Jean A. Dyer, PhD

Michael L. Stotts, CAS

Editors

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PUBLISHER’S NOTE

Identities and circumstances of individuals discussed in this book have been changed to protect

confidentiality.

Cover design by Lora Wiggins.

Handbook of remotivation therapy / Jean A. Dyer, Michael L. Stotts, editors.

p. ; cm.

Includes bibliographical references and index.

ISBN 0-7890-2470-5 (hard : alk. paper)—ISBN 0-7890-2471-3 (soft : alk. paper)

1. Remotivation therapy—Handbooks, manuals, etc.

[DNLM: 1. Mental Disorders—therapy. 2. Psychotherapy, Group—methods. 3. Motivation.

WM 430 H2353 2005] I. Dyer, Jean. II. Stotts, Michael L.

RC489.R43H36 2005

616.89'14—dc22

2004012039

Dorothy Hoskins Smith 7

Philadelphia State Hospital 8

Walter F. Pullinger Jr. 9

Training in Remotivation 10

National Organization 10

Decline of Remotivation 11

Remotivation Today 11

Overview 19

Models for Advanced Remotivation Therapy 22

The Advanced Remotivation Therapist 25

Summary 25

Appendix: Steps in the Remotivation Process 26

Support Principles for Remotivation Therapy Implementation 32

Three Samples of Remotivation Therapy Models 35

Challenges for Remotivators 39

Summary 41

Historical Context 43

Intended Outcomes of Remotivation 43

Scientific Research Outcomes 44

Research on Motivation, Self-Determination Theory,

and Remotivation Methods 50

Introduction 55

A Deinstitutionalization Model 59

Summary 61

Epilogue 62

Basic and Advanced Remotivation in Physical Rehabilitation 65

Basic and Advanced Remotivation in Psychosocial

Rehabilitation 72

Conclusion 77

Goals for Activity Therapy 80

Remotivation Therapy 80

Discussion of the Remotivation Therapy Approach:

The Five Remotivation Steps 84

Recommendations and Conclusion 86

Overview of the Disease 89

Remotivation: A Program Model for HD 93

Epilogue 99

Resources 99

The Group Formation Process 111

The Sessions 112

Case Studies of Our Group Members 113

Results of Our Men’s Group 116

Introduction 119

Benefits for Alzheimer’s Patients 120

The Process 121

Summary 123

Introduction 127

Uses of Remotivation Therapy 128

Remotivation and Moving Experience 130

Activities Blended with Remotivation Therapy 132

The Classic Remotivation Group 136

The Double Trouble (Dual Diagnosis) Group 140

The Staff Development Group 145

Epilogue 145

Pretreatment Variables 147

Remotivation Therapy 148

Introduction 157

Definitions 158

National Remotivation Therapy Organization

Survey Results 160

Discussion 161

Chapter 1

Robert S. Garber

Why does remotivation work?

Ever since I became convinced that remotivation is good for patients, I’ve asked myself why.  Here, in a tentative way, I’ll 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 world’s 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.

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 person’s distorted view of reality.  We use this trust and communication to try to restore the patient’s 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 techniques—but 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.

den from the psychiatrist, but there is nothing sick about his putting on boots to walk in the snow—if 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 patient’s 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 patient—just as it gives all of us—a 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.

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.

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 patient’s sense of certainty in the concrete facts of his or her life, the psychiatrist tries, you might say, to reconstruct the patient’s 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 works—because 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.

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.

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