Remotivation therapy After 1 hour of classroom discussion the level III students will be able to: 1.

Define the following terms 1.1 Remotivation Therapy 1.2 Apathy 1.3 Delusion 1.4 Disorientation 1.5 Hallucination 1.6 Illusion 1.7 Therapist 1.8 Therapy 1.9 Disengagement 1.10 1.11 1.12 Conflict Emotions Environment

2. Cite the Remotivation therapy: 2.1 goals 2.2 purposes 2.3 indications/contraindications 2.4 guidelines 2.5 nursing responsibilities 3. Discuss the qualities of a good therapist 4. Enumerate the steps in Remotivation therapy 5. Explain the nursing responsibilities before, during and after 6. Demonstrate beginning skills in Remotivation therapy

1. Definition of terms Remotivation therapy Is a simple group therapy technique used to re-orient patients to the reality around them Apathy A state of indifference Delusion A false belief held to be true even with evidence to the contrary (e.g., the false belief that one is being singled out for harm by others) Disorientation Confusion and impaired ability to identify time, place and person Hallucination A sense perception (seeing, hearing, tasting, smelling, or touching) for which no external stimulus exists (e.g., hearing voices when none are present) Illusion An error in the perception of a sensory stimulus. For example, a person may mistake polka dots in a pillow for a hairy spider. Therapist A person with special skills, obtained education and experience, in one or more areas of healthcare Therapy The course of treatment used to cure disorders of the body and mind Disengagement In family theory, disengagement refers to extreme separateness among family members.it is promoted by rigid boundaries or lack of communication among family members.

Conflict A mental struggle, either conscious or unconscious, resulting from the simultaneous presence of opposing or incompatible thoughts, ideas, goals, or emotional forces such as impulses, desire or drive Emotions The outward expression or display of mood or feeling states Environment External conditions and surroundings, especially those that affect the quality of life of plants, animals and human beings

2. Remotivation therapy as to its: Goals:

Increases participants sense of reality Stimulate interest in the environment, increase communication skills and help patients to learn a wide variety of skills Self esteem will be increased by means of belonging to a group, as well as by means of participation in offering answers, learning new knowledge and gaining skills

Purposes: Resocialize regressed and apathetic clients Re-awaken their interest in the environment Increase the participants sense of reality Help patients who have undergone long-term institutionalization to become less isolated and be more socially adept

Indications

Client who are experiencing: Withdrawal Depression Loneliness Alienation Confusion Disorientation

Contraindications Clients with hallucinations, illusions, delusions Clients who are severely anxious, aggressive an hyperactive Clients who are violent

Guidelines: Groups are made up to 10-15 clients Meetings are held once or twice a week Meetings are highly structured in a classroom-like setting Chairs should be arranged in a semi-circle formation Group uses props Each session discusses a particular topic Inform clients a day before the therapy Remind the group about the activity on the day itself Each patient are given nametags Introduce yourself and reorient them the date, time and place of the activity

Set rules or lagda and explain the mechanics of the activity Give instructions slowly and clearly Use visual aids that are large, clear, colorful and uncluttered Show one picture at a time to each of the clients and let them identify individually Avoid telling them whether right or wrong unless everybody is finished Give recognition to all answers given by the clients, observe the five (5)steps in remotivation technique Always appreciate Use repetitions, summarizing is another form of repetitions that helps to establish relationships between ideas and to set learning Present a poem or a story related to the topic and let the patient share understanding of the presentation and process their answer Ask the clients how they feel about the therapy Acknowledge and appreciate the clients presence Remind them that their presence is expected in the next therapies and state the date, time, and place of the next session Do after care

Nursing responsibilities Before Inform and coordinate with the institution for the upcoming activity Inform the patients a day before the therapy Remind the group on the day itself right after the morning activity Prepare the materials needed Prepare the venue provided with the chairs arrange in a semi-circle formation Attend to their physiologic needs Gather the patients and bring them to session hall

 During After

Put on their name tags

Greet the patients Introduce yourself to the patients and state the date, time, and place of the activity Let them introduce one by one Always appreciate through clapping State the mechanics of the therapy and remind them of lagda Show pictures or object at a time and let patient identify them individually Give recognition to all answers given by the patients, observe the five (5)steps in remotivation technique Avoid telling them whether right or wrong unless everybody is finished Summarize their answers and explain briefly the pictures presented Present a poem or story related to the topic Let the patient share understanding of the presentation and process their answer Ask them how they feel about the therapy

Acknowledge the patients presence Thank them for attending the therapy Remind them that their presence is expected In the next therapy State the date, time, and place of the next session Do after care

3. Qualities of a good therapist

The ability to communicate communication skills are important as you will be dealing with people of all ages, sexes, many different temperaments and personalities. Friendliness to make people feel welcome and at ease Sincerity always put the best interests of the client first Honesty never mislead clients or give them unrealistic expectations Cheerfulness- to relax the client and promote a pleasant atmosphere Politeness treat clients with respect no matter how difficult they may be Discretion- the client must feel secure in the knowledge that any personal information or anything that has been said in confidence will not be passed on Approachable helps to put clients at ease, particularly when they are new, and this allows them to communicate their requirement and feel able to confide in you A good listener your listening skills are important as clients often like to talk about their lives and problems Warmth is the means by which psychotherapists provide their patients an atmosphere in which they can feel relaxed, safe and appreciated for who they are. Genuineness to derive maximum benefit from psychotherapy, patients must be able to describe their thoughts, feelings, and experiences in an open, truthful, and nondefensive manner

Freedom from neurotic difficulties - to conduct psychotherapy effectively, therapists must be free from neurotic difficulties, which present purposes which can be defined as psychological issues and conflicts that interfere with their ability to respond openly and flexibly to the needs of their patients. Empathic feel compassion and provide comfort Patient not easily provoked Good listener listen to what is really said Active shows alertness Creative own way of dealing Tactful sensitive to the feelings of somebody else

Flexible able to adapt in different situations Fair free from favoritism or self interest

4. Steps in remotivation therapy Remotivation session Step 1: CLIMATE OF ACCEPTANCE The leaders personally will welcome each participant as he or she arrives in the group session. After the leaders introduce themselves, each group member will make a self-introduction. The leader will use a calendar to orient the members to the date and time of the current remotivation session. The theme for session will be introduced by the leader. Step 2: CREATING A BRIDGE TO REALITY A visual aid is used to stimulate the discussion. The leader asks questions. Then leader reads poems about the topic. Visual aids and props will be provided for direct sensory stimulation. Music with lyrics can also be used. Step 3: SHARING THE WORLD WE LIVE IN This step provides time for discussion of topic introduced in the bridge of reality. Planned questions help keep the group focus on the topic. Props can be used to stimulate interest. The key in this step is the careful planning of questions and props.

Step 4: AN APPRECIATION OF THE WORK OF THE WORLD This time will be used for the members to think about work in relation to others. More experiences in past-related work roles as well as hobbies and pastimes will be discussed. Step 5: CLIMATE OF APPRECIATION The group members will be thanked individually by the leaders for coming to the group and sharing their experiences. The following remotivation session theme and meeting will be announced prior to termination of the session.

Subjects to be considered during Remotivation therapy:

1. geography 2. history 3. science 4. literature 5. industry 6. sports 7. hobbies 8. nature

Subjects not to be considered during Remoyivation therapy:

Process recording Objectives: After 4 hours of varied teaching-learning activities, the level III students will be able to: 1. Define the following terms: 1.1 process recording 1.2 communication 1.3 context 1.4 content 1.5 congruent message 1.6 incongruent message 1.7 therapeutic communication 1.8 proxemics 1.9 active observation 2. explain the purpose of process recording 3. review the following: 3.1 therapeutic communication 3.2 non-therapeutic communication 3.3 phases of nurse-client relationship 4. explain the content of process recording 5. state the guidelines of process recording 6. enumerate the nursing responsibilities before, during and after 7. demonstrate beginning skills in making a process recording

1. definition of terms:

Process recording Is a tool used to analyze nurse-client interactions and is seen in various formats. Communication Is the process of sending a message to one or more persons Context Is the environment in which communication occurs and can include the time and the physical, social, emotional, and cultural environments. Context includes the situation or circumstances that clarify the meaning of the content of the message Content Is the literal words that person speaks. Congruent message Is conveyed when content and process agree Incongruent message When the content and process disagreewhen what the speaker says and what he or she does not agree the speaker is giving an incongruent message Therapeutic communication

Is an interpersonal interaction between the nurse and the client during which the nurse focuses on the clients specific needs to promote an effective exchange of information. Proxemics Is the study of distance zones between people during communication. People feel more comfortable with smaller distances when communicating with someone they know rather than with strangers (DeVito, 2008). Active observation Means watching the speakers nonverbal actions as he or she communicates

2. purposes of process recording: Purposes of process recording The aim of process recording is to improve the quality of the interaction for better effect to the patient and as a learning experience for the nurse to continuously improve her clinical interaction pattern. When correctly used, it Assists the nurse or student to plan , structure and evaluate the interaction on a conscious rather than an intuitive level; Assists her to gain competency in interpreting and synthesizing raw data under supervision Helps to consciously apply theory to practice Helps her to develop an increased awareness of her habitual, verbal and non-verbal communication pattern and the effect of those patterns on others Helps the nurse to learn to identify thoughts and feelings in relation to self and others Helps to increase observational skills, as there is a conscious process involved in thinking, sorting and classifying the interaction under the various headings

Helps to increase the ability to identify problems and gain skills in solving them Used to teach communication skills to student nurses in the clinical setting and focuses on verbal and nonverbal communication

3. Therapeutic communication Is an interpersonal interaction between the nurse and the client during which the nurse focuses on the clients specific needs to promote an effective exchange of information. Skilled use of therapeutic communication techniques helps the nurse understand and empathize with the clients experience. All nurses need skills in therapeutic communication to effectively apply the nursing process and to meet standards of care for their clients. Therapeutic communication can help nurses accomplish many goals: Establish a therapeutic nurse-client relationship Identify the most important client concern at that moment (the clientcentered goal) Assess the clients perception of the problem as it unfolds, this includes detailed actions (behaviors and messages) of the people involved and the clients thoughts and feeling about the situation, others, and self Facilitate the clients expression of emotions Teach the client and family necessary self-care skills Recognize the clients needs Implement interventions designed to address the clients needs Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution

Establishing a therapeutic relationship is one of the most important responsibilities of the nurse when working with clients. Communication is the means by which a therapeutic relationship is initiated, maintained, and terminated. To have effective therapeutic communication, the nurse also must consider privacy and respect boundaries, use of touch, and active listening and observation.

Privacy and respecting boundaries Privacy is desirable but not always possible in therapeutic communication. An interview or a conference room is optimal if the nurse believes this setting is not too isolative for the interaction. Proxemics Is the study of distance zones between people during communication. People feel more comfortable with smaller distances when communicating with someone they know rather than with strangers (DeVito, 2008). Four zones of distance awareness or spatial territory:

Intimate zone :( 0 to 8 inches between people): this amount of space is comfortable for parents and with young children, people who mutually desire personal contact, or people whispering. Invasion of this intimate zone by anyone else is threatening and produces anxiety. Personal zone: (18 to 36 inches) : this distance is comfortable between family and friends who are talking Social zone: (4 to 12 feet) : this distance is acceptable for communication in social, work, and business settings Public zone: (12 to 25 feet) : this is an acceptable distance between a speaker and an audience, small groups, and other informal functions (Hall, 1963)

Touch As intimacy increases, the need for distance decreases. Knapp (1980) identified five types of touch:

Functional professional touch is used in examinations or procedures such as when the nurse touches a client to assess skin turgor or a masseuse performs a massage Social-polite touch is used in greeting, such as hand-shake and the air kisses some women use to greet acquaintances, or when a gentle hand guides someone in the correct direction

Friendship-warmth touch involves a hug in greeting, an arm thrown around the shoulder of a good friend, or the backslapping some men use to greet friends and relatives Love-intimacy touch involves tight hugs and kisses between lovers or close relatives Sexual-arousal touch is used by lovers

Active listening and observation To receive the senders simultaneous messages, the nurse must use active listening and active observation. Active listening means refraining from other internal mental activities and concentrating exclusively on what the client says. Active observation means watching the speakers nonverbal actions as he or she communicates. Therapeutic communication techniques: Accepting- indicating reception Broad openings-allowing the client to take the initiative in introducing the topic Consensual validation-searching for mutual understanding, for accord in the meaning of the words Encouraging comparison-asking that similarities and differences be noted Encouraging description of perceptions-asking the client to verbalize what he or she perceives Encouraging expression-asking the client to appraise the quality of his or her experiences Exploring-delving further into a subject or an idea Focusing-concentrating on a single point Formulating a plan of action-asking the client to consider kinds of behavior likely to be appropriate in future situations General leads-giving encouragement to continue Giving information-making available the facts that the client needs Giving recognition-acknowledging, indicating awareness

 Making observations-verbalizing what the nurse perceives Offering self-making oneself available Placing event in time or sequence-clarifying the relationship of events in time Presenting reality-offering for consideration that which is real Reflecting-directing client actions, thoughts, and feelings back to client Restating-repeating the main idea expressed Seeking information-seeking to make clear that which is not meaningful or that which is vague
Silence-absence of verbal communication, which provides time for the client to

put thoughts or feeling into words, to regain composure, or to continue talking Suggesting collaboration-offering to share, to strive, and to work with the client for his or her benefit Summarizing-organizing and summing up that which has gone before Translating into feelings-seeking to verbalize clients feelings that he or she expresses only indirectly Verbalizing the implied-voicing what the client has hinted at or suggested Voicing doubt-expressing uncertainty about reality of the clients perceptions Non-therapeutic communication In contrast there are many nontherapeutic techniques that nurses should avoid. These responses cut off communication and make it more difficult for the interaction to continue. Responses such as Everything will work out or Maybe tomorrow will be a better day may be intended to comfort the client, but instead may impede the communication process. Asking why questions (in an effort to gain information) may be perceived as criticism by the client, conveying a negative judgment from the nurse. Many of these responses are common social interaction. Therefore, it takes practice for the nurse to avoid making these types of comments. Nontherapeutic communication techniques: Advising-telling the client what to do Agreeing-indicating accord with the client

 Belittling feelings expressed-misjudging the degree of the clients discomfort

Challenging-demanding proof from the client Defending-attempting to protect someone or something from verbal attack Disagreeing-opposing the clients ideas
Disapproving-denouncing the clients behavior or ideas

Giving approval-sanctioning the clients behavior or ideas Giving literal responses-responding to a figurative comment as though it were a statement of fact
Indicating the existence pf an external source-attributing the source of thoughts,

feelings, and behavior to others or to outside influences Interpreting-asking to make conscious that which is unconscious; telling the client the meaning of his or her experience Introducing an unrelated topic-changing the subject Making stereotyped comments-offering meaningless clichs or trite comments Probing-persistent questioning of the client Reassuring-indicating there is no reason for anxiety or other feelings of discomfort Rejecting-refusing to consider or showing contempt fopr the clients ideas or behaviors Requesting an explanation-asking the client to provide reasons for thoughts, feelings, behaviors, events Testing-appraising the clients degree of insight Using denial-refusing to admit that a problem exists

Phases of nurse-client relationship

The ability of the nurse to engage in interpersonal interactions in a goal-directed manner for the purpose of assisting clients with their emotional or physical health needs is the foundation of nursing practice. 1. Orientation phase The orientation phase can last for a few meetings or can extend over a long period, depending on the clients psychopathology, the complexity of the clients problems, the comfort and experience of the nurse, and other variables. As the relationship evolves through a series of ongoing reactions, each participant may elicit in the other wide range of positive and negative emotional reactions. The stirring up of feelings in the client by the nurse is referred to as transference, and the stirring up of feelings in the nurse or therapist by the client is referred to countertransference. During the orientation phase, four important issues need to be addressed: (1) The parameters of the relationship (2) The formal and informal contract (3) Confidentiality
(4) Termination

2. Working phase Moore and Hartman (1988) identify specific tasks of the working phase of the nurseclient relationship: 1. Maintain the relationship 2. Gather further data 3. Promote the clients problem-solving skills, self-esteem, and use of language 4. Facilitate behavioral change 5. Overcome resistance behaviors 6. Evaluate problems and goals and redefine them as necessary During the working phase, the nurse and client together identify and explore areas in the clients life that are causing the problems in living.

The nurse can work with the client to identify these unconscious motivations and assumptions that keep the client from finding satisfaction and reaching his or her potential. The client may use various defenses against anxiety and displace his or her feelings onto the nurse. Therefore in the working phase, intense emotions such as anxiety, anger, self-hate, hopelessness, and helplessness may surface. Behaviors such as acting out anger inappropriately, withdrawing, intellectualizing, manipulating, denying, and others are to be expected. The nurses awareness of personal feelings and reactions to the client is vital for effective interaction with the client. The development of strong working relationship can allow the client to experience increased levels of anxiety and demonstrate dysfunctional behaviors in a safe setting, as well as to try out newand more adaptive coping behaviors. 3. Termination phase Terminated is discussed during the first interview. During the working stage, the fact of eventual termination may also be raised at appropriate times. Six reasons for terminating the nurse-client relationship (Campaniello 1980): 1. Symptom relief 2. Improved social functioning 3. Greater sense of identity 4. More adaptive defenses 5. Accomplishment of goals 6. Impasse in therapy that the nurse is unable to resolve In addition, forced termination may occur, such as when the student completes the course objectives. The termination phase is the final phase of the nurse-client relationship. It is important for the student to work with the client to bring into awareness the feelings and reactions the client may be experiencing in relation to separations. Summarizing the goals and objectives achieved in the relationship is part of the termination process. Reviewing situations that occurred during the time spent together and exchanging memories can help validate the experience for both nurse and client and facilitate closure of that relationship.

A common response students have is feeling guilty about terminating the relationship.

4. The content of process recording Clients initials Nursing diagnosis Goal of interaction: state your goal Description of environment: give a visual description of the setting in which the conversation took place, including noise level and odors. Verbal communication: state the communication verbatim, including what the client states and your responses. List in sequential order and identify therapeutic and nontherapeutic techniques used during the conversation. Identify any defense mechanisms used by the client. Nonverbal communication: include your thoughts and feelings, as well as any facial expressions, gestures, position changes, or changes in eye contact, voice quality and voice tone by the client or yourself Evaluation of interaction: discuss whether the goal was met. What changes would you make, if any, after evaluating this interaction?

5. State the guidelines of process recording

Student-client role-play situations are one method used to familiarize students with the process recording. Interview guidelines may be given explaining how to intervene with a client who gets up and leaves during an interview; what to do if another client interrupts the interaction; what to do if a client asks the student to keep a secret; and why a student should not write the interactions verbatim during the interview. Process recording can be written as short notes during the interaction and rewritten immediately after it.

Total time spent on the recording can be around 30 minutes. The active time can be 20 minutes, with 10 minutes for conclusion and recording. Although video or tape recorders give more accurate recording, the impact of this equipment on the interaction will make an unnatural influence. How to Begin the interview

Effective communication could take place almost anywhere. However, because the quality of interaction, whether in a clinic, ward, or office, depends on the degree to which the nurse and client feel safe and secure, establish a setting that enhances the feelings of security can enhance the helping relationship. A specific location such as a conference room or a quiet part of the unit that has relative privacy but is within view of others is ideal. In all settings, chairs need to be placed so that conversation can take place in normal tones of voice and so that eye contact can be comfortably maintained or avoided. In the orientation phase, students tell the client who they are, the name of their school, and how long and when they will be meeting with the client. The issue of confidentiality is also covered at some point during the initial interview. The nurse can ask how he or she like to be addressed. this question accomplishes several tasks: 1. it conveys respect 2. It gives client direct control over an important ego issue. 3. The nurse may learn something about the client when his or her preference is revealed Once introductions have been made, the nurse can turn the interview over to the client by using one of a number of open-minded statements. Where should we start? Tell me a little about what's going on with you What are some of the stresses you have been coping with recently? Tell me a little about what has been happening in the past couple of weeks.

Perhaps you can begin by letting me know what some of your concerns have been recently. Tell me about your difficulties.

Tactics to avoid The nurse should avoid some behaviors: Do not argue with, minimize, or challenge the client Do not praise the client or give false reassurance Do not interpret to the client or speculate on the dynamics of the client's problem Do not question the client about sensitive areas Do not try to "sell" the client on accepting treatments Do not join in attacks the client launches on her mate, parents, friends, or associates Do not participate in criticism of another nurse or any other staff member

6. Nursing responsibilities Before 1. Inform the client of the activity a day before the interaction 2. Establish a setting that enhances the feelings of security 3. Chairs need to be placed so that conversation can take place in normal tones of voice 4. Prepare and gathers the materials to be needed

During

1. Remind the client again of the planned activity on the day itself 2. Students tell the client who they are, the name of their school, and how long and when they will be meeting with the client. 3. The issue of confidentiality is also covered at some point during the initial interview. 4. The nurse can ask how he or she likes to be addressed 5. Once introductions have been made, the nurse can turn the interview over to the client by using open-ended statements 6. The nurse should avoid some behaviors

After 1. Acknowledge the client's presence and extend your gratitude to the client 2. Do aftercare 3. Do the documentation of process recording

Book Sources: Psychiatric-Mental Health Nursing; 4th and 5th edition; Sheila L.Videbeck Foundations of Psychiatric Mental Health Nursing; 2nd edition; Elizabeth M. Varcarolis Psychosocial Nursing; Theory and Practice in Hospital and community Mental Health; 3rd edition; Frances Monet Carter,R.N., Ed.D. Basic concepts of Psychiatric-Mental Health Nursing; 5th and 7th edition; Louise Rebbaca Shives, Ann Isaacs Psychiatric Mental Health Nursing Concepts of Care; 2nd edition; Mary C. Townsend A Guide to Mental Health and Psychiatric Nursing; 2nd edition; RSreevani Principles of Psychotherapy: Promoting Evidence-Based Psychodynamic Practice; 3rd edition; Irving Weiner, Robert F. Bornstein The Beauty Therapy Fact File; Susan Cressy