Remotivation therapy originated in the United States in the mid-50s by Dorothy H. Smith, a hospital volunteer at Philadelphia State Hospital.1 This type of group therapy was originally designed to be used by psychiatric aides and attendants in mental institutions to promote more involvement between patients and staff. The five structured steps of the remotivation technique were developed to stimulate individuals to become interested in their environment by creating a link between the objective world and their subjective reality.
As this therapy grew in popularity, the American Psychiatric Association developed a remotivation advisory committee between 1966 and 1970. 2 This committee helped to train healthcare-related personnel in remotivation technique and established many programs throughout the country. Remotivation kits were also developed by the committee and sold to institutions who wanted to train their staffs in this technique. Remotivation techniques are still being used today in mental institutions, nursing homes, and on psychogeriatric units.3'6
This article describes remotivation therapy in a community-based adult day care setting where a majority of the participants have moderate to severe intellectual and cognitive impairments. A growing number of individuals with primary degenerative dementia (PDD) are living in the community and using the services of adult day care.7-8
Eight sessions of remotivation therapy were designed for a group total of 14 participants at the former NorWest Adult Day Health Center in Seattle, Washington, now called Seattle Day Center for Adults. This adult day center offers rehabilitative and respite care to the older adult living in the community and in need of these services. A BSNprepared staff nurse and a BSN nurse in a master's degree nursing program at the University of Washington planned the sessions. Both nurses participated in all of the sessions.
Who would be the leader or co-leader was designated prior to the beginning of each group. The leader focused on presenting information in a fashion structured closely after the five steps of the remotivation technique. The co-leader monitored the verbal and nonverbal responses of each participant.
When inappropriate behavior occurred or there was a lack of attention to the group topic, the co-leader intervened by redirecting and refocusing attention, or giving direct verbal feedback to the disruptive individual. The co-leader attempted to promote group cohesiveness by facilitating verbal interaction among the participants and through modeling appropriate group behavior to the members.
Although this was not a scientific, controlled study, remotivation therapy was thought to provide additional socialization and sensory stimulation to cognitively impaired individuals in a structured group setting. Important modifications were made to the five basic steps of the remotivation technique which gave added emphasis to sensory stimulation. The basic structure of these steps was changed and included the following: a) introduction, b) reading aloud, c) sharing time, d) considering the work of the world, and e) expressing appreciation and pleasure.
Group membership was limited to individuals with moderate to severely impaired levels of cognitive functioning. NorWest staff members observed that a therapeutic group targeted specifically for this population of individuals had not been developed at the day center. The group membership was designed to exclude all but the 14 moderately to severely cognitively impaired clients who began with the first session of the remotivation technique. It was hoped by the group leaders that increased sensory stimulation would facilitate the participants' ability to interact with others at the day center, increase their sense of self-esteem, and enhance overall group cohesiveness.
FIVE BASIC STEPS OF REMOTIVATION THERAPY
Seventy percent of the participants had a diagnosis of PDD. This disease process has a progressively deteriorating clinical course of intellectual and cognitive decline that may last over several years. Currently there is no known cure for PDD, which is considered the fourth leading cause of death in the United States.9
There were nine females and five males in the remotivation group. The ages of the members ranged from 55 to 94 years, and they were alJ white, with the exception of one English-speaking Chinese participant. The members were all ambulatory, but wheelchaïrbound individuals would not have been excluded if their level of cognitive functioning had been appropriate.
The M i ni -Mental State Exam developed by Folstein and Folstein10 was used to assess the mental status of the 14 participants. Clinical assessment of cognitive decline, using the mental status exam tool, indicated outcome scores of moderate to severe cognitive impairments for all 14 of the group members. The number of score errors on the mental status exam has been used as a psychometric concomitant to the seven clinical ratable stages of PDD operationaltzed by Reisberg, Ferris, DeLeon, and Crook." These seven states of PDD are measured by the Global Deterioration Scale (GDS). Frequent mistakes on three or more items on the mental status exam correlates most closely on the GDS with ratable stages four through seven, moderate to severe cognitive decline.
Each of the eight sessions of remotivation therapy was offered twice weekly for 60 minutes. The same theme was presented twice in one week to both of the groups , each with different membership. However, the same participants did meet weekly with infrequent change in membership, and absence in the group was usually due to a cancellation in day center attendance for that day.
The eight themes that were chosen based on suggestions from the leaders and interests of the group members included the following: a) gardening, b) wind, c) pets, d) bodies of water, e) canning fruits and vegetables, f) hobbies, g) transportation, and h) celebrations. Group leaders found these themes to be suitable for introducing remotivation techniques with added emphasis on stimulation to the visual, tactile, olfactory, auditory, and gustatory senses. Each remoiivation session included the five basic steps described by Pullinger,12 and adapted by Dennis2 (see Table 1).
Important modifications were made to the five original remotivation steps to enhance sensory stimulation and to be used with cognitively impaired clients.
Step 1 Climate of Acceptance
The first five minutes of each session were used as a time for the group leader to orient the members to person, place, and time. This was accomplished through the use of a calendar with established meeting times and dates. Going around the group circle, each member then introduced himself or herself or was introduced by the group leader. Before the initial remotivation session, group leaders determined what seating arrangements would minimize membership conflict and enhance group participation. Seating arrangements remained the same for each group session. Name tags were placed on each chair prior to the group meeting.
Step 2 Creating a Bridge to Reality
The next 15 minutes of the remotivation technique were used by the leader to create a bridge between the participants' objective world and subjective reality. The leader read poems and used leading topic questions to stimulate interest among the group members about the remotivation theme.
Step 3 Sharing the World We Live In
The following 15 minutes of remotivation technique were used to increase sensory stimulation to individual members. This was accomplished by sharing simple physical objects among the members. Material aids and props were used to facilitate this step. Sensory stimulation was provided through several senses by the use of sight (pictures), sound (music), smell (spices, flowers), taste (eating fruits and vegetables), and touch (petting a dog).
Step 4 An Appreciation of the Work of the World
Approximately 20 minutes were used in this step, as group members were given the opportunity to share parts of their past work history and how they identified with these work-related roles. Often this step is left out when using remotivation techniques with the chronically mentally ill because they may have had limited opportunities for employment. However, it had been observed by the NorWest staff that many clients at the day center were able, with prompting, to recall some of their life's work with obvious satisfaction.
Step 5 Climate of Appreciation
The last step of remotivation technique was used to close the session. Members were told the theme of the next session as well as the date and time of meeting. Appreciation for attending the group was expressed by the leaders. Members were thanked individually for being a part of the group (see Table 2).
At the termination of the eight remotivation sessions, the group leaders felt their goal to enhance and increase sensory stimulation to cognitively impaired individuals had been met. They felt that an adult day care center may provide an ideal setting to offer remotivation therapy. The services of an adult day care center are available to cognitively impaired clients who may benefit from additional socialization and sensory stimulation in a structured group environment.
Each member in the remotivation group was given an opportunity to participate in several different and stimulating activities. The use of visual aids and physical props helped to enhance sensory stimulation to members by promoting their sense of sight, sound, touch, taste, and smell.
One member of the group who could not communicate verbally was able to benefit from the nonverbal forms of sensory stimulation. This 55-year-old woman with advanced Alzheimer's disease, as evidenced by expressive aphasia, appeared to particularly enjoy the olfactory and gustatory stimulation. She sat through the entire group, and her affect was pleasant and often bright. This was seen as a positive change in this participant, as compared to her other group involvements at the adult day care center, where she often appeared disinterested and frequently attempted to leave.
ANEXAMPLEOFA REMOTIVATION SESSION THEME FOR SESSION 4: BODIES OF WATER
Group identification and cohesiveness increased throughout the eight- week sessions. Members increased in their participation and showed more interest in group projects. Verbal exchange among the members of the group increased, as did expressed pleasure shown by occasional laughter and clapping. One member of the group got up and danced on two occasions, -while other members clapped to the music. Two of the participants, unable to remain for the entire 60 minutes of remotivation technique in the beginning sessions, eventually were staying for the full hour.
Socialization increased among group members and this carried over into other activities at the adult day care center. Often group members would walk to lunch and eat together following the remotivation sessions, or were observed with each other during unstructured time at the day center. The leaders facilitated group processes and attempted to promote cohesion among the members, and to minimize conflict. Some of this was accomplished by the group leaders making preassigned seating arrangements before the first remotivation session began. Each member of the group was assigned to a seat that was labeled with his or her name. Members soon began to look forward to finding their names and chairs in the same location.
Remotivation therapy, used in a community-based adult day health-care center, may be beneficial for intellectually and cognitively impaired individuals, many of whom may have a diagnosis of PDD. Scientific, controlled studies in the use of remotivation technique in an adult day care setting need to be conducted. Modifications in the five basic steps of the remotivation technique are necessary to provide optimal sensory stimulation to such individuals. The members of this group appeared to benefit from the increased social interaction and identification with a special group. An increase in self-esteem and positive self-confirmations was fostered by the leaders toward all group members, and encouraged among group peers.
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FIVE BASIC STEPS OF REMOTIVATION THERAPY
ANEXAMPLEOFA REMOTIVATION SESSION THEME FOR SESSION 4: BODIES OF WATER