplex
infection.
Treatment 8
Jane
was excited to see me today and showed me lavender bath oil she had been given
for Christmas. She was beginning to
show an interest in perfumed cosmetics and had started to ask her parents to buy
them for her. I saw this as a
positive development from our sessions together smelling oils and talking about
which smells we liked best.
Staff
said that they had resorted to using the cue blend several times over the
holiday, and coupled with a hand massage, Jane had calmed considerably on each
occasion. She liked using her
music at night, which was becoming part of a permanent bedtime routine.
Her thrush infection was still apparent so I selected the same blend used
for the last treatment: immuno-stimulating oils for her frequent infections with
oils to address hormonal imbalance. Staff
were keen to continue using the cue-smell to help her relax and had written it
up formally into her care plan.
I
suggested to the staff that now the cue-relaxation methods had been introduced
and seemed to be working, I could reduce Jane’s sessions to one every 2 weeks
in order to help save her money. Staff
agreed, but when I mentioned it to Jane, she started to cry.
I worked out a compromise that she could have a long treatment every 2
weeks, with a short hand massage and talk for the weeks in between – she was
much happier with this arrangement.
Conclusion
Jane
had such a wide range of significant problems that it was often very difficult
to prioritise for the purpose of treatment.
Many of her symptoms were interrelated and her immediate needs changed
drastically from day to day. The
pre-prepared blending charts were very useful to see at a glance common
essential oils for a wide variety of problems, it also helped to save time at
the start of each session because Jane found waiting quite difficult at times.
Although
I selected sedating and relaxing oils at first to help with her anxiety and
psychosis, I could not evaluate the effectiveness due to changes to her
medication. Neither could I
effectively evaluate the success of using hormone balancing oils, as half way
through treatment she was prescribed Clonidine.
I was also limited in my use of oils at first due to their stimulating
nature, then limited further after the Clonidine due to their relaxing
properties. Despite these
difficulties, I was able to use essential oils and massage techniques to
complement orthodox treatment, and was able to achieve the main aim of
introducing a relaxation routine based on associating smell and music with
feeling calm and relaxed. I was
also successful in helping Jane feel less anxious about being touched, and
helped her realise that being touched was not necessarily a threat to her
safety. I also hope that by
enabling Jane some control of her own anxiety, I was developing her self esteem
and confidence. Jane had also
gained an interest in cosmetics and perfumes as a direct result of our sessions
together, which also contributed towards self esteem and quality of life, both
important issues for people with learning disabilities.
I
recognise that there were things I could not address effectively (such as daily
treatments for her thrush and skin infections) due to needing an intensive and
consistent approach, something that is not always possible in a care home with a
high turn over of staff working shift systems. I also recognised my own lack of knowledge in confusing early
signs of Impetigo with the Herpes simplex virus and made appropriate steps to
develop my knowledge in this area.
In
treating Jane over a period of 2 months, I saw move through passivity towards
genuine social interaction. I
considered this a major indication of the development of a positive therapeutic
relationship and the development of trust between us. I continue to treat Jane on a fortnightly basis and she is
always pleased to see me.