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Lynda
Introduction
Lynda is 34 years old woman with a severe hearing impairment and severe learning disabilities. She has lived in her present home for people with learning disabilities since 1993 when her parents died. She likes to hoard food, which could be reminiscent of days when she would only be allowed to eat at set meal times. She attends a local day centre during the week and in the evenings she likes to lie on her bed and watch television. Her key worker has decorated her room with coloured lights and bright pictures, which Lynda seems to enjoy looking at when not watching TV. She is also happy to sit with the other residents downstairs in the lounge and watch what goes on.
Lynda is sociable and likes to go out in the minibus with the other residents, enjoys pub visits, discos, and going shopping to but new clothes.
Staff told me that although not autistic, Lynda needs a familiar routine to feel safe. She knows a few Makaton signs and will often get frustrated if she cannot make her needs known through signing and gestures.
I first met Lynda when treating other residents in her home. By chance I met her Speech Therapist who was interested in some of the work I had done with severely learning disabled people, particularly with using sensory experiences and aromatherapy to help develop relationships and communication skills. The Speech Therapist asked me if I would like to help Lynda with sensory awareness and communication skills, particularly awareness of her hands for signing, and to help in any way I could for assessing her ability to communicate.
The Consultation
Lynda
was normally very healthy, reasonably active during the day, slept well, and was
not on any medication. She was born
with a severe hearing impairment and has learnt to communicate using Makaton
signing, a simple signing system based on British Sign Language, used mostly by
people with learning disabilities and their carers to help communication.
As a learning Disability Nurse I have qualified up to advanced level in
Makaton - signing is usually learned through copying signs while associating
them with a meaning – the learning process can be accelerated by using a
hand-over-hand method of learning where the teacher physically prompts the
student by taking their hands to physically help them sign a word, learning
being reinforced immediately by the actual activity or action.
The Speech Therapist was trying to help expand Lynda’s repertoire of
signs but was finding her resistance to hand-over-hand learning a problem.
She was also using a Picture Exchange Communication System (PECS) with
Lynda, which involved using photographs, pictures and symbols to help
communicate by ‘exchanging’ a picture for her needs. Lynda would
appropriately use a collection of pictures prepared specially for her to
indicate needs such as ‘toilet’, ‘drink’, ‘apple’, and ‘TV’.
The staff would use pictures and signing to indicate things they needed
Lynda to do, such as ‘minibus’, ‘bath’, and ‘bedtime’.
Lynda would use the thumbs up sign for ‘good’ if she was happy or
wanted something to continue. If
Lynda was unhappy about something and could not make her needs known, she would
scream and bite her arm. Staff and
the Speech Therapist were all involved in working with Lynda to help develop
better ways for her to communicate to avoid the frustration of not being able to
make her needs known.
The
initial aim of treatment was to help Lynda feel more comfortable about someone
touching her hands in order for the Speech therapist to use the hand-over-hand
method of learning signs more effectively.
I planned to achieve this through offering a hand massage; the idea was
for it to be an enjoyable experience, enabling Lynda to be more receptive to the
hand-over-hand method of learning Makaton.
The long-term aim of treatment was to enhance her ability to communicate
with others, as this forms the basis of all speech therapy work whether verbal
or non-verbal. In order to utilise
the massage sessions to help develop Lynda’s communication skills I planned to
use the Interactive Massage Sequence.
The Interactive sequence
McInnes
et al. (1982, p36-39) outline an eight-stage sequence to promote the growth of a
bond between an intervenor and child with severe sensory disabilities.
It follows the child through an initial resistance towards co-operation
and eventual full participation. It is a way to help multi-sensory impaired people to explore
themselves and their relationship with the environment – a prerequisite for
all learning. The sequence can also
be used to help reduce challenging behaviour by occupying the person’s time
positively and increasing their tolerance towards others.
The idea of the Interactive sequence was then taken up by Sanderson et
al. (1991) and Longhorn (1993, 1993a) who relate it to a massage sequence for
people with special needs - the main focus being to encourage responses,
participation and interaction in a non-threatening way (Sanderson et al. p991,
p74).
The
eight stages listed are:
-
Resists
-
Tolerates
-
Co-operates passively
-
Enjoys
-
Responds co-operatively
-
Leads
-
Imitates
-
Initiates
(McInnes
et al. 1982 p36-39)
Planning the approach
The main aim of working with Lynda was to help develop social skills and enhance communication. The specific goal of my treatment plan was to help her become more tolerant to someone touching her hands, the rationale being that increased tolerance to touch would help the Speech Therapist teach her more signs. The care plan was for me to offer a hand massage for half an hour once a week. I also hoped that as well as working towards a specific goal, Lynda would greatly benefit from the therapeutic use of massage with essential oils. Also, by offering massage as an enjoyable experience, I hoped to help Lynda develop trust and encourage non-verbal expression, eye contact and gestures, all of which are necessary pre-requisites to communication and acquiring language skills (Coupe-O’Kane et al. 1996 p2).
In order to evaluate the effectiveness of Lynda’s treatment, I would need to find a way of measuring progress and success. As Lynda had no verbal skills, I would have to rely on observations to determine whether or not a particular treatment was working. Observing behaviour can be very subjective so I needed to find a way to record observations methodically and objectively, particularly in relation to her progress through the Interactive Massage Sequence. Objective behaviour analysis needs a baseline (starting point) measurement on which to measure future progress in order to determine whether or not an intervention is working. With this aim, I decided to adapt a sensory schedule I had developed for use with severely autistic clients as part of my work with children in special education (see The Sensory Schedule: Assessment). The assessment is designed to help assess and record abilities in people who are at the non-verbal stage of communication - it can help identify strengths and weaknesses as well as key skills relating to communication and social abilities. As an integral part of the schedule I had also included a section for recording progress through the Interactive Sequence using aromatherapy and massage techniques. After completing the baseline assessment, I planned to repeat the assessment in 3 months time in order to measure any progress and help re-plan the programme if necessary.
Session 1
The
main aims of the first session were to introduce myself to Lynda, to assess her
abilities using the sensory schedule, and start to find out which fragrances
Lynda preferred, the rationale being that if I used fragrances she liked, she
would be more likely to enjoy the sessions and associate favourite scents with
feeling relaxed and comfortable.
I
wanted to build an element of choice into the sessions, because developing
choice is an integral part of helping to develop independence (O’Brien et al
1981, p177; Raynes et al. 1994, p2). The
process of choosing would also be part of the interactive process to help work
through the Interactive Sequence and develop her social and communication
skills.
As
an object of reference to signify the start of each session, I placed a pink
towel across Lynda’s knees, and then rubbed my hands together to indicate a
hand massage. She showed a few
signs of avoidance as I sat myself next to her, but eventually appeared
comfortable with a gap between myself and her of about 18 inches to preserve the
comfort of her own personal space.
I
decided to offer Lynda 2 essential oils to start with because I did not know how
long her concentration span was and I did not want to overload her sense of
smell. I deliberately selected oils
with very different scents in order to see if she would (or could) express a
preference – her ability to do this would be recorded in the assessment
schedule. I planned to use her
reaction to determine a preference and record the result on her client record
sheet, hopefully building up an overall picture of what she liked and disliked.
The
first two oils I chose to offer Lynda were Lemon and Sandalwood.
With physical prompting she was able to copy my action of smelling the
bottle and soon smelt the bottles with only gestured prompts from me.
She showed much more interest in the Lemon, laughing then moving forward
for another smell at the bottle. I
determined that Lemon was her preference and used it to give her a hand massage. I let her watch the process of measuring the carrier oil,
pouring it into a glass dish, then adding a few drops of lemon oil for her to
see the sequence of events, and how her choice had affect the outcome.
Lynda
appeared bewildered at the start of the massage, probably because she had never
experienced anything like it before – the only physical touch Lynda was used
to was functional, associated with safety and self care. However, after an initial avoidance by withdrawing of the
hands, she tolerated the hand massage by keeping her hands still, but still
looking round the room, occasionally making eye contact.
For
purposes of defining the baseline, I recorded the longest time she allowed me to
massage her hands before being distracted as being 3 minutes.
After I had finished massaging her hands, I made a point of prompting her
to smell her hands while signing “good?”, using my expression to signify a
question. I then used my
hands to hand-over-hand sign ‘finished’ to help her relate all the hand
touching to Makaton signing.
I
was encouraged by Lynda’s tolerance of the massage. Overall I considered it a
positive session achieving the aims of introducing a new routine, completing the
assessment, and starting a positive relationship with Lynda.
Subsequent sessions leading up to 2nd assessment
As
the sessions progressed, Lynda became more used to the routine of choosing an
oil, then accepting a hand massage. She
soon began to show extreme excitement at choosing the oils indicating her
pleasure by laughing and flapping her hands.
She was beginning to show a preference for citrus and floral fragrances
and would enjoy the scent left on her hands from the massage throughout the rest
of the evening.
Gradually
she took more and more interest showing positive enjoyment in the sequence of
events, although I did not estimate that she was at the responding
co-operatively stage yet. She would often signing “good” during the massage,
laughing and offering plenty of eye contact.
She was very comfortable with me sitting next to her and her attention
span had increased to 15 minutes, then she would start to become distracted.
I was very pleased with the progress achieved over the 3 months and
decided to extend the routine to include a foot massage. I suspected that I had
reached her full attention span of 15 minutes for one activity and needed to
offer a change half way through the session.
After
the 2nd assessment, I made an appointment with the Speech Therapist
to discuss progress and ask for advice on how best to plan future sessions.
The Speech therapist was very pleased with Lynda’s progress saying that
she now started her own signing session with a short hand massage.
She had noticed considerably more acceptance of hand-over-hand signing
and was basing more of her interventions on a tactile sensory approach. She suggested that if Lynda accepted a foot massage, to
introduce another element of choice into the routine using picture cards.
She prepared 2 laminated pictures, one of a foot massage, and one of a
hand massage. The plan was to let
Lynda indicate her choice of treatment by selecting the appropriate card.
This would also serve to reinforce other work the Speech therapist was
doing with Lynda on developing a picture communication system and offer more
opportunities for interaction.
We
also discussed ideas on how to move Lynda forwards through the Interactive
sequence into the next stages of co-operation and leading by building in pauses
and gestured questions to enable Lynda the opportunity to anticipate what would
come next.
Sessions leading up to 3rd
assessment
After
an initial uncertainty, Lynda took great delight in having her feet massaged.
I had developed a very good relationship with her and was able to
introduce the new routine without any resistance shown at all.
For
the first few sessions I would get her to chose the oil, then show her a picture
of the hand massage, followed immediately by a hand massage, which she would
enjoy. Working within her attention
span, which was usually about 15 minutes, I would stop and offer her the picture
of the foot massage, followed by a 10-15 minute foot massage to end the session.
When Lynda accepted the new routine comfortably, I decided to start the
session with offering Lynda both pictures, asking her to “choose”.
She immediately made a choice by touching the picture of the hand
massage.
For
the next few sessions she continued to participate in choosing the oils and
choosing the order of massage. From
her body language and verbal expressions, she obviously thoroughly enjoyed the
sessions, starting to rub her hands together when she saw me arrive at the
house.
The
3rd assessment saw great progress in her interactive skills.
She was recognising my arrival by signing (rubbing her hands together)
which indicated real anticipation. She
was making appropriate choices using the picture system and was beginning to
show signs of anticipation during the massage sessions by offering a hand or
foot without prompting. Staff
reported that Lynda always seemed visibly more content immediately after the
treatments with fewer incidents of shouting and self-harm.
After
the 3rd assessment, I showed Lynda’s key worker how to give Lynda a
hand massage using a blend of 1.5% lavender left for this purpose.
I also left the laminated hand massage picture for the key worker to
offer Lynda when she had time to give her a massage.
It would not have been appropriate to give Lynda the card to use herself
as she would be asking for a massage all the time and would only become
frustrated if she couldn’t have one. It
was written in to Lynda’s care plan at the home for her to be offered a hand
massage in the evenings as often as practicable.
Sessions leading up to 4th
assessment
At
first when Lynda realised that she could have a massage from her key worker as
well as myself, she expected a massage from staff all the time and showed
frustration when she was told she couldn’t have one. However, she soon came to associate the chance of a hand
massage only with her key worker who always made some time to spend with her at
the end of the day. After a few
weeks, Lynda was learning to ask her key worker for a massage by signing, but
would then calmly accept the instruction to “wait” until later. She had started to anticipate and initiate sessions by
signing on my arrival, leading me up to her room where she would attempt to take
her shoes and socks off. Staff told
me that she had started calling me “Lady hands” in sign language and they
would use the same sign to tell her that I would be arriving on days scheduled
for my sessions with her.
By
the time of the 4th assessment, I estimated that Lynda was well into
the stage of initiating interaction and all throughout treatments I was
confirming this by building in little opportunities for her to communicate,
choose and control the sequence of events.
I had started to add variety and more opportunities for choice by
offering a foot spa and taking in various massage tools to try on her arms and
back over her clothes.
Conclusion
Using
a structured approach to massage using essential oils, I was able to use
aromatherapy to help Lynda work towards various goals in communication and
social development. While I was not
able to help develop any verbal skills, I had been able to increase her
attention span, enable her to make appropriate choices, moving from an initial
resistance and tolerance towards real enjoyment and interaction. I enjoyed the support of the staff; particularly her key
worker and Speech Therapist, without their enthusiasm, a programme such as this
would not have worked.
One
of the original aims of treatment was to help Lynda become more tolerant to
hand-over-hand learning of sign language – observations from the Speech
Therapist confirmed that this had been achieved. With the guidance of the Speech Therapist, additional
goals were planned and implemented in order to help Lynda with more complex
communication skills. As the
programme developed, Lynda started to associate signs and pictures with real
events, actually starting to form her own vocabulary (Lady hands) in order to
make her needs known. She developed
enough trust and understanding with her key worker to be able to wait without
confrontation after asking for a hand massage, a significant step in her social
development. I hoped that this
would be a starting point on which to build new skills and opportunities to
communicate.
Working
in a methodical way using a structured assessment to measure progress, I was
able to raise the acceptance of aromatherapy as having a positive and worthwhile
contribution with this client group. Contributing to success was the willingness on behalf
of the staff and other professionals to accept an unconventional approach, and
my willingness to accept and use their advice in the course of a partnership of
treatment planning and identifying new goals.
While
not using essential oils specifically for their therapeutic properties, I used
them as a way to stimulate the senses, encourage interaction and communication.
I was able to develop the sessions into a worthwhile activity so adding
to quality of life. I’m positive that Lynda did benefit from the
therapeutic effects of massage with the oils, because she was always visibly
more relaxed and content after the sessions, with fewer outbursts afterwards.
As
a result of working with Lynda, I was asked to present an overview of the
programme to the multidisciplinary team involved in planning her care.
From the measure of their enthusiasm and requests for referrals, I took
this to be a considerable measure of success.
I continue to visit Lynda every week and we are now working towards new
goals.