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Introduction Types Cause Pathophysio Psychodynamics Signs and symptoms Differential diagnosis Multiaxial Management Nsg mngt

REMOTIVATION TECHNIQUE - A t h e r a p y o f v e r y s i m p l e g r o u p t h e r a p y of an objective nature used in an effort to reach the unwounded areas of the patients personality & get them moving back into the reality Indication:- C a n b e u s e d i n a w a r d s i t u a t i o n regardless of the length of time the patient has been hospitalized, his age or the reason of his illness & sex. Objectives 1.Stimulate patient to be fellow explorer of the real world 2. develop t he abilit y t o communicat e & share ideas & experience with other 3. develop f eeling of accept ance & recognition

Values of the patient 1. St imulat e pat ient t o t hink about something & talk about himself 2.G ives him reason t o value himself & increase his self-respect 3.Takes him out of the darkness of the world life 4. Makes him part of t he group 5.Take the patient out of the vegetable class Duration: 45-60 minutes- 4 5 m i n 1 h o u r f o r o n c e o r t w i c e p e r week No. of sessions & Evaluation 12 sessions consists a series. The student evaluates the patients reactions with the guidance of the CIEvaluation report is attached to their respective chair of the physicians to note Subject to be considered 1.Geography 2.History 3.Science 4.Literature 5.Industry 6 . S p o r t s 7.Hobbies 8.Nature Subject NOT to be considered 1.Religion 2.Politics 3 . L o v e 4 . S e x 5.Family Problem

STEPS/ Procedures 1. Climat e Accept ance (5min) a. The leader who is at the center of the group introduces him & the rest of the group. b. Leader must ask t he pat ient t o introduce themselves. c.Aft er t he int ro., t he leader may comment on the weather, the patients appearance or may give a pleasant complimentd. T he object ive: Creat e a pleasant & relaxed atmosphere 2. Bridge t o Realit y (15min) a. Ask bounce quest ions. Q uest ion showed be short & easy to answer. b.Then ask for anybody who knows a poem about the topic of discussion c. Questions are from general-specificd. T ry t o read your poetry to t he group & later ask the patients to read it. Show your visual aid 3. Sharing t he world we live in (15min) a. St imulat ing quest ion leading t o t he topicb. Leader should t ry t o explore t he topic under discussion 4. Apprecia t ion of t he wo rks of t he world (15min)a. T he st ep is blended wit h st ep 3b.Be sure t o relat e t he pat ient so he will be able to think of himself in relation into certain job5. Climat e of Appreciat ion (15min)

a. Leader should t ry t o ask a summary about the topic w/c has discussed b. Express your appreciat ion t o t he patient for coming to the sessions &tell them about the next session &what topic to be discussed

Set 2
Remotivation therapy is a set of individual and group questioning skills that you can use to "motivate" and "engage" those you serve in health, work and recreation. Remotivation is a well researched, evidenced based , method of education. It is based on over 50 years of experience with people of all ages, in school, at home, residential settings and in hospitals. Remotivation training teaches you questioning skills that you can use to develop and/or maintain a positive, productive caring relationship with the person you lead or serve. Learning remotivation skills helps you keep a healthy balance between attending to the problems (social, financial, physical or mental) of people and their healthy, normal physical and mental abilities (social skills, talents, hobbies, work or vocation). You may ask why I need to focus on the normal, non-problem, abilities or capacity of persons I help? Why can I not just focus on fixing their problems? It is because helping can sometime hurt unintentionally and be counter productive. Unintentional harm has a formal name "iatrogenesis" in medical settings. The same dynamic happens in family life and at work. You can read

the definition at Wikipedia or do an online search to learn more about it. http://en.wikipedia.org/wiki/Iatrogenesis Helping and leadership relationships can result in unintended consequences or negative outcomes if a proper BALANCE is not kept between focusing on the problems of the person helped and the healthy abilities and personality of the person you are attempting to help. Helping and leadership relationships that are exclusively or predominantly problem based tend not to help as much as balanced relationships that focus also on health and wellness. When the helper and the person helped, spend all their time and energy focusing on what is wrong, the helper can become depressed or burned out and person helped/lead can become withdrawn, depressed, apathetic, unmotivated and/or discouraged. This can interfere with work productivity in employment and achieving the most in caregiving. It can also contribute to the progression of chronic disease and perpetuate dysfunctional relationships with employees. The person's strengths and abilities are needed in healing and recovery from illness and to cope with chronic disease and disability. These abilities are also needed to be productive in other areas of life. So helping in a manner that preserves and further develops the healthy body and mind of the person helped, is the best kind of helping relationship. NRTO believes that most helpers want the best for the other person. The pressures of life and the limitations on time and money tend to push helping relationships out of balance in favor of focusing almost exclusively on problems, illness and disability. Learning remotivation skills can help you to be the best possible helper/caregiver by maintaining normal functioning and facilitating greater health and wellness.



By Denise Lima-Laskiewicz ADC/EDU, ICRmT In these Remotivation therapy sessions the facilitator asks questions which is related to the topic at hand. The topic is determined by the Remotivational therapist. One question leads to another which is referred to as bounce questions. The Remotivational therapist also uses visual and audio cues during the session. If the clients are suffering with cognition deficits or A.D. there needs to be more visual cues. The facilitator creates an environment where the clients feel safe. In this environment whatever the client says is accepted by the Remotivational therapist in a non-judge mental manner. Thereby a trusting relationship is established between the client and the Remotivational therapist. The Remotivational therapist accepts and appreciates what the client provides which could be actively participating in the session or remains silent throughout the session. The gift of their presence is what the Remotivational therapist acknowledges. Remotivation therapy is broken into five steps because each one serves a function for the client and Remotivational therapist. The first step is referred to as the Climate of Acceptance which is a very important step in the therapeutic context of the session. The clients are set up in a circle of 8-10 people. In the circle the Remotivational therapist goes around to each individual to greet the client. While the Remotivational therapist is doing this, he greets the clients by name. Then the Remotivational therapist compliments the individual on his/her personal appearance, jewelry or clothing. It is okay to touch the client in an appropriate way, such as a hand shake or laying a hand on his shoulder. In so doing, the facilitator is informing the client that I paid attention to you. It also informs the individual that you are important and the Remotivational therapist accepts the person for who they are; including the illness. The second step is called Bridge to the Real World. In this step the Remotivational therapist leads the session in a question and answer on the topic. The topic is normally broad then leads to a specific point. Normally there are three to four questions in Step II with four possible answers which the Remotivational therapist writes in advance. This way the answer leads to the next question. If a client chooses not to reply that is acceptable. Also the client may not know the answer to the question. If this is the case than thank the individual and proceed to the next individual asking the same question. The last question in step II leads into the poem which is objective in nature. The poem is provided by the National Remotivation Therapy Organization Inc. When one is certified as a Certified Remotivation therapist , then programs and poems can be written up by the individual. The poem is read the clients or the clients can read it aloud to the group. Do not forget to use visual and audio aids to augment the program. The lower the mental cognition the more visual and audio clues are better. Once this is accomplished the Remotivational therapist leads the session into Step III

Step III is called Sharing the World in Which We Live. In this part of the step the Remotivation therapist expands on the topic by asking 8-10 questions about the topic. The questions are not emotionally based but objective in nature. Each person in the group is asked the same question. The questions are asked in newspaper format such as:

What When Where Why How

During Step III if the group goes on a tangent or a conversation about the topic that is good. When the group goes off on an tangent it is sharing their experiences. For example, if the topic is camping. One of the questions that could be in Step III is Where does a family go camping? Each one in the group replies, a park, the beach or the backyard. Another client could reply that my family camped backyard one time per month. Then others could add to the conversation. Eventually the Remotivational therapist brings the group back to the discussion. However, the Remotivational therapist need not finish step III because the tangent took care of it. The Remotivational therapist moves on to step IV. Step IV is referred to as Appreciation of the Work World. In this step the questions are related to the Work World and again the questions are objective in nature. The question begin with the newspaper formatsuch as:

What When Where Why How

When moving from Step III to step IV the Remotivational therapist asks a transitional question. For example, to use the transitional question from the previous example about camping. The transitional question could be how many people have gone camping? The rest of the questions center around the work of camping. Such as where does one get camping supplies? What national parks or state parks allow camping? What type of equipment is used for camping? Again the facilitator prepares 8-10 questions to ask the group. The same question is asked from everyone. Remember that as the facilitator, whatever response you receive is okay. If there is no response it is okay. The last step in the Remotivation therapy session is called Climate of Appreciation. This step is a reverse of step I. In this step the Remotivational therapist thanks each person individually for attending the group. Remember, even if the individual does not say a word, choosing to remain

silent throughout the session that is perfectly acceptable. This individual is giving you the ultimate gift, the gift of his presence in your session that youre acknowledging. Inform the group of when the next session occurs and invite the clients to attend. There is no need to tell them the topic. Also the facilitator can sum up the topic of the session that was held for the day.


VA Robert S. Garber

Psychiatrists View of Remotivation

Why does remotivation work? Ever since I became convinced that remotivation is good for patients, Ive asked myself why. Here, in a tentative way, Ill try to answer that question. In looking for an answer, I needed to review a few fundamentals about mentally ill people, the ultimate purpose of those of us who work with the mentally ill, and the means we use to achieve that purpose. In spite of the many diagnostic categories of mental illness, one single trait seems to characterize all mentally ill persons: they behave as though they live in a world different from the one in which the rest of us live. In their world, the absence of a smile may spell condemnation; a television set may be a brainwashing apparatus; a neighbor may be an agent of the devil. We are all familiar with highly elated patients who endeavor to cure the worlds ills by writing checks for a billion dollars, depressed patients who believe that life is utterly hopeless, and patients who think that the FBI has recruited their spouses to spy on them. From the moment that their concepts of reality change, mentally ill people do what is natural: they adjust to their new reality, just as we adjust to our reality. One patient uses an imaginary vast wealth for good causes. Another withdraws from a life that offers no joy or even hope. Other patients become secretive so that it will be harder for their families and the FBI to spy on them. In short, mentally ill people adjust to what they believe to be the facts of life. Given this generalization, what is our ultimate purpose? By our purpose I mean the purpose of everyone on the psychiatric team
Reprinted with permission from Mental Hospitals, American Psychiatric Association, Washington, DC, August 1965.

psychiatrist, nurse, aideeveryone who has contact with the mentally ill patient. To put it simply, we are trying to help mentally ill persons recognize the realities we recognize. We want them to see themselves for the persons they really are, to see other people as they really are, and to see relationships as they actually exist.

That is what we try to do, but we have learned that in dealing with the mentally ill we do not need to change patients completely in order to restore them to their families, jobs, and communities. In other words, we have learned that we do not need to cure them in order to send them home. Like the diabetic who must remain on insulin, the cardiac patient who needs digitalis, and the patient who loses a finger, the mentally ill person can become an ex-patient without being cured. When we send home a person who can function in the outside world, we have to a large degree achieved our purpose. How have we done this? Basically, by establishing communication with the patients: by encouraging them to speak to us and by speaking to them. The underlying condition for this communication is, of course, trust. By one means or another we must inspire confidence, for without it we communicate the wrong message, and we reinforce the mentally ill persons distorted view of reality. We use this trust and communication to try to restore the patients ability to recognize people, things, and relationships for what they really are. To help us do this we may use drugs, shock therapy, and other techniquesbut every technique is directed at restoring reality to the patients. We all communicate with patients, but we do not all do so in the same way. In fact, if we keep in mind that each patient is a many sided human being, we might say that we communicate with different sides of the same patient. This requires us to use different techniques. My technique is psychotherapy. Yours is remotivation. I said before that mentally ill patients have in common a distorted view of some significant aspects of reality. The key word here is some. Most mentally ill persons recognize, for example, that they are alive, so they will take nourishment as other living human beings do; many of them will complain appropriately if they get a toothache; many will dress appropriately for the weather, and so on. We can say, then, that not every role they play is a sick role. It is sick when a patient puts a swastika on his forehead to keep his thoughts hid2 HANDBOOK OF REMOTIVATION THERAPY

den from the psychiatrist, but there is nothing sick about his putting on boots to walk in the snowif there is snow. Each patient has sick roles and healthy roles. The sick ones have come to dominate his or her life, but the healthy roles are not entirely dead. I as a psychiatrist deal mainly with the sick roles. You as remotivators are in touch with the healthy roles. I deal with the patients weaknesses. You deal with their strengths. These weaknesses and strengths are both contained in a single individual; they are as inseparable as the two sides of a coin. If we dealt only with weakness or only with strength, we would do little for the patient, because we ourselves would not have a clear, well-rounded view of reality: it would be distorted by our own one-sided approaches. The patients strength, as you know, can be very surprising, once you find it. You have considerable room for exploration, since every patient, like every other person, plays many roles: child, youth, brother, sister, student, parent, worker, housekeeper, reader, bowler, neighbor, club

member, driver, eater, drinker, lover, traveler, thinker. The list is almost endless, and it grows as we age. Many of these roles may be distorted; others may become obscure; others may go on seemingly unaltered; and new ones may emerge. The totality of all these roles gives the patientjust as it gives all of usa sense of identity, of uniqueness, of individuality. These are the simple, fundamental thoughts I found useful to keepin mind in trying to discover why remotivation works. I believe that remotivation works because it recognizes mentally ill people as I have just described them. Remotivation, from the very beginning, tells the patient that he or she is accepted as an individual, a man or woman with a name, with specific features, with many roles, with unique traits that distinguish him or her from everyone else. The patients who are recognized so specifically have already been reached, in a way. They have been told that among the hundreds or thousands of patients in this hospital, their faces and names are recognizable. They are not lost in the shuffle; they are not confused with someone else. In spite of the inevitable regimentation in almost every institution, they stand out; they are known to important people, that is, to the staff. The ability to do this for the patient is a reflection of the remotivators own self-image, as Hildegard Peplau pointed out in her fine book, Basic Principles of Patient Counseling. Although she was writing of nurses, her conA Psychiatrists View of Remotivation 3

cepts are applicable to everyone who comes in contact with patients. Peplau advocates for respect for the patient by treating him or her with the courtesy accorded a stranger. The nurse must be comfortable as a person and a professional in order to help patients accept their own independence and be constuctive problem solvers. Why is this good for the patients? The changes in some of their old roles, and their new roles as mental patients, have altered their sense of identity and have created confusion for them. They may believe that their identities have been stolen from them or have suffered some kind of injury. Take the patient who is guilt ridden and depressed. He is sure that his sins make him an outcast. A remotivator says to him, Nice to see you, Mr. Jones. Glad youve come. The remotivator shakes his hand. How does Mr. Jones interpret this? He may say to himself, This man doesnt know how rotten I am. When he finds out . . . However, the remotivator has plenty of time to find out, and he continues to treat Mr. Jones politely, warmly, cheerfully. The remotivator has brought him a new awareness. Not only the remotivator but other staff members treat him this way. There is some chance, then, that Mr. Jones will need to take another look at himself. He may be confronted with the possibility that he is not as bad as he thought, or that he was pretty bad but has reformed. One of the great values of remotivation is that it emphasizes to the patients that they have an objective existence to other people: not an existence that depends only on what the patients think of themselves, but one that depends to a large degree on how we, their fellow beings, see them. If remotivation emphasized only the objective identity of the patient, it might not be really effective. Remotivation creates a bridge between the patients as they appear to the world and the patients as they appear to themselves. It does so by encouraging them to browse around in the

concrete world and to identify and assert their experiences in interactions with other human beings. The only restriction you place on their browsing is that they must, in remotivation, come up with concrete, specific information. They must describe their experiences concretely. A patient must say, This is how I built cabinets at the factory, or It used to takeme three days to plow one-hundredfifty acres, or Cactus plants need less water than other houseplants. The patient must participate in this interaction as a plumber, a gardener, a sign painter, sailor, salesperson, geography teacher, cab driver,

or in some other healthy role. The result is that the patients are strengthened in two ways. First, they are encouraged to describe themselves concretely and accurately as individuals with specific social functions, jobs, a place in theworld. Second, they are encouraged to speak concretely and accurately of what they did in these jobs. While the remotivator tries to build up the patients sense of certainty in the concrete facts of his or her life, the psychiatrist tries, you might say, to reconstruct the patients recognition and understanding of himself or herself and the world in which he or she lives. You can see how these two efforts complement each other. That, in short, is why remotivation worksbecause it helps set in motion two processes that are vital to the patients if reality is to be restored to them. First, it builds on the patients strengths, reinforcing them as objective people in our eyes and, in respect to their healthy roles, as subjective people in their own eyes. Second, remotivation works because the psychiatrist tries to challenge the distortions of reality that plague the patients. Put anotherway, remotivation works because it is a useful experience to the patients. They learn that there are roles they can play that do not create problems for them, that do not fill them with anxiety. They find that they do not need to block out or revise their understanding of every area of their lives, that some areas can be shared with a certain amount of freedom, competence, dignity, and even pleasure. In this way the texture of their lives does not get altogether lost. The smell, touch, and feeling of reality remain recognizable for them. They are not permitted simply to abandon themselves by abandoning, one by one, all the roles that made their lives meaningful; they are encouraged to keep them alive. This is what patients need, and this is why remotivation works. We as mental hospital workers are obligated to be realists. Some patients were getting well before remotivation appeared on the scene. In fact, they were getting well long before psychiatry evolved. However, I would venture a good guess that they got well because their recognition of reality was somehow strengthened, and their distortions of reality were overcome. The corrective processes that were put in motion were like the ones we put in motion today. That is entirely understandable, since we human beings probably have not changed much in the few thousand years of history. We have, however, developed a better understanding of mental illness and, at the same time, a better understanding of how to treat it.
A Psychiatrists View of Remotivation 5

What the healers of ancient times relied on, I believe, was their intuitive sense of what the mentally ill person needed, combined with a natural sensitivity and artfulness in communication, and, of course, persistent optimism. To this day, in my opinion, those same attributes characterize the best psychiatrists, psychiatric nurses, psychiatric aides, adjunctive therapists, and everyone else involved in understanding and communicating with the mentally ill. This, therefore, is the final reason for the workability of remotivation: the remotivators. You cannot separate technique from technicians. A fact of life is that a technique is no better than the man or woman who uses it, and it often turns out that the technician is really much better than the technique. In the last analysis, after all the techniques are outlined, the science behind them is verified, and the art of application is recognized, remotivation works because the remotivatorregardless of his or her title or condition of servicemakes it work. REFERENCE
Peplau, H.E. (1964). Basic principles of patient counseling. Philadelphia, PA:

Smith Kline & French Laboratories.