Supportive Counseling in With a nurse-therapist's help, an outpatient gained the confidence to handle her problems.

P. H E L E N W H I T E

In late July 1977, 66-year-old Mary Eustace Blake was invited to become a geropsychia t r ic outpa- tient. At that t ime she was awaiting abdominal exploratory surgery and was very worried about who would care for George, her sick husband.

Mary had been seen informally on a regular basis as she accompan- ied George to the geropsychiatric clinic. He had been a patient there since 1975 when he had suddenly become psychotic and, in a violent outburst, had threatened his family and neighbors. He was hospitalized involuntarily, stabilized on psy- choactive medications, discharged, and followed as an outpatient.

Ma r y declined to become a ge- ropsychiatric outpatient before her surgery, but did accept referral to a section of the geriatric service that specializes in communi ty outreach. There she received help in obtain- ing and coordinating supervision for George.

While Mary was convalescing at home, her husband again became psychotic, violently threatening her and other family members who were visiting. Mary instituted pro- ceedings to commit him, and in September 1977 she agreed to ac- cept assistance as an outpatient.

Background

Ma ry Eustace was the child of Ix)or white parents. Born in 1911 on a farm in eastern Tennessee, she

P. Helen White, RN,C, MS, is a practition-. e r - teacher at Methodis t Hospital , Houston , Tex. This case s tudy was originally submi t - ted to the A m e r i c a n Nur se s ' Associat ion to fulfill certification requi rements .

was the eldest of three children. She received little formal educa- tion. Her father died when she was 12, and her mother died from pella- gra when Mary was 14. The three children were taken in by a 75- year-old neighbor. Hunger was a constant problem.

Marr ied at 15, Mary moved into her husband's household. Mary ' s mother-in-law did not like her or approve of the marriage. The mar- riage ended when Mary ' s infant son was found dead early one morning. She was blamed for his death and abandoned by her hus- band.

Mary married a second time and had another son. This husband left her for "another woman." Mary supported herself and two little boys by working in a sewing room.

In 1943 she married George Blake. Unhappy during the early years of her third marriage, be- cause George drank heavily and of- ten left her for days at a time, Mary gradually became more con- tent as George came to need her psychological support, in the early 1970s, the Blakes moved from their small town into a rental house on the outskirts of a large city. By that t ime Mary had little contact with her older son, who lived out of state. She saw her only other child and his family fairly often.

Problem, Goal, Assessment

Mary stated her problem as "a worried mind about George and what 's going to happen in the fu- ture ." Her goal was to "get rid of Park in i sm-- i t gives me stiff mus- cles, no energy, trouble smiling, and makes my hands t remble ."

Mary was assigned to the nurse therapist who had been working with her husband since the previous July and who had originally invited her to become an outpatient. The intake procedure included a multi-

. J

phasic examination, a psychosocial history, and evaluation by the ger- iatric psychiatrist.

After reviewing Mary 's medical findings, which were within normal limits, and her psychosocial his- tory, and interviewing Mary, the psychiatrist made the following di- agnoses: transitional situational disturbance, anxiety neurosis with depressive features, and mild Par- kinson's disease.

The problems identified by both Mary and the nurse therapist w e r e "

�9 difficulty coping with George and her present situation

�9 difficulty sleeping �9 financial pressure �9 expensive medical care �9 absense of pleasurable activi-

ties. Later in the course of therapy,

two other large problems emerged, Mary ' s fear that her husband's family would accuse her of not tak- ing proper care of him and the ter- mination of her sessions with the nurse therapist.

The ' t reatment plan to which Mary agreed included antidepres- sant and antianxiety medication, community outreach services, and supportive counseling. Appoint- ments were made for visits twice a month, with flexibility to allow for transportation problems and con- flicting medical appointments.

Therapeutic Approach

Nursing intervention consisted of reality-based supportive counsel- ing. With supportive counseling de- fined as problem solving, Mary and the nurse therapist considered pos- sible alternative solutions, planned a course of action, acted on the plan, a n d reviewed the resul, l,t.s

The nurse therapist hstened to Mary, warmly accepted her a s a worthwhile intelligent individual, and encouraged her to b e a s inde-

176 Geriatric Nursing May/June 1983

Action

pendent as possible. Praise was giv- en freely. A review of Mary 's life enabled the nurse to emphasize Mary 's strengths and allowed Mary to share some of the bad times she had encountered. During each clinic visit, she saw the geriat- ric psychiatrist, who consulted with the nurse therapist, evaluated Mary 's need for medication, and offered praise and encouragement.

After Mary 's intake procedures were begun, George was dis- charged from the hospital and sent home under her care. He continued to at tend the outpatient clinic, so concurrent appointments were made for them, to decrease supervi- sion and transportation problems. In the early stages of Mary 's treat- ment, this responsibility for bring- ing George to clinic strengthened her resolve to keep appointments. However, as therapy continued and her self-concept improved, Mary recognized her right as an individu- al to come to the clinic.

She became interested in grow- ing plants and demonstrated self- assurance when she brought plant cuttings to the nurse therapist. She began to show a sense of humor that at times could be rather sharp. After her quietness and high anxi- ety during her first visits, she be- came more relaxed, able to voice complaints and talk about everyday happenings.

Toward the end of the nurse therapist 's involvement, August 1978, Mary even began to criticize the nurse about personal things like weight, condition of the office, and so forth. This indicated that Mary was feeling more comfortable, se- cure enough to interact more spon- taneously because she was confi- dent of the nurse's acceptance.

George Blake's chronic psychosis with moderately severe memory impairment could not be reversed. However, Mary was helped to learn

that psychoactive medication and consistent s tructure could influence his behavior. She monitored his be- havior at home, reported changes, and came to the clinic early if she thought he needed help. Her watchfulness and assistance were rewarded with praise.

Taught reality orientation princi- ples, she proudly related her hus- band's progress. The stresses she faced daily in caring for him were acknowledged and suggestions made to reduce these when possi- ble.

Existing on Social Securi ty and Social Securi ty Supplement, Mary functioned as the household man- ager. Paying their rent took almost half their combined income. After examining other housing possibili- ties, she decided that for this period she enjoyed living in the house and that George needed familiar sur- roundings. So she chose to spend her money that way.

By her last visit, Mary was feeling better and coping adequately with the demands of her home situation.

She investigated and took advan- tage of a communi ty program to help pay utility bills. Her food stamp allotment remained about the same. By attending a senior cit- izen program she obtained free transportat ion to medical appoint-

o

ments. Her need for less expensive

health care was identified at the t ime of intake. Taught how to ap- ply for a county hospital district medical card, she followed through. Thus she secured free medical care, including dental and optical work, for herself and George.

The search for pleasurable activ- ities continued. Coming from a ru- ral, poor white culture, Mary had difficulty finding people with whom she felt comfortable in a

metropolitan area. With the nurse therapist 's encouragement , she ventured out. Attending the senior citizen activities to obtain free transportation and enable George to play dominos, she finally found several people she could talk with.

Her fear that George's family would accuse her of not taking proper care of him increased fol- lowing his routine physical exami- nation by a physician of the county hospital district. A thoracic aneu- rysm was discovered but deemed inoperable. Mary recognized that her fear s temmed from the death of her infant and her inlaws' accusa- tion that she was to blame.

Besides listening to Mary, the nurse therapist gave her informa- tion about sudden infant death syn- drome. Learning that SIDS might have been the cause relieved Mary of considerable guilt and fear.

During the last clinic visits Mary and t h e n u r s e worked with the ter- mination process . They acknowl- edged how they felt about working together, summar i zed their experi- ences, and shared their regret at parting. The new nurse therapist had not been appointed, but Mary was told whom to call and who would see her if necessary.

Evaluation

The success of the nursing inter- ventions can be judged by Mary 's good health at the last visit. She no longer required antidepressants and was taking a low dose of an- t ianxiety medication only on a P R N basis. She was sleeping more soundly and her energy had re- turned. She was coping adequately with a demanding home situation.

The hand tremors persisted whenever she was under stress, but she said her muscle stiffness was less. Although she was receiving no medication for Parkinson's disease, she could smile more spontaneousl), and her facial expressions were less masklike.

Despite an impoverished back- ground and t raumatic life experi- ences, Mary did gain from her first psychotherapeutic sessions. Her im- provement continued as she met with the new nurse. GN

Geriatric Nursing May/June 1983 176A