REMOTIVATION PROCESS: PROGRESSIVE · PDF fileChapter Four..The Exploration Module – An Introduction Understanding Decreased Motivation ... Environmental factors

Carmen Gloria de las Heras, MS, OTR

Veronica Llerena, MS, OTR/L

Gary Kielhofner, DrPH, OTR, FAOTA

The Model of Human Occupation Clearinghouse

Department of Occupational Therapy

College of Applied Health Sciences

A User’s Manual for

REMOTIVATIONPROCESS: PROGRESSIVEINTERVENTION FORINDIVIDUALS WITHSEVERE VOLITIONALCHALLENGES(Version 1.0) Copyright 2003

Version printed 2003

Carmen Gloria de las Heras, MS, OTR

Veronica Llerena, MS, OTR/L

Gary Kielhofner, DrPH, OTR, FAOTA



College of Applied Health Sciences

A User’s Manual for

REMOTIVATIONPROCESS: PROGRESSIVEINTERVENTION FORINDIVIDUALS WITHSEVERE VOLITIONALCHALLENGES(Version 1.0) Copyright 2003

Version printed 2003

Copyright 2003 by the Model of Human Occupation Clearinghouse, Department of Occupational Therapy, College ofApplied Health Sciences, University of Illinois of Chicago, and UIC Board of Trustees. All Rights Reserved.

This manual may not be reproduced, adapted, translated or otherwise modified without express permission from theMOHO Clearinghouse.

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Remotivation Manual Version 1.0

TABLE OF CONTENTS

Introduction ......................................................................................................................................4

Chapter One

Theoretical Background.

Clinical Origins and Research ..............................................................................................7

What is Volition?................................................................................................................. 8

The Volitional Process and Individual Experience................................................................9

The Environment and Volition............................................................................................10

Volition and the Art of Occupational Therapy...................................................................10

Recognizing Volition ..........................................................................................................11

The Transpersonal Nature of Volition ................................................................................13

Doing with .........................................................................................................................14

Chapter Two…Volition and Continuum of Change

The Exploration-Competence-Achievement Continuum.....................................................19

What is Exploration? .........................................................................................................19

What is Competency? ....................................................................................................... 21

What is Achievement?....................................................................................................... 22

The Volitional Questionnaire .............................................................................................23

The Volitional Questionnaire and the Continuum of Change.............................................24

Chapter Three…. The Remotivation Process

What is the Remotivation Process? ................................................................................... 29

Who Administers the Remotivation Process? .....................................................................32

Assessment and Re- evaluation...........................................................................................33

Using the Remotivation Process: The importance of theory and reasoning........................33

Direct and Indirect Services...............................................................................................34

Version 1.0 Remotivation Manual

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Chapter Four…..The Exploration Module – An Introduction

Understanding Decreased Motivation............................................................................. 37

What is the Exploration Module? .......................................................................................38

Pre-requisites for Applying the Module: The Evaluation Process........................................38

Micro and Macro Realities .................................................................................................39

Checking Procedure and Progress of the Exploration Module: Use of the VQ...................40

Chapter Five….. The Exploration Module Stages and Strategies

Case Example – Lydia.........................................................................................................44

Chapter Six…..The Competency Module

What Are Goals And Objectives Of The Competency Module?.........................................71

The Competency Module: Stages, Goals, and Strategies ....................................................73

The Competency Module Stage 1: Internalized Sense Of Efficacy .....................................74

Provide Physical Or Emotional "Accompaniment" In New And Challenging Situations ....74

Facilitating Skill Learning ...................................................................................................74

Facilitating the learning process.........................................................................................75

Introduce The Counseling Process And Use Of Feedback..................................................75

Recommended Assessment Tools for the Competency Module Stage1 ............................. 75

The Competency Module Stage 2: Increased Challenges And Responsibilities Within Meaningful Roles................................................................................................................76

Change Is Often Disorderly: Allowing For Moments Of Reflections ..................................77

What Happens To Clients During “Moments Of Reflection?”............................................77

What To Do During Moments Of Reflection......................................................................77

Continuing the Counseling Process Furthering Insight Through More in Depth Analysis and Questions ...........................................................................................................................78

Recommended Assessments For The Competency Module Stage 2....................................80

Case Example: Michael..................................................................................................... 81

Chapter Seven….The Achievement Module

Goals and Objectives of the Achievement Module ............................................................98

Reflection Moments and Moving Towards Achievement ...................................................99

What Strategies do Therapists Use in the Achievement Module?.....................................100

Advising ...........................................................................................................................100


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Giving Feedback...............................................................................................................100

Identifying Information and Resources ............................................................................101

Stepping back...................................................................................................................102

What are Natural Alternatives to Therapy?......................................................................103

Case Example: David........................................................................................................104

Progress through Competency .........................................................................................106

Achievement Module: Autonomously Choosing Courses of Action................................. 108

Achievement Module: Continuing to Learn Critical Skills ................................................109

References........................................................................................ 111


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INTRODUCTION

This manual describes the Remotivation Process, a strategic intervention process for people with impaired volition. It begins with an overview of the theoretical and clinical background of the Remotivation Process, followed by brief explanations of the general constructs upon which the process is based. These include the constructs of volition and the notion of a volitional continuum. The manual then explains each phase of the Remotivation Process. The Remotivation Process can be broken down into three broad general phases – Exploration, Competency, and Achievement. Each phase implies different levels of volition in individuals, and interventions are structured accordingly. Phases are broken down into more specific stages and steps to guide interventions. The manual details all of these with the aid of case examples.


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CHAPTER ONE

Theoretical Background


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CHAPTER ONE THEORETICAL BACKGROUND

Clinical Origins and Research The Remotivation Process was developed and clinically studied by Carmen Gloria de las Heras over a period of years. The process was created in response to a lack of well-developed intervention strategies aimed at people with very low volition. Low volition is reflected in an obvious decrease in the motivation to act on the world, and the tendency in the past has been to dismiss such persons as unreachable.

Motivation can be affected by a myriad of physical and mental illnesses as well as life experiences. Though some motivational problems may resolve themselves without the need for intervention, the principles put forth in this manual and the Remotivation Process guidelines for environmental management can facilitate the healing process. This allows individuals to recover from motivational problems more quickly. In certain instances, such as disabilities affecting the central nervous system, the decrease in motivation is pronounced and enduring (de las Heras 1996, 1999). De las Heras examined motivation in cases of chronic schizophrenia, profound mental retardation, dual diagnosis, dementia, and other instances where the effects on motivation were most pronounced. Based on literature reviews of treatment approaches, personal observation of individuals, and careful study of environmental influences, de las Heras began to develop strategies for interventions in volition. Her work is guided by the Model of Human Occupation (MOHO) (Kielhofner, 2002).

Using MOHO together with first person accounts of direct and indirect experiences with such profound illness, de las Heras began to piece together a picture of the process of recovery from a state of decreased motivation and how this process could be facilitated through clinical intervention. The Remotivation Process details this clinical intervention. The process is based on the idea that individuals move through a continuum of volition that can roughly be broken down into three phases:

Exploration Competency Achievement

These phases correspond to a developmental sequence identified by Mary Reilly (1974) in examining the emergence of play behavior. Kielhofner (2001) uses these phases to describe a continuum of occupational change. This manual examines this continuum of change with a special emphasis on the volitional process involved.


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The Remotivation Process consists of a collaborative work between the individual and the

therapist in relevant environmental contexts. This process consists of important elements such as: The clinician’s understanding of the subjective experience of the client Appropriate management of physical and social environments

A reconnection with the world through a gradual increase in the client’s sense of self-worth, effectiveness, and belonging.

MOHO provides the theoretical foundation necessary for understanding the experiences of persons with severely decreased motivation. MOHO presents an explanation of volition, how it manifests itself in individuals, and its relationship to the environment. From MOHO, we draw a detailed vision of how a person’s reconnection with the world is possible through skilled use of environmental elements and environmental management.

The following sections review some of the theoretical concepts underlying the Remotivation Process.

What is Volition? This section will briefly overview the concept of volition and how it guides the Remotivation Process. This discussion is intended as an introduction to volition. In addition to A model of human occupation: Theory and application, 3rd Ed. (Kielhofner, 2002) therapists who are not already well versed in the concept of volition should consult additional references.

Volition is a central concept in the MOHO. Volition, or the motivation for occupation, at its most basic level, appears as the innate need for action in every individual. All humans are drawn to act on the world. Eventually, volition may guide actions and choices. Thus, volition, which drives us to act on the world, can eventually facilitate self-organization, guiding how we understand ourselves.

A wide array of influences shape volition so that every individual demonstrates a unique configuration of the need to act and the way that need is expressed. These include:

Physical states Thoughts and feelings Environmental factors

Three components make up volition: personal causation, values, and interests. Personal causation refers to the belief in one’s ability to be effective. Values refer to individual convictions and a sense of obligation, which give meaning to

occupations. Interests refer to individual preference or attraction towards certain things.

Volition depends on how we view ourselves as effective in the world and in any given situation, the kinds of things or situations that attract us, and those that we find gratifying (Kielhofner, 2002).

Moreover, volition is an ongoing process wherein one experiences occupations, interprets the experience through the process of reflection, anticipates further experiences based on this reflection and learning, and finally chooses activities and occupations based on the experience anticipated. This basic process is fundamental to volition and to volitional change. It is through new choices and new experiences that lead to new interpretations of oneself and one’s environment that volition is altered. The therapist using the Remotivation Process is always working to support and


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enhance this volitional process. The Remotivation Process calls attention both to how one can facilitate the process and how one can influence the process.

The Volitional Process and Individual Experience As noted, volition implies a conscious choice expressed through occupational behavior. Thus, volition depends on cognition and can be altered with varying cognitive abilities. However, all individuals, regardless of cognitive abilities, have volition. The volitional process helps establish a sense of living in the world and a continuity of one’s experiences in the world, regardless of such abilities. Individuals with cognitive impairments still experience volition in the feelings derived from their experiences in the world.

Some individuals may experience volition only through immediate feelings of comfort, without moving to a level of interpretation but still, in a simpler way, reaching a level of understanding of what they feel. Others may experience it more like the volitional process describe above of experiencing, interpreting, anticipating, and choosing occupation.

Therapists need to recognize the way in which the volitional process manifests itself in all individuals. Intervention should be aimed at developing the most positive feelings of volition an individual can experience. The volitional process is further explained in Example 1 below.

Example 1: The Volitional Process Volition is an ongoing process and determined by what has been learned from past experiences. A child may engage in a game of baseball for the first time and discover that he is a fast runner and has a natural ability for hitting and catching the ball. This child may learn to anticipate the joy in playing baseball and to seek more opportunities to play baseball. Another child similarly introduced to baseball may discover that, try as he might, he cannot make contact with the ball at bat and that he often trips over his own feet when he runs. For this child, baseball and other sports may be humiliating experiences to be avoided in the future. A third child confined to a wheelchair may not ever be given the opportunity to play baseball. This child may have a narrowed range of experience in which to base occupational choices.

As mentioned, volition involves making judgments and interpretations of how people interact with the world. Each person’s volition will be a function of the kinds of cognitive processes of which he or she is capable. Individuals with cognitive impairments will make simpler judgments and interpretations and may show volition through straightforward expressions of pleasure or displeasure. It is important to recognize that while cognitive impairments may influence the nature of a person’s volition, the basic human need for action that expresses what the person feels capable of and finds enjoyable and meaningful still remains. Thus, while two persons with differing cognitive abilities express volition in very different ways, volition is nevertheless still important for both. A man with mental retardation whose day is structured for him at a sheltered workshop and a group home may still demonstrate many aspects of volition. He can express what tasks he prefers at the workshop, identify who his favorite housemates are, and choose what he likes to eat for dinner. He can also use these preferences to guide his activity choices. A social and physical environment that facilitates this process by providing opportunities to make and act on choices is critical. Thus, environmental factors also influence volition


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The Environment and Volition The most important tool that occupational therapists have is the environment. The volitional process is inextricably linked to environmental factors. Sameroff (as cited in Kielhofner, 1995) states, “The environment is so intimately linked with how the human system is organized and behaves that some theorists see it as “part of the organism” (p.91). A recent study by Jonsson et al (2000) underscores that motivation is often a combination of inner desires and convictions and external demands, supports, encouragement and so on. Consequently, the concept of volition underscores that motivation is always a function of the dynamic interaction between the person’s inner thoughts and feelings and external conditions in the environment. An anxious person in a supportive and encouraging environment will be differently motivated than an anxious person in a threatening and unresponsive environment.

Not surprisingly, individuals seek out and attempt to shape environments favorable to their own volitional characteristics. These environments, in turn, influence what people will choose to do and how their volitional thoughts and feelings evolve.

Understanding how individuals interact with their environments is crucial to occupational therapy. Occupational therapists using the Remotivation Process must become especially proficient at managing external circumstances to facilitate the volitional process in individuals with lowered volition. Example 2 illustrates possible ways in which the environment and volition interact.

Example 2: Occupational Behavior Emerges from the Interplay Between the Individual and the environment.

Looking once again at the three boys in the baseball scenario, we can identify environmental elements that may shape the boys’ future actions with regard to sports as well as their understanding of themselves and their attributes. The reactions of their peers, parents, and coaches to their performances would play a role. Similarly, the materials and rules of the game may influence the overall experience of the game. Allowing extra strikes at bat, using a slow pitching style, using a larger ball and lighter bat, and using a T for batting are adjustments that may encourage and reduce the demands while supporting the possibilities for success. Finally, the boy’s feelings and thoughts about his ability to bat may change from generally confident during practice among a small group of supportive, familiar people to filled with doubt and anxiety during his very first actual game among a larger crowd of unfamiliar spectators.

Volition and the Art of Occupational Therapy Occupational therapy has long recognized the need to incorporate meaningful activities into the therapeutic process. Kielhofner (1983) addresses the question of how this process is managed, highlighting the orchestration of “meaningful activities” as one of the “most important challenges to occupational therapy” (p. 297). In response to this challenge, Kielhofner stresses the importance of weaving together a myriad of factors in the creating of meaning.

The meaning of anything is the impact or change it warrants in the perceiver’s framework of knowing about the world. Thus, the meaning of an activity is in part determined by a person’s accumulated experience and the way in which it predisposes the person to attribute significance. Simultaneously, external context is a powerful determinant of meaning….Thus behavior is never


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simply behavior per se, but a part of an action sequence belonging to some type of event, whether a friendly greeting, business encounter, social occasion, or religious ceremony (p. 298).

Kielfhofner asserts that occupational therapists must concern themselves with the human experience of meaning within contexts This differentiates occupational therapy practice from a purely scientific, prescriptive approach. The art of occupational therapy thus necessitates a combination of crucial elements. These include:

An appreciation of each individual’s subjective experience An awareness of the variations of experience within contexts (physical, social, cultural, etc) Flexible interventions that operate harmoniously within different individual realities

Thus, when considering an individual’s volitional development, the occupational therapist asks not only what the individual’s interests and values are but how, when, why, and with whom they are expressed.

Recognizing Volition An important underlying skill all therapists need is the ability to recognize volition in all individuals, regardless of skill level, impairments, or abilities for verbal expression. In persons with lowered volition, the kinds of behaviors indicative of volition may be subtle and require careful attention by the therapist. The following examples illustrate this point.

Example 3: Facilitating the Emergence of Volition A baby was born in rural Nicaragua. He had cerebral palsy and was blind and unable to speak. This child was limited in his ability to act on the world. His communication with others consisted of crying when he was displeased and smiling when he experienced pleasure. Moreover, this child was born into a family who had little access to health care, few economic resources, and many other children to feed. He was confined to a hammock and lucky to have basic needs, like hunger, met. Though he often cried and fussed his mother rarely had time to attend to him. On the other hand, he had an eight-year-old sister who was very fond of him. She spent time rocking his hammock because she saw that he laughed when she did this. She noticed that the breeze calmed him when she opened the window. She enjoyed singing to him and using him as the baby when she played house with other children. The child’s responses - smiling, laughing, and calming down- were indications of his volition. During his first two years of life, he learned to recognize his sister’s voice and to anticipate play at a very basic level. He smiled and increased movements of his arms and legs when he heard her voice. Thus, the kinds of environmental factors that surround an individual can influence the development of a volitional process in that individual and the extent to which he or she will experience a sense of control over interactions with the environment. Without knowing it, the baby's sister was facilitating his positive volitional experiences.

Example 4: Deciphering Volition From Behavior and Life History Clues Another example is of an 85-year-old woman with dementia living in a nursing home whose motor and processing skills were so compromised that the only voluntary


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movement she could do was slowly move her head to focus momentarily on an object. However, though she was unable to speak, she cried when the television was turned on, made loud sounds of protest when dressed or fed, but sat quietly when others were in close proximity to her. Looked at carefully, these actions express likes and dislikes and give clues as to where meaning stems from in this woman’s life. These actions are given additional significance when we understand that this woman, in her past, valued being active and making decisions, running a home with three children and working as a teacher. Her interests included dancing and gardening. In the past, her volitional process may have led her to plan interesting outings for her school class or visit garden centers. Currently, however, she is dependent on others to achieve any satisfaction in her daily life. Appropriate intervention for this woman would involve arranging elements of her environment. Some examples include decorating the room with flowers and plants, playing soft music, reading her stories, having her look at gardening pictures, or spend time in a garden. As these activities are introduced, the woman’s responses should be noted for indications that they are enjoyable for her. Time spent each day engaged in these activities can be gradually increased. In this way, the woman, despite her inability to move on her own, might be re-introduced to meaningful activities in her daily life and regain a sense of connection with her environment and herself.

Therapists must become experts at recognizing volition in individuals with varying degrees of abilities. This manual describes a therapeutic approach that is appropriate for individuals who have lost or never adequately developed a volitional process. It aims to help therapists both recognize indications of volition and assist individuals in developing volition. As mentioned, volition is influenced by physiological states, as well as thoughts and feelings. Conditions that affect volition may be transient such as a mild illness, or they may stem more severely disabling and permanent conditions that have more lasting effects. Disease can affect volition in a number of ways:

• Disease alters the underlying desire for action that is based on the nervous system. Extreme depression, for example, can interfere with the basic desire for action

• Disease alters thoughts and feelings that are part of the volitional process. This can occur when disease or trauma alters mood states or alters cognition, such as in cases of traumatic brain injury or schizophrenia. It may also happen when disease of trauma takes away abilities, interferes with enjoyment, and otherwise interrupts how one experiences and interprets action in the world. A person adjusting to becoming quadriplegic may limit the amount of time spent socializing with friends or visiting favorite places because of the amount of effort such activities now require. As repeated attempts to socialize with friends in these places are met with frustrating consequences, the activity loses its appeal to the individual and can eventually lead to a reexamining and redefining of interest and values

• Extreme disease or trauma places extreme limits on volition, necessitating some alteration of the disease before remotivation can begin. For example, a person with

brain injury who is semi-comatose or very disoriented will need to be medically

stabilized and extreme symptoms will first need to be managed. Similarly, a person with extreme depression may need to have the effects of medication work before beginning Remotivation. A final consideration is knowing how long to wait for medical intervention to attenuate disease and to begin Remotivation. This is always


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a matter of clinical judgment. Sometimes, it is a trial and error process guided by when the person is able to respond (in the most basic ways) to circumstances in the environment created by the therapist

The Transpersonal Nature of Volition As already noted, one’s motivation to act on the world is inextricable from the environment. What one feels at any given moment - excitement, boredom, frustration - is a function of both volition and characteristics of the environment. In the Remotivation Process, special attention is given to the social characteristics of the environment. Individuals can learn or relearn ways of enjoying participation in meaningful activities through the interaction with others in their social sphere. These others validate their volitional experiences. Because others in the social sphere play such a critical role in shaping volition, it can be described as having a transpersonal nature. In other words, volition is socially constructed. This aspect is especially apparent when considering individuals whose volition is significantly impaired. In such situations, individuals may need to rely more heavily on others to affirm their realities than on internal aspects.

Like all other environmental aspects, the social sphere can provide support, demands, opportunities, and constraints for individual’s actions, which in turn impacts volition. An individual with very low volition may benefit from constant supports in the social environment that reaffirm his/her worth as an individual and his/her effectiveness to act on the world. The social environment influences how one sees the world and his/her self. Social messages can convey to individuals that they are competent, that they are appreciated, and that they have the power to influence their own circumstances. Likewise, social messages may communicate to individuals that they are inferior because they have a disability, that they are fit to perform only the simplest of tasks, or that they are unable to make decisions about their own lives. The inner characteristics of individuals are often comprised of what they see reflected about them by the outside world.

Individuals may come to see only their ineffectiveness and experience lowered volition. The ability to recognize other positive aspects in themselves is lost. To counteract such a state, the social environment around the individual can be managed to increasingly provide validation of an individuals’ self-worth. Gradually with continuous and normalized validation, individuals may begin to internalize these positive messages and begin recovering a volitional process.

The Remotivation Process outlines strategies by which occupational therapists can facilitate such a recovery. It begins with the most basic validation of the individual and his or her interests and values and gradually invites more and more active involvement from the individual.

Intervention strategies that make use of the social environment for validation include providing supports for developing and pursuing interests, creating opportunities for developing competence, and establishing ways to feel connected to a larger group. Such strategies are incorporated in accordance to each individual’s level of volition and needed support. The following example illustrates what is meant by the transpersonal nature of volition.

Example 5: The Transpersonal Nature of Volition A man arrived at a community-based rehabilitation center. For 15 years the man had lived with his overprotective mother. Because she was so fearful of the world and other people, she severely limited his experience of the world and taught him to fear it as she did. Consequently, this man developed a catastrophic sense of himself in the world and a deeply rooted fear of people. He reacted aggressively to people who were different


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than him, who acted in unfamiliar ways, or who expressed opinions that were strange to him. The center offered individuals a safe environment in which to explore their own capacities through involvement in projects and interaction with others at a level appropriate to each individual’s needs. In this environment, he began to gradually know more about how the world of other people. Still, for a period of time, his personal causation, as scored by the Volitional Questionnaire (VQ), (de las Heras et al 2003) was only acceptably demonstrated when he did house cleaning for the center, a familiar chore that he had also voluntarily done at home despite his mother’s objections. It took three years for him to develop realistic expectations of others and to recognize the opportunities in novel situations. He needed constant support from peers and safe opportunities to explore novelty.

This example illustrates how decreased volition can develop when there are continuous and severe deficits in the amount of arousal and the demands an individual encounters in the environment. The culture of the man’s home managed to curtail his experience of the world so that he only saw others as harmful and bad. Because these misconceptions about other people were so deeply ingrained, the effects were hard to reverse. This example also illustrates how volition contains a transpersonal element. Without a positive experience of this transpersonal element, the individual feels at odds or disconnected with the world and a sense of identity.

Doing with Doing is a process of investigating, trying out, and gaining evidence of one’s capacities for experiencing, responding, managing, creating, and controlling. It is through such action with feedback from both non-human and human objects that an individual comes to know the potential and limitations of self and the environment and achieves a sense of competence and intrinsic worth (Fidler & Fidler, 1983, p.269).

One important consideration emphasized by de las Heras in applying the Remotivation Process is the distinction between “doing for” or “doing to” the individual and “doing with” the individual. The individual must gain a sense of his or her active participation in the world. The therapist must strive to understand the individual’s reality and provide appropriate opportunities and support for the individual’s own rediscovery of a sense of self. A sense of competence is similarly acquired. According to Fidler and Fidler (1983), competence emerges from a combination of one’s actions on the world and having those actions verified by others.

“Doing with” the individual can take many forms. In all of these, the therapist’s role is to become a partner to the person, validating and reaffirming the individual’s own volitional experience. "Doing with" always implies sharing. The following are examples of "doing with".

• Physically supporting. At one end of the continuum, “doing with” may mean the

therapist is doing most of the actions within a giving context of participation. For example, a therapist can sit beside a person and put together an album of photos of loved ones for an individual whose low sense of personal causation prevents her from completing of the activity, though she expresses a desire to see it done. Though the therapist may be the person who performs the physical steps of putting


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the pictures in the album, the communication and attitude the therapist takes toward the individual makes it clear that the she is of primary importance in this activity. This may be done by the kinds of questions or comments the therapist uses, by the therapist’s attempts to facilitate the individual’s active participation to the greatest extent possible, by sharing in the emotions of her special memories, etc.

• Collaboration. On another level, “doing with” an individual may mean joining him

or her in a collaborative project where individuals are working towards a common goal. For example, the therapist accompanies the person in putting together an indoor herb garden with others. The group experiments with ideas on how to plant, where to plant, what materials to use, etc. The therapist’s participation is no different than any other member of the group. He or she makes mistakes or has the similar questions and doubts. A process of negotiation occurs. Such accompaniment reaffirms the individual’s own abilities to participate.

• Indirect support. “Doing with” may also involve a more indirect role from the

therapist according to the individual’s needs. An individual who has reached a very high level of volition, for example, characteristic of the Achievement Module of the Remotivation Process, in general will perform daily routines and occupational roles autonomously. The therapist may advise, coach, or encourage now from a distance. The individual may need only an occasional word or two from the therapist to reaffirm that he/she is performing well or celebrate with him or her the successful attainment of goals.

Within the Remotivation Process, “doing with” the individual results in a natural validation,

reaffirming the individual’s self-worth and ability to perform within an occupational context. “Doing with” can also be an impetus for facilitating an individual’s participation, giving the activity an immediate social significance.

The next chapter describes the volitional continuum from which the Remotivation

Process is based.


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CHAPTER TWO

Volition and the Continuum of Change


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CHAPTER TWO VOLITION AND THE CONTINUUM OF CHANGE

The Exploration-Competence-Achievement Continuum One of the central themes in the Remotivation Process is that volition corresponds to a continuum of change that can roughly be broken down into 3 levels – Exploration, Competency, and Achievement. This continuum builds on what Reilly (1974) in Play as Exploratory Learning refers to as the “exploratory drive of curiosity” (p. 145) observed in play behavior. Reilly identifies three types of behavior characterizing play: Exploratory Behavior, Competency Behavior, and Achievement Behavior. Kielhofner (1995) takes this idea and discusses the implications of such a continuum has for planning treatment. The levels of the Remotivation Process correspond to this continuum, representing progressive volitional development. An overview of the concepts of Exploration, Competency, and Achievement are found below.

What is Exploration? Exploratory Behavior, as observed by Reilly (1974) naturally occurs when an event is very new or different. It is characterized by functional pleasure, engaged in for its own sake, and driven by intrinsic motivation. Persons who have very low motivation to act on the world, or a very low sense of personal causation have lost this innate drive to explore their surroundings. They may benefit best from strategies that seek to facilitate exploratory behavior. Kielfhofner (2002) describes exploration as follows:

Exploration is the first stage of change in which persons try out new things and consequently, learn about their own capacities, preferences, and values. Persons explore when they are learning to do new occupational forms, making role changes, or searching for new sources of meaning. Exploration provides the opportunity for learning, discovering new modes of doing, and new ways of expressing ability and apprehending life. It yields a sense of how well one performs, how enjoyable it is, and what meaning it can have for one's life. Exploration requires a relatively safe and undemanding environment. Since a person who is exploring is still unsure about capacity or desire, the resources and opportunities in the environment are critical (Kielhofner, 2002, p. 148).

An exploratory frame is most appropriate for persons who have lost the most basic motivation to act on the world. Exploration is the base for building personal causation. The Remotivation Process is structured according the continuum outlined by Reilly and Kielhofner. The first phase of the Remotivation Process, The Exploration Module, focuses the development of a sense of pleasure from activity, or engaging in something for its own sake, free from the drive for need-fulfillment. Exploration should always be a positive experience for the individual and the focus should be on the process and not the results.

An exploratory context should contain the following elements:


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The absolution of failure: This is the most important dimension in the exploratory context, and represents for the individual endless opportunities to experiment with success or failure as equally accepted forms of participation. According to Kielhofner (1983), “Exploration is perhaps one of the few situations that has no possibility of failure, since what is found out is not at issue; rather finding out serves as an end in itself” (p. 300). This allows even individuals with a low sense of capacity to be motivated to act.

Enjoyment or pleasure: This aspect emerges from discovering diverse, attractive aspects of

the environment and one’s own abilities in the world. Enjoyment is reaffirmed by the acceptance of failure and by the challenges and freedoms the environment grants.

Discover: This originates from the natural curiosity to explore experiences through objects,

opportunities, and others. It also refers to the process of self-validation that occurs through experiencing the responses from the physical/social environment, reaffirming one’s sense of impact on his/her surroundings. Discovery should result from a combination of a safe and familiar environment and novelty and complexity.

Choice: This refers to the concept of “freedom” provided by the exploratory context. The

exploratory environment provides opportunities to make decisions about what is important and valuable. The concept of freedom does not mean that the therapist abandons the person, leaving them to rely on their own resources. Instead, it refers to structuring the environment to promote the level of stimulation required for the individual to explore and make decisions. Pre-selected and organized materials, culturally meaningful opportunities and past interests, controlled levels of sensory stimulation, guidance and support from a companion, etc are all examples of ways the environment might be structured. An exploratory environment is that which provides the “Structured Freedom” (de las Heras, 1996, 1999) through which the individual develops a sense of control and competence in self-assurance and a feeling of being respected and trusted.

The absence of time limits: The absence of time limits has different aspects. For one, it

implies that the exploratory process is not limited to a session or series of sessions but extends through all the stages of rehabilitation. There will be times, for example, when individuals will participate solely as observers for a brief period (5 minutes or so), or periods where they will take a long time in exploring materials by touch, trying to understand them. Thus, the process is highly individualized and each unique individual will vary in his/her readiness to begin the next phase.

Example 1 illustrates these components of Exploration.

The Absolution of Failure A woman is exploring materials and ingredients for making a cake and accidentally drops and breaks the eggs. The reigning attitude toward the situation should be that the eggs can be cleaned up and replaced. The woman learns that eggs are delicate and should be approached with care, and thus next time will be more careful. The important point is that there will be a “next time” or a new opportunity, and that it is not shameful to need to try again.


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Enjoyment of Pleasure While making the cake, the woman discovers that she is good at mixing and stirring ingredients but that she also needs great coordination to not break the eggs. In spite of everything, she is happy to see that something edible resulted from this mix of things.

Discovery In making the cake the woman confirms that, despite having made mistakes, she is capable of creating a acceptable product that others can enjoy. Also, while the activity is new to her, she works at home with her mother nearby.

Choice While she is making the cake, the woman has the option of using milk or juice. Her mother always used milk. She thought that perhaps juice would be tastier but first consults with her mother. Her mother tells her that she should do whatever she thinks is best, and that using juice might produce a new consistency that they could taste together. The woman decides to use juice and estimates the proper quantity.

The Absence of Time Limits The first time the woman watches her mother making a cake, she gets frustrated and goes back to her room. The next three times, she stays to watch and maybe washes a utensil or two. Her mom tells her where the utensils are and explains each one’s use. One day, she decides to try to work together with her mother but leaves after less than a minute, though her mother was very helpful and understanding, and always accepted her. The day she finally makes a cake, she makes mistakes, incorrectly breaking the eggs, but she realizes that no one got hurt because of this. Moreover, she and her mother both enjoy themselves and she is willing to try to make a cake again and see if next time she will break the eggs correctly.

What is Competency? Reilly (1974) refers to the next level of behavior, competency behavior, as characterized by an awareness of the ability to influence and be influenced by the environment. This behavior is often manifested by an individual wanting to “do it alone and my way” (p. 146), and by practicing tasks to attain mastery. The “wanting to do it alone” attitude transforms the feeling of hope and trust in the environment to self-confidence or self-reliance” (p. 146).

Kielhofner (2002) describes Competency as follows:

Competency is the stage of change when persons begin to solidify new ways of doing discovered through exploration. During this stage of change persons strive to be adequate to the demands of a situation by improving themselves or adjusting to environmental demands and expectations. Individuals at a competence level of change focus on consistent, adequate performance. The process of striving for competence leads to the development of new skills, the


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refinement of old skills, and the organization of these skills into habits that support occupational performance. Competency affords an individual a growing sense of personal control. As persons strive to organize their performances into routines of competent behavior that are relevant to their environment, they immerse themselves in a process of becoming, growing, and arriving at a greater sense of efficacy (Kielhofner, 2002, p. 148).

At this level of behavior, external standards for performance are introduced. These can take the

form of time limits (deadlines), measures that look at the quality of a person’s performance, etc. Practice, skill building, and an overall striving for self-confidence or self-reliance within a given context of occupational performance are elements characteristic of Competency. Individuals seek to improve, attain, and organize skills into habits for consistent and adequate performance. This allows for a growing sense of personal control and a sense of mastery. A purpose or objective for performance may exist beyond the simple pleasure derived from one’s actions.

Thus, intervention at this level may look at the person’s ability to adequately maintain role performance, habit patterns, and set realistic, appropriate goals. In the second level of the Remotivation Process, the Competency Module, individuals learn and test new skills in novel situations with the goal of increasing self-efficacy.

What is Achievement? Reilly (1974) refers to achievement behavior as that which “inherits the acquired learning from the previous two stages. Achievement is linked to expectancies, particularly to the standards of winning or losing” (p. 146). Individuals displaying this behavior now use external standards to evaluate their performance.

Kielhofner (2002) describes Achievement as follows:

Achievement is the stage of change when persons have sufficient skills and habits that allow them to fully participate in some new work, leisure or activity of daily living. During the achievement stage of change, the person integrates a new area of occupational participation into his or her total life. Occupational identity is reshaped to incorporate the new area of occupational participation. Other roles and routines must be altered to accommodate the new overall pattern in order to sustain occupational competence (Kielhofner, 2002, p. 148).

In the Achievement phase, the idea of external standards of excellence to evaluate performance

is even more pronounced and it implies a sense of mastery or a feeling of confidence in one’s ability to successfully meet challenges in a given occupational context and across a variety contexts. A person at the Achievement level of functioning will have developed skills and habits for autonomous engagement within specific routines. Thus, autonomous engagement in appropriately challenging situations is characteristic of this phase.

Intervention at this level may seek to facilitate consistency in integrating skills and habits into successful role behavior or looking at a person’s overall (global) pattern of life. The Achievement Module is the last level of the Remotivation Process. Individuals at this level have acquired the self-efficacy and skills for increased risk-taking. At the Achievement Module level, individuals set and strive toward goals with increasing reliance on social factors to gauge their progress.


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The Volitional Questionnaire The Remotivation Process requires repeated use of the Volitional Questionnaire (VQ) to determine the client’s level of volitional development. While other assessments are important to be used along with the Remotivation Process (as will be discussed below), the VQ is the central assessment. Moreover, research with the VQ has been important in validating and elaborating the underlying construct of volition that is central to the Remotivation Process. Therefore the VQ is discussed here along with the research that has been part of its development.

The VQ was designed to evaluate volitional components through observation of individuals with limited cognitive and verbal abilities. The 16-item VQ allows the evaluator to assess volition by observing the individual or group in a series of activities. Individuals are rated on a 4-point scale. The VQ also includes a section for assessing the environmental context in which activities are performed.

The third edition of the VQ (1997) contains revisions made after the first study by de las Heras and after Rasch analysis was conducted on the original VQ to determine its adequacy in measuring the construct of volition. Items were added and the scoring was refined. The result was a valuable tool that provided a structured method of observation for evaluating volition in individuals who are unable to self-report (Chern et al, 1996).

An analysis conducted by Anderson (1999) on the third edition of the VQ in conjunction with research done by de las Heras with the Remotivation Process indicated a ordering of the VQ items from less to more volition as depicted in the chart below. Items were further revised and a rough ordering of 16 items was produced. The ordering of items corresponds to the three levels of motivation also identified as part of volition (i.e., Exploration, Competence, and Achievement). Based on empirical findings, theory, and practical experience, the most recent 4th edition of the VQ has been developed. The items in this new VQ are shown below in a roughly hierarchical order.

1. Seeks challenges 2. Seeks additional responsibility 3. Invests additional energy/emotion/attention 4. Pursues activity to completion/accomplishment 5. Tries to correct mistakes 6. Tries to solve problems 7. Shows pride 8. Stays engaged 9. Indicates goals 10. Shows that an activity is special or significant 11. Shows preferences 12. Tries new things 13. Initiates actions/tasks 14. Shows curiosity

Thus, shows curiosity is the item requiring the least amount of volition and seeks additional challenges requires the most. The remaining items fall somewhere in the middle.

Less volition

More volition


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The Volitional Questionnaire and the Continuum of Change Discussions on revising the VQ are focusing on a concept closely linked to volition, that of a continuum of progress or change in volition through the general stages of Exploration, Competency, and Achievement. Research indicates a close correspondence between the hierarchy of the items in the VQ and this continuum. Exploration is the first stage that generates experience and learning, leading to the next stage of Competency. Competency, in turn, represents experience and learning that leads to the highest stage - Achievement. The 14 items of the VQ can be divided into these stages in the manner shown on Figure 2.1 below.

The Remotivation Process relies on VQ ratings for indications of when individuals are ready to progress through the steps and stages it outlines. Ranges of expected VQ scores are provided at the end of each step. However, such indications can serve only as general guidelines and may vary according to each unique individual.

The preceding section highlighted aspects of the MOHO and the theoretical principles from which the Remotivation Process stems. The following sections detail the Remotivation Process and the levels, stages, steps, and specific strategies that compose it.


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Figure 2.1: VQ Items and the Continuum of Change

Seeks challenges

Pursues activity to completion/accomplishments

Seeks additional responsibilities

Invests additional energy/emotion/attention

ACHIEVEMENT

Tries to solve problems

Stays engaged

Shows pride

Indicates goals Tries to correct

mistakes

COMPETENCY

EXPLORATION

Initiates actions/tasks

Tries new things

Shows preferences

Shows that an activity is special or significant


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CHAPTER THREE

The Remotivation Process


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CHAPTER THREE THE REMOTIVATION PROCESS

What is the Remotivation Process? The Remotivation Process is a continuum of strategic interventions designed to enhance the motivation to engage in occupations. It is used with individuals with varying skills, abilities, impairments, and illnesses but who share a marked decrease in the motivation to act on the world. Since change begins and is sustained with individual motivation and choice, the Remotivation Process is a key strategy in enabling persons to redevelop functional capacity.

The Remotivation Process is based on the natural continuum of volitional process development through which individuals move. It is a detailed strategy consisting of a series of levels, stages, and steps arranged in a progressive but flexible sequence. Each phase in the continuum of volitional process is addressed in this manual. Emphasis is given to the importance of recognizing each individual’s unique progression through this continuum and using interventions that are matched to the person’s volition both in terms of the person’s unique volitional characteristics and in terms of the person’s volitional status.

The concepts and strategies presented in this manual originally appear in the series of training manuals “Rehabilitation and life: Theory and application of the Model of Human Occupation” (de las Heras, 1999). The Remotivation Process describes stages of volitional progression and details strategies for use by therapists, other health workers, family, or significant others seeking to help individuals develop volition.

Three general, progressive levels of intervention are outlined which roughly correspond to the continuum of change outlined in the previous chapter. These are the Exploration Module, the Competency Module, and the Achievement Module. Each module is then broken down into a series of stages with their own set of strategies. Figure 3-1 shows the sequence of Remotivation Process modules. Table 3-1 provides a general outline of the Remotivation Process and the breakdown of modules, stages of each module, and goals of each module. Later, the manual will elaborate on specific strategies used in each stage to meet these goals.


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Figure 3-1: The Remotivation Process Modules

AUTONOMY

FACING NEW CHALLENGES

EMERGING SELF-EFFICACY EXPLORATION

COMPETENCY

ACHIEVEMENT


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T 3.1 THE REMOTIVATION PROCESS

MODULES STAGES Goals

1. Validation 2. Disposition for environmental

exploration 3. Choice Making

Exploration Module 4. Pleasure and efficacy in action

Facilitate sense of capacity, a sense of personal significance, and a sense of security with the environment

1.Meeting new performance expectations

Competency Module

2. Increasing challenges and responsibilities within roles

Developing a sense of efficacy, reaffirming sense of capacity and sense of control over own decisions and occupational performance

1. Self-monitoring and identification of critical skills

Achievement Module

2. Self-advocacy

Integrating new areas of occupational participation into total life.


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Along with these three levels, a process of environmental management is carried out throughout all levels of interventions. Managing the environment can include controlling the amount of sensory input, the number of people present, the responses elicited by activity in the place, the amount of structure needed for performance, the amount of social support given, the objects present in the room, etc. Therapists skillfully manage environments where individuals can safely explore ways of participation. Familiarity is very important initially. Starting in familiar environments, therapists can begin to manipulate elements to introduce new combinations of activity. Increasing complexity can be introduced through changing more elements and eventually using new, unfamiliar environments.

Because each individual will present a unique volitional configuration, the following indications should be observed by therapists applying the Remotivation Process:

The level and stage at which the Remotivation Process is initiated will vary Levels and stages can be interrelated or overlap at any given moment. This reflects a

volitional continuum that is dynamic, not rigid and invariable. Thus, the Remotivation Process levels and stages are not fixed or predetermined. Instead, progress through these levels and stages depends on the unique interaction of the individual with the Remotivation Process. As previously stated, the VQ is a useful tool for aiding therapists in this dynamic intervention process.

The time it takes to move through each level and stage in the Remotivation Process or through the entire process will depend on each individual’s rate of development of the volitional process.

VQ indicators are mentioned throughout levels and stages. The steps within each stage are to be followed according to signs demonstrated by the individual. The steps and stages of the Module comprise a logical sequence of volitional development based on increased self-confidence in the environment. Nevertheless, steps can be combined or occur simultaneously according to each individuals’ unique demonstration of volitional indicators.

Similarly, the VQ scores assigned to levels and stages are suggestions meant to guide interventions. They should be taken as averages or ranges, not absolutes.

Who Administers the Remotivation Process? The strategies of the Remotivation Process can be adapted to meet these individual needs. The process is guided and supervised by an occupational therapist with a sound foundation in the theory of MOHO. Nonetheless, in application, the Remotivation Process can be undertaken by a range of health professionals and others. For practical reasons, the occupational therapist may not be the sole person implementing the Remotivation Process. Rather, the therapist may often teach elements of the process to interdisciplinary health care providers and lay persons, including family and other caregivers, who are directly involved with the individual who is participating in this process. Throughout this manual, services provided by the occupational therapist will be referred to as direct service. Other services such as training interdisciplinary staff and lay persons to provide services to the client will be referred to as indirect service.

The Remotivation Process may be administered by the person(s) deemed most appropriate, such as the health professional or family member who has the most extensive contact with the individual. The occupational therapist’s role may vary. The therapist may be the person who:


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Administers the process Teaches the process to others Coordinates the administration of the process Evaluates volitional status and the need for environmental intervention Does any combination of the above in conjunction with others Family members and significant others may be best suited for administering the process since

they often have the most continuous contact with the individual in the most relevant environments. Who administers the process may change as the individual progresses. For example, the individual may start off in a clinical setting where an occupational therapist and/or other health workers initiate the process of administering the Remotivation Process. Family members can be introduced to the process in the clinic and may eventually take over its administration at home.

Assessment and Re-evaluation The Remotivation Process requires repeated use of the VQ throughout the entire process to continuously determine the client’s level and characteristics of volition needs. The VQ guides progress through the Remotivation Process intervention. At the end of each phase in the process, VQ indicators and scores are offered as guidelines for knowing when a client is ready to progress to the next phase. While other assessments are important for use along with the Remotivation Process, the VQ is the central assessment.

REMOTIVATION PROCESS:

Details 3 levels of intervention based on 3 levels of volitional process development:

Exploration, Competency, and Achievement An intervention strategy designed to enhance motivation for occupation Based on an understanding of the client’s unique volitional characteristics and development Guided and supervised by the occupational therapist but often implemented by a variety of

persons along with the OT Should ideally be applied in environments that are relevant and meaningful to the client.

Using the Remotivation Process: The importance of theory and reasoning The Remotivation Process stems from MOHO. This manual includes an overview of the MOHO concept of volition. However, a more in depth study and understanding of MOHO and its concepts is essential for proper application of the Remotivation Process. It provides suggestions and examples for moving through a series of steps and stages towards increased volition. Moreover, the Remotivation Process represents a blending of theory and practice in which consistent reasoning is a crucial element. Therapists applying the Remotivation Process use MOHO to guide their observations and evaluations of volition, to understand the individual’s experience of volitional process development, and to maintain realistic and appropriate expectations for progress. While this manual contains many specific recommended strategies for intervention within an overall framework for sequencing intervention, it should not be viewed as a recipe for applying intervention. Instead, it


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should be seen as a set of flexible guidelines for approaching each unique individual’s volitional process according to the principles of MOHO.

MOHO provides a perspective on human motivation for occupation and how this motivation is fed. Occupational therapists applying the Remotivation Process must be aware of this perspective and use it to understand the experiences of individuals who have lost such motivation and the factors that can lead to changes in motivation. Using MOHO, occupational therapists applying the Remotivation Process, must constantly formulate questions aimed at applying the theory to the client’s unique situation and actively problem solve around the issues surrounding an individual’s volitional development. Among questions that may arise are:

What are the factors contributing to a sense of personal causation in the individual? How are an individual’s interests and values related, and does this present any problems? How are environmental factors contributing to or impeding volitional development? What are some ways in which the individual may begin to show competence? Based on the individual’s current volitional status and their configuration of skills and

functioning, at what level is he/she on the continuum of volitional change? How much of the volitional process of experiencing, interpreting, or anticipating might the individual be expected to achieve?

Direct and Indirect Services The role of occupational therapists in the application of the Remotivation Process varies. An occupational therapist in a hospital or clinical setting who maintains continuous and prolonged contact with an individual may find it most appropriate to implement the Remotivation Process through direct care.

However, because the therapist’s direct service represents only part of the client’s time and environmental context, indirect care is always a necessary part of intervention, involving all persons who are part of the individual’s life. The Remotivation Process requires that physical and social environmental factors be carefully managed for the client. Therefore, other staff and other persons who are in the client’s environment often need to be trained in the process to assure its effectiveness. Training others to use the Remotivation Process may involve any of the following:

The occupational therapist trains family members who continue caring for the individual once he or she is home. Involvement of family members and other significant people in the individual’s life is essential given the importance such people have on his/her everyday reality, and consequently the ability they have to influence the individual’s volition

The occupational therapist trains other professionals or support staff. The therapist also plays a role in identifying and assessing individuals appropriate for the Remotivation Process and referring them to professionals trained in its application

Occupational therapists may act as consultants, introducing the process to a variety of community settings and training employers, educators, care providers, etc. in its use


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CHAPTER FOUR

The Exploration Module: An Introduction


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CHAPTER FOUR THE EXPLORATION MODULE: AN INTRODUCTION

Understanding Decreased Motivation One of the greatest challenges family or significant others may face is how to help a loved one find interest in the world and explore. A question frequently asked is “How can I motivate my son or my brother to get out of bed or out of his room to do something else?” The answer is not simple. Motivation is very complex and influenced by many factors including illness processes, personal causation, interests, values, and environmental conditions. Decreased motivation often confounds professional staff and family members because it is unclear where to begin trying to help the person and what to expect.

Often we expect that clients will respond to our verbal invitations to engage in activity. Professionals and family members, convinced that such participation will “do the client good”, can be frustrated when he/she does not respond to such requests. Understanding each client’s micro reality is the key. Whatever other factors (e.g. pathophysiological) are involved, decreased motivation is a product of painful occurrences in a person’s life that have produced perceptions of self and the world based on feelings of loss, confusion, fear, anguish, etc. Time and a patient, supportive environment free from unrealistic expectations are necessary ingredients to facilitate recuperation from such powerful experiences.

Patricia Deegan (1988), an esteemed psychologist and a person with schizophrenia, recounts the story of how she recuperated from the first episodes of her illness. She relates feelings of sorrow and disbelief when she first became aware of her illness. She mourned for the young energetic person she had been, and she feared the future, filled with a sense of hopelessness. She spent months in her parents’ home doing little, but watching television and smoking cigarettes. She recalls an instance during these months when her mother invited her to help bake bread. She rose from her chair, went to the kitchen, and looked at the bread. She immediately returned to her chair and began to cry. The feeling of being incapable of doing anything was so powerful. However, she also describes a time when she felt hope again. She could not recall the exact moment when hope arrived or how, but what she does remember are the people who surrounded her at that time, loved ones who had not abandoned her despite her retreat from the world for months. Their presence and their willingness to be with her through her suffering was significant to her recuperation.

Patricia Deegan’s experience sheds important insight into how much motivation to act can be expected when people are faced with enormous life changes such as acquiring a chronic illness, suddenly losing the ability to walk, etc. These same expectations hold for people who have lived for long periods of time with disabilities in environments where they could not experience feelings of fulfillment, or those who have tried and failed so many times before that they fear once again taking action. The Remotivation Process highlights the importance of the sense of social connection, belonging, and being accepted by others. Within the Remotivation Process, the Exploration Module details strategies for how to facilitate these feelings.


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What is the Exploration Module? The Exploration Module, the first level of the Remotivation Process, is a specific procedure applied when the lowest levels of volition are observed in clients. Such clients appear to experience little pleasure, making few attempts at interacting with the world. Many have a long and/or extreme history of passivity. The Exploration Module intervenes at the most basic level of volition, seeking to elicit initial feelings of curiosity and discovery. The main objective of this first level is to facilitate exploration of objects, activities, people, skills, values, and interests in safe, supportive, and interesting environments.

Though the strategies of this module can be used in combination with other procedures, they generally should be used as the sole strategy until the client has shown some level of occupational engagement with environmental supports. At this point, other strategies may be integrated as initiated by the client's response.

The Exploration Module, shown in figure 4-1, facilitates an emerging sense of efficacy in clients and thus is the foundation for clients’ continued change and development.

Figure 4-1 The Exploration Module in the Remotivation Process

Pre-requisites for Applying the Module: The Evaluation Process In keeping with MOHO, a thorough evaluation of each candidate for the Exploration Module needs to take place before the Module is applied. Table 4-1 shows three information-gathering strategies and outlines ways to obtain relevant information on a client's background and personal history.

AUTONOMY


EMERGING SELF-EFFICACY EXPLORATION

COMPETENCY

ACHIEVEMENT


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Table 4.1: Strategies for Gathering Client Information

STRATEGIES FOR GATHERING CLIENT INFORMATION

Strategy Type of information obtained Suggested tools

Collect information on performance history with an emphasis on volitional process

An understanding of how the client has experienced and understood his/her reality:

• What kinds of past experiences have been significant?

• Who are the important people in his/her life, and how are they important?

• What kinds of occupations and roles has the client been engaged in?

• What are his/her interests? • How does he/she view his/her life

story?

• Occupational Performance History Interview II (OPHI-II) (Kielhofner et al, 1998)

NOTE: The OPHI-II at this stage is usually done with surrogate respondents ( family members, caretakers, etc.)

• Volitional Questionnaire (VQ)

Collect information on the environmental context and assess its impact on client's volition

Kinds of past and present environmental factors that have impacted and impact an client’s volition:

• How does the he/she respond to different sounds, smells, lighting, objects, tasks and people?

• Is there a time of day when he or she is more alert?

• What have past and present routines been like?

• How does he/she react to different people? And so forth.

• Occupational Performance History Interview (OPHI-II)

• Environmental Impact Scale of the VQ

• Interviews with the client and/or significant others

• Informal and formal observation

Gather information from any source on the client's past roles, skills, and performance potential

Sense of each client’s occupational life and volition and unique experience of reality

Insight into: -Appropriate facilitating opportunities

Needs to manage environmental aspects Realistic expectations of performance

Occupational Performance History Interview (OPHI-II)

Micro and Macro Realities De las Heras (1999) uses the term "micro” reality to refer to the reality uniquely experienced by each client. It consists of:

The client’s perception of past and present involvement in occupations His/her experience of physical and cognitive capacities and environmental opportunities and

conditions His/her experience of social and physical aspects of the environment


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His/her sense of capability for future involvement On the other hand, the “macro” reality, according to de las Heras, consists of:

Materials, resources, and information generally available in clients' communities. General or impersonal things that may not be intrinsically motivating to clients, at times

because of a lack of understanding of how these resources may be of use. Clients may more readily be motivated by the feelings and realities created by their families,

homes, and immediate worlds in general. The therapist should consider how “micro” and "macro" realities relate and interact. Examining demands, supports, and expectations for the client in the client's environment is crucial.

Checking Procedure and Progress of the Exploration Module: Use of the VQ The VQ guides the application of the Exploration Module. It helps identify:

Clients for whom the Exploration Module strategies are appropriate At which step clients should begin the Exploration Module When clients are ready to advance within the Exploration Module and take on more

autonomy When it is appropriate to incorporate other strategies along with the Exploration Module

strategies.

Thus, the VQ should be used repeatedly to observe and note changes in clients' volition and determine progress through the Exploration Module.

Throughout this process, therapists must show flexibility, accounting for each client’s unique set of values, functional history, volitional experiences, skill mix, and environmental contexts. Exploration Module strategies are designed to be adapted to these elements in order to meet the unique needs of each client. For clients beginning the Remotivation Process at the Exploration Module, the accumulation of positive experiences in the world is of primary importance. At this point, therapists or other people using Exploration Module strategies must strive for accurate analysis and interpretation of clients' experiences.

Accurate knowledge of each client's volitional status is crucial. After the initial assessment of the client (involving the tools mentioned earlier under pre-requisites), the VQ is the sole tool used to assess the client's progress during the Exploration Module. In later stages of the Remotivation Process, other assessment tools that allow clients to self-evaluate and self-monitor are used, but during the Exploration Module, the VQ provides therapists with the information needed to accurately understand how to facilitate positive experience for clients.


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CHAPTER FIVE

The Exploration Module Stages and Strategies


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CHAPTER FIVE THE EXPLORATION MODULE STAGES AND STRATEGIES

As mentioned earlier, each level of the Remotivation Process contains a series of stages and specific strategies. Table 5-1 provides a brief overview of each of the four stages of the Exploration Module

Validation Environmental Exploration Choice-making Pleasure and Efficacy in Action In the following sections, these stages and specific strategies will be illustrated through a case

discussed in detail.

Table 5-1 Stages and Strategies of the Exploration Module

STAGE THERAPIST STRATEGIES GOALS FOR CLIENTS

Validation

• Significant greeting • Introduce meaningful

elements into personal space • Participate in activities of

interest to client in close proximity to client

• Generate interaction

• A sense of personal significance

• A basic sense of capacity • A sense of security with the

environment.

Disposition for environmental exploration

• Move familiar routines into novel spaces

• Facilitate observation of others engaged in activities of interest

• Invite participation through doing things in the presence of a client

• Exploration of interests in novel contexts

• Self-initiated occupational behavior

• Confidence in trying new things


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Choice making

Similar to Stage 2 • Increase novelty (new settings,

people, etc.) • Increase invitations for

participation

• Continue to develop exploratory feelings

• Initiate a process of self-validation by exploring one’s values and interests through activity

• Reinforce a sense of personal significance and capacity through opportunities to choose activities.

Pleasure and efficacy in action

• Facilitate participation in collaborative projects

• Incorporate feedback • Facilitate a sense of life story

• Reinforce exploratory feelings, the sense of personal significance and sense of capacity through preliminary participation in roles

• Continue the process of self-validation

• Reinforce self-efficacy in decision-making

• Develop an awareness of one’s skills

The Exploration Module's four stages each emphasize a different focus of a detailed

intervention process that can be followed at variable paces and in varying ways according to each client's characteristics. While the stages are often undertaken in sequence, they will overlap and sometimes occur simultaneously. How they are undertaken depends on the client’s needs and responses.

Each stage is further broken down into specific strategies, shown previously in Table 5-1. Throughout this section, the Exploration Module will be illustrated through a case. It tells the story of Lydia, a woman with severe mental illness and her occupational therapist who applies Remotivation Process strategies in her treatment. Below, the background, initial assessments, and family related services of Lydia’s case are discussed. Later, as the stages of the module are discussed, the case will be used to illustrate them.

Lydia, a Smile of Hope: An Introduction

Life History Lydia, a 25 year-old woman, was admitted into a psychiatric hospital directly from her home in

Puerto Rico. Lydia’s mental illness was longstanding. Her parents were poor, uneducated farmers in Puerto Rico, therefore she had not received care in the past. One of Lydia’s sisters had become educated and moved to the U.S. where she made a good income. On a visit home, she was shocked to see the extent of her sister’s deterioration. She insisted that the parents bring her to the U.S. for care. She arranged for Lydia to be seen at a psychiatric hospital and paid for Lydia and her parents to fly to the states. The parents stayed with Lydia’s sister during the 8 months of her hospitalization.


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At home, Lydia refused to eat and had become increasingly emaciated and weak. She weighed only 80 pounds and was unsteady walking. She was admitted to an acute care ward, but overall Lydia was at a much lower functional level than the typical patients.

When Lydia first arrived at the hospital, she was extremely frightened. She had never left home much less flown on a plane. The hospital environment was extremely foreign for Lydia who did not understand any English.

Lydia was diagnosed with Chronic Catatonic Schizophrenia with poor prognosis. She did not speak, but communicated in a very primitive way by making sounds with her mouth closed. Lydia spent the day in her hospital bed screaming and making sounds with her teeth, banging her head on the wall of her room, and rolling on her bed and on the floor. She alternated between rubbing herself with the bed sheets and tossing them off the bed. She did not tolerate any social contact, and would throw pillows at anyone who entered her room. She was placed in a private room because she disrupted other people in the ward.

The psychiatrist immediately began with pharmacological treatment. Additionally, a nutritionist developed a special diet for Lydia due to her malnutrition. Lydia refused to take solid food. Instead, she drank juice with medication and dietary supplements added.

Initial Assessment: Understanding Lydia’s history and present behavior Since Lydia’s occupational performance was very affected by her mental illness, the therapist

decided to wait for the medications to have some effect before directly assessing Lydia. Meanwhile, she conducted a modified version of the OPHI-II with Lydia’s parents in order to get to know Lydia’s occupational history. Lydia had lived all her life with her parents in the country, miles outside the nearest small village. Her family was poor and survived by farming a small plot of land. Lydia’s parents had no formal education and were illiterate. They had strong Catholic religious values. The whole family was very loving and communicated their affection physically. Lydia’s siblings had been educated and all had moved away to towns and cities in order to obtain jobs

As a child, Lydia especially liked physical activities, such as dancing, singing, running, swinging, and playing with water. Her parents noted that Lydia used to smile when she accomplished something important and felt proud of herself, but that this had not occurred for years now. Her mother recalled that Lydia had been a girl with a strong will who clearly expressed what she did and didn’t like to do. This had also changed over time as Lydia became increasingly isolated. Initially, Lydia was shy, but extremely affectionate. However, as a child she began to show difficulties in communicating with others, eventually isolating herself and rejecting physical contact. Lydia was unable to attend school. Over time, her isolation and unusual behavior worsened. Often, Lydia would bang her head on the walls and scream when somebody came into her room. Unable to fathom Lydia’s behavior, her mother became convinced that Lydia was possessed by a demon. Nonetheless, they believed that everything could be cured with love and faith. So they invited many family members and other relatives to pray and visit Lydia to give her affection. As is typical of Latin cultures the relatives demonstrated their affection through physical gestures such as hugging and kissing Lydia. However, the more that they physically approached Lydia, the more she was agitated, eventually becoming aggressive and self-abusive.

As Lydia's parents became more and more unable to control her behavior, they began in desperation to lock her in her room. For the last 5 years, she often spent long periods of time during the day confined to her room. On sporadic occasions when Lydia was in control, she liked being


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outside in the sun, touching the walls of her house as she walked, flipping through magazines, and moving her body while she listened to music.

The therapist also used the VQ as the basis for doing an informal interview with Lydia’s parents. The therapist did this to learn more about Lydia’s volition and how the environment affected it. Through careful interviewing, the therapist ascertained that it was when her mother was washing clothes outside of the house and her father was working in the field that she came out of the house. It was then that she would play with water in the garden, swing, or walk along touching the walls of the house. When the mother was inside of the house, she gave Lydia physical affection and tried to involve her in housework or some other activity. At these times, Lydia would become withdrawn or begin crying. This reaction, along with the fact that she preferred to do things when her parents were “busy doing something”, suggested that Lydia was most motivated when not overly attended or challenged by others.

Despite their confusion and frustration, Lydia’s parents were very concerned about doing what was best for Lydia. They were dedicated to and clearly loved her. They had been suffering for years from seeing their daughter’s pain and feeling unable to do anything to help her. Despite their longstanding difficulties with Lydia, they were eager to learn new things to help their daughter.

As soon as the psychiatric medication began to calm Lydia, the therapist began informal observations. It was clear that Lydia’s volition was very low since she showed none of the behaviors on the VQ. The therapist observed that Lydia’s behavior of rubbing herself with sheets and rolling on her bed seemed to comfort and calm her.

Addressing Lydia’s Environment

Volition changes only though constant interaction with the physical and social environment. So, the therapist began by seeking to optimize the impact of her immediate ward environment and to address what would be Lydia’s long-term family environment.

Historically, Lydia liked activities with gross movement. Moreover, as noted, initial observation suggested that rolling around on her bed calmed Lydia. Consequently, the occupational therapist arranged her room in a way so she could safely move and roll as she wished. The therapist put a mat on the floor close to her bed, so she could roll out of her bed without hurting herself. The therapist also negotiated with nursing staff to bring Lydia’s food to her room, rather than expecting Lydia to eat in the dining room. Finally, the therapist arranged to have the window in Lydia’s room kept open, since she observed that Lydia liked to feel the air flow against her. These measures gave Lydia more tranquility and some space for engaging in actions that comforted her.

The therapist shared with the team and ward staff information she had gained about factors that could help Lydia’s volition. Generally, staff are more reluctant to interact with patients whose behavior is as extreme as Lydia’s, so the therapist aimed to give them ways to see Lydia as a person along with some basic strategies for dealing with her.

Although the therapist was identified as Lydia’s case manager since she spoke Spanish, a nurse was identified who would assure that Lydia’s physical environment was properly arranged. As time went on, this person would also lead nursing staff in carrying out aspects of Lydia’s intervention.

A key factor in successfully informing Lydia’s parents was to consider how they saw the world and their long painful experience with Lydia. For this family, the concept of mental illness was totally new. In much of rural Latin America mental illness is explained as demonic possession or some


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related malady. Since the family understood Lydia’s condition as supernatural in its origin, they had expected that only God’s intercession and their faith could make a difference.

The therapist began by explaining that part of Lydia’s condition included her unusual sensory experiences. She explained how this accounted for Lydia’s compulsion to generate some kind of stimuli (rubbing herself and walking with her hands touching the walls) and her rejection of other sensations such as the physical hugs and kisses. It was also explained that Lydia’s habit of covering her ears with her hands or banging her head when she was overwhelmed with others talking around her was a similar reaction to being over-stimulated. These things were explained to her parents in a simple way using the kind of language they used and reflecting back to them situations and facts they had given in the interview process. The therapist also began sharing with them simple ideas about how occupation and the motivation for occupation develop.

This education helped the parents understand their daughter’s condition in a new way and gave them hope for her. Throughout Lydia’s hospitalization, the therapist continued to meet regularly with the parents, giving them information and instructions as Lydia’s situation unfolded. The next phase for Lydia was the beginning of the Exploration Module, beginning with Stage 1, Validation

Stage 1: Validation Of the four stages of the Exploration Module, Validation is the most basic and may take the most time. The main objectives of the Validation stage are:

• To facilitate a client's sense of personal significance • To facilitate a client's basic sense of capacity • To facilitate a sense of security with the environment

Clients at this stage need to learn new ways of experiencing and perceiving themselves. Recall that often clients have been passive and withdrawn for long periods of time, resulting in a tendency not to believe in their own abilities. They may not show a disposition to initiate changes in themselves.

During the Validation Stage, the therapist approaches clients wherever they wish to be. Therapists must “give consistently” without expecting any external result. Therapists become the means by which clients relate to the external world, whatever form it may take (e.g. one’s bedroom, one’s house, one’s community, one’s culture).

To meet the objective of this first stage, therapists should begin by establishing a significant relationship with each client, one in which the client has a sense of him/herself as a valuable partner. Next, therapists should make use of each client’s personal space by introducing meaningful objects and activity into that space. Then therapists attempt to facilitate increased participation in activities or interests and finally, generate interaction with clients. A client’s personal space will most typically be the room he or she inhabits. For some, personal space may be quite limited. A client, for example, may feel most secure sitting in a specific chair in one corner of a room. Thus, the interaction between client and therapist should begin within that corner. By introducing meaningful objects and activity within this space, therapists hope to increasingly engage clients in their surroundings.

Within the Validation stage are four distinct strategies that are helpful to follow and are based on the transpersonal nature of volition. These strategies are:

• Significant greeting • Introducing meaningful elements into the client’s personal space


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• Participating in activities of interest • Generating interaction

These strategies are outlined in Table 5-2 and will be explained in further detail in the following discussion.

Table 5-2: Validation Strategies

STRATEGY ACTIONS ASSOCIATED WITH STRATEGY

Significant greeting Establish a significant relationship with the client through small gestures recognizing the client's uniqueness and showing appreciation for things that are of possible interest to him/her. Establish trust through consistency and continuity.

Introducing meaningful elements into the client's personal space

Bring objects or activities from the client’s past or that reflect the client’s interests into the client's personal space to strengthen connection. Allow time, space, and flexibility for the client to respond.

Participating in activities of interest.

Accompany client in simple activities of apparent interest. Engage in activities of interest in close proximity to the client.

Generating interaction

Make more direct attempts to engage the client's participation by asking questions, but never demanding a response.

Significant Greeting Greeting the client by using his/her name, with a smile, or with some acknowledgement of his/her interests, if done consistently, can establish a positive relationship between therapist and client. Therapists should begin every encounter by greeting the clients. This small gesture communicates recognition of the client’s uniqueness as a human being. The statement, “Hello, John, it is good to see you again today,” for example, can convey to John that he is important to the therapist, as well as establish familiarity.

Also, at this stage it is important to establish a sense of trust and continuity. When each encounter draws to a close, the therapist should indicate this and specify when the next encounter will take place and thus provide a sense of continuity. Other information that may help clients trust the reliability and openness of the therapist should also be offered. If one is leaving for the weekend, for example, and will not see the client until Monday, such a break should be acknowledged with the assurance of another encounter in two days.

Along with using clients’ names and being sensitive to their experiences, therapists should comment directly on their interests or values. Objects like photographs of loved ones, books, music, artwork, crafts, and other things clients may have in their personal space (see next section) may


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provide opportunities for this. If a client took pride in being a police officer, for example, a therapist might comment on police work. No expectations should be placed on clients to respond or react. Instead, therapists should simply seek to convey to clients that they are valued and worthwhile. Therapists should remain watchful for any reactions clients do have and learn to interpret them appropriately. These responses may be verbal (e.g., a greeting) or non-verbal (e.g., a slight nod, a glance, a grimace, a smile). It is the therapist’s task to use these signals as clues for structuring the encounters in a way that will assure optimal interaction. Initially, encounters may be very brief and may solely consist of a significant greeting. Therapists again should take cues from clients as to how long to remain in their personal space.

Introducing Meaningful Elements into the Client’s Personal Space Once familiarity has been established through the use of significant greetings, therapists can begin introducing elements that hold meaning or interest for clients into their personal space, whatever forms that space may take. This may mean that encounters take place in a corner of the client’s room, beside the bed, or even under the bed if that is where the client feels most safe and secure. Taking a favorite magazine and placing it next to the client or on the his/her lap, placing a photograph in front of a client, or moving a flower arrangement onto a table beside him/her are all examples of introducing significant elements.

A significant element need not be a tangible object but may also include such things as sounds or music. The therapist may choose to play a tape of music a client likes. Similarly, other sounds like grandchildren’s voices on tape, may be used. Again, no expectations should be placed on the client. Instead, therapists should allow time, space, and flexibility for clients to become comfortable with the encounters and the evolving relationships, keeping in mind that even the simplest of actions require great efforts for many at this stage. Therapists should respect any reactions clients may have to the elements and choose further action accordingly. Therapists should continue to use the strategies of the significant greeting discussed above.

Participation in Activities of Interest to the Client For some, participation in activities may prove a very large step to take. A verbal invitation alone is insufficient and may be perceived as challenging or threatening. Instead, therapists should join in activities in which clients can engage and which are meaningful to them, doing the activities with clients even if these are seemingly very passive like watching television.

Simply staying near the person, providing accompaniment while the person rests or does whatever else he/she pleases can be effective. Another approach might be to participate in activities of known interest to the client near the client even if he/she does not actively participate.

Generating Interaction The approaches mentioned in the previous strategy can be used repeatedly, occasionally

making more direct attempts to invite clients to participate but never insisting. The point is not to force clients into interaction but to convey respect and enjoyment with regards to these activities of known importance to clients. Therapists can also ask for assistance in activities, ask for opinions, suggestions, etc. Appropriate activities can include any number of things and will vary according to


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each client's needs and preferences. They may be passive like reading or listening to music or more active like singing, painting, sewing, etc. If activities of past interest are impossible to do given the space and resources available, appropriate alternatives should be sought. For example, if one’s interest is basketball, magazines or posters about the sport can be incorporated if they seem to please the client.

Interaction between the client and therapist at this stage may remain very simple and does not yet move beyond his/her personal space. The duration of each encounter depends on the client’s reactions. Generally, a span of no more than 30 minutes, 2-3 times a day is suggested. At the end of each encounter, any materials introduced should be relatively near the person. Therapists should verbally acknowledge having enjoyed spending time and sharing an experience with clients.

Once the client begins responding to the therapist’s attempts to involve him/her in participation, a relationship of reciprocity begins to form. When this moment is reached, the therapist may attempt to directly invite the client to participate in activities. This is normally a gradual process in which careful consideration should be given to the activity chosen, the time used, etc. Accepting the invitation, however, marks the client’s first attempt to explore the world of others. Clients at this point may be observers, make take part in activity, may make comments about an activity, or may be involved by helping another with the activity. To facilitate the relationship of reciprocity and mutual involvement, therapists need to be flexible and respectful of the clients’ decisions if they choose not to participate.

By the end of Stage 1, therapists may still need to be very attuned to subtle, non-verbal communication. However, by providing continuous company, by repeating significant greetings, and by accompanying the client in meaningful activity, therapists seek to enhance clients’ abilities to make social connections. In time the therapist and client should be able to build a repertoire of shared experiences that enhance interaction. Reciprocity in the relationship increases, as the client is more consistently involved in the routine activities that happen during therapist-client encounters.

Using the VQ Again, the VQ should be used as a guideline for how to progress through the Exploration Module. By the end of the Validation Stage, clients should begin to indicate the most basic signs of volition indicated on the VQ, such as showing curiosity and initiating actions without hesitation. It is suggested that such indications be present before the client participates in the next stage of the Exploration Module. Returning to the story of Lydia, we have an illustration of the steps and strategies taken in the Validation Stage.

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Lydia a Smile of Hope, Part 1: Validation strategies Because of Lydia’s low tolerance for interacting with others, the therapist began with only 2 visits per day of 5-minute duration. Knowing Lydia’s past interests allowed the therapist to make appropriate statements during the validation process. The therapist began visits by greeting Lydia by name and commenting on Puerto Rico and Latin music. The content and duration of her comments were guided by Lydia’s reaction. For example, Lydia’s mother had explained that Lydia demonstrated discomfort by making sounds with her mouth. Lydia’s silence indicated that she could continue listening.

Sometimes Lydia made sounds with her teeth or threw a pillow at the therapist. Other times she listened. By the end of the first week, Lydia looked at the therapist for the first time. Visits by the


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therapist were always made at the same time. The therapist made clear to Lydia that when visits would happen, linking them to key daily events on the ward, such as breakfast, or after medications were given. Continuity is a very important element in the Validation stage.

Once Lydia’s visual attention to the therapist grew more frequent than her signs of discomfort, the therapist knew that Lydia was experiencing some satisfaction from the visits. Consequently, she increased the time she spent with Lydia. The therapist also began to bring objects that were meaningful to Lydia into her room. These included a small radio and some brightly colored magazines. The therapist placed these objects close to the bed where they were accessible to Lydia.

The therapist kept the same approach in visiting her as before, observing Lydia’s reaction to these objects. At first Lydia only looked at them. However, this indicated that Lydia was at least demonstrating curiosity about them, even if she did not manipulate them. Furthermore, at this point, active participation is not yet expected. Lydia’s first VQ scores shown in Figure 5-1 reflect her low volition.

Rating Scale Key: P= Passive H= Hesitant I= Involved S= Does without Support

Figure 5-1: Lydia’s initial VQ Scores

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S S S S S S S S S S S S S S I I I I I I I I I I I I I I H H H H H H H H H H H H H H P P P P P P P P P P P P P P


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Lydia’s therapist at first turned the radio on very softly and sat on the floor flipping through magazines (as Lydia used to do at home). Throughout this, Lydia would look at the therapist and rock to the rhythm of the music from the radio. She seemed relaxed by the music. The therapeutic routine now consisted of fifteen-minute intervals in the morning and afternoon. The therapist also began to make comments to Lydia about their participation in these activities, adding to the usual comments she employed in her visits.

The routine was continued for two weeks during which the therapist made attempts to change the radio station and pass magazines to Lydia. The first of such attempts were not well received by Lydia, despite constant encouraging remarks from the therapist. Lydia threw magazines at the therapist’s head. When this occurred, the therapist simply retrieved the magazines and resumed flipping through pages as before.

The therapist then decided to adhere to the same strategy, but with only one alteration (i.e., changing the radio station). This did not require Lydia’s participation in the same way offering her magazines had. Moreover, Lydia indicated her enjoyment of changes in music by changing the rhythm of her rocking. Lydia was now able to rock to the music for an entire session, looking at the therapist and radio when she wanted the therapist to find a new station with different music. The new volitional behaviors are reflected in Lydia’s second rating on the VQ shown in Figure 5-2.

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Figure 5-2: Lydia’s Second VQ Scores

As the therapist began to better understand Lydia and Lydia learned what to expect of the therapist, their relationship became more fluid. One day, after a month of their meetings, the therapist arrived to find Lydia seated on her bed waiting for her and changing the radio settings herself. This reflected Lydia's ability to volitionally anticipate what was going to happen. It also reflected a growing sense of efficacy on Lydia’s part based both on her trust in another person and her confidence in being able to control her own experiences.

Consequently, the therapist decided to move forward with other activities involving music, because music most elicited Lydia’s desire to act. The therapist chose to sing along with the songs that Lydia picked on the radio while Lydia rocked to the rhythm. One day, as they followed this


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routine, the therapist asked Lydia if she could try finding some music and Lydia passed the radio to the therapist so she could do so. Several sessions included such “sharing” between the therapist and Lydia. Eventually, flipping through magazines was also an activity they shared.

Noting that Lydia appeared to spend more time listening to softer folk music, the therapist decided to try singing to Lydia. She chose to sing a familiar song in Spanish. Lydia began to rock herself and follow the music with her own murmurs. And for the first time, she smiled. As noted earlier, the therapist learning from the OPHI-II based interview with Lydia’s parents that Lydia’s smile meant not only that she was experiencing pleasure but also that she was feeling a sense of efficacy. Singing in Spanish became an important activity to Lydia and one she asked for daily by initiating melodies herself. One day, when the therapist had finished a session with her, Lydia verbally said the word “mas”, which means more. After a month and a half in the Validation Stage, Lydia’s VQ scores were as shown in Figure 5-3. Her score indicated that she was ready to move onto the next stage of the Exploration Module

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Figure 5-3: Lisa’s Third VQ Scores

Environmental Interventions and the Influence of Bodily Experiences It is important to note that, when Lydia was not with the therapist, she still spent much of her

time rolling on the bed and rubbing her body with the bed sheets. This illustrated how important the environment was to elicit Lydia’s occupational performance. The therapist used her experiences with Lydia to educate nursing staff on how to reinforce the work done during Lydia’s occupational therapy session, incorporating important elements like greeting Lydia in Spanish and keeping meaningful objects close to her. Before moving to the next stage of the Exploration Module, two important events intervened. The first was a dental referral for Lydia, and the second, a relocation to a new ward in the hospital.

Lydia persisted in grinding her teeth and making uncomfortable sounding noises with her mouth, but when she began to smile, the therapist noticed that Lydia’s teeth were in extremely bad condition. It appeared that the poor condition of her teeth was causing her extreme pain. After the therapist brought the matter of Lydia’s teeth to the team’s attention, it was determined that Lydia would receive dental treatment at the hospital.


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The therapist worked to prepare Lydia for this treatment by explaining to her the treatment she would receive. She offered to accompany Lydia during her dental appointments and Lydia indicated she wanted this. Thus, the therapist negotiated with nursing to plan Lydia’s appointments so she could be present.

It is important to note that volition is intimately liked with bodily experience. Factors such as pain can interfere with the volitional process. The therapist believed that Lydia’s low frustration tolerance for stimuli she was unable to control and her resistance to activities that involved walking, standing, and continuous combinations of motor actions were related to her chronic pain. After the dental treatment, the psychiatrist decided to move Lydia to a new ward in accordance with the hospital policies and those of the acute service ward. Consequently, it was necessary to begin making appropriate environmental adjustments for the move to be made as smoothly as possible. On the one hand, Lydia had not moved from her room since her arrival at the hospital with the exception of going to the dentist, something that proved a big a big challenge. In the new ward, Lydia would be required to share a room with three other people. She still had difficulty tolerating others talking. The new ward also had higher expectations for functioning. Patients were required to wash daily, keep their clothes orderly, eat in the dining room, and remain relatively quiet. The ward was designed for patients who were “difficult to manage”. Lydia’s occupational therapist talked with the head nurse of the new ward to make arrangements for a volunteer aid to establish the routine of greeting Lydia in Spanish and to appropriately arrange her room. Additionally, she negotiated necessary adjustments for Lydia’s needs and the work that was in progress with Lydia. These were

• Lydia was allowed to eat in her room until she was able to tolerate being in the dining room • In talking with the nurse, the occupational therapist discovered that there was a big, unused

old bathroom in the ward that had a bathtub. The therapist, remembering that Lydia liked playing with water when she was home, decided to try having Lydia use the tub instead of a shower for bathing. Also, the sensation of water on her skin would be less harsh in the tub than in a shower. Lydia would feel more in control of the water in the bathtub than the running water of a shower. Finally, she would be able to stabilize her body in a seated position. The nurse agreed with the decision to try the bathtub with Lydia

• The therapist requested that Lydia be given the bed closest to the window, allowing Lydia to get air and sun as she pleased. She also had the bed placed against the wall so Lydia could support herself when seated. The location and placement of the bed also would give Lydia more privacy when needed

The day Lydia was transferred to the new ward, her parents and the therapist accompanied her. The therapist showed Lydia her new bed and personal space, allowing her to touch the bed and open the window. Lydia spent about ten minutes feeling the bed and rolling on the floor. She did not eat that day, throwing food at the nursing aid and rocking continuously. The therapist, given her extreme sensitivity to environmental conditions, expected her regression.

The two other people sharing Lydia's room were anxious about Lydia's presence. They tried to help her but without success. So, the therapist taught them ways to approach Lydia and how to say a few short, pleasant phrases in Spanish to her.

Lydia spent the first few days on the new ward angrily rejecting any contact with the therapist. The therapist continued to use the familiar routine of greeting Lydia and talking to her


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about Spanish music a few minutes at a time. Once Lydia seemed to attend to her again, the therapist put music on softly and left the radio by her bed. After this, Lydia began responding to the therapist again as before. The same routine done in the old ward was put in place at this new ward and continued for a week as Lydia got adjusted.

At this point with Lydia re-stabilized at her previous level of volition, she was able to move to the next stage of the Exploration Module, developing a disposition for environmental exploration.

Stage 2: Disposition for Environmental Exploration This stage of the Exploration Module reinforces the relationship of reciprocity begun in the Validation stage. The main objectives for this step are:

• Facilitate exploration of interests in novel contexts • Facilitate self-initiated occupational behavior • Facilitate confidence in trying new things

In Stage 2, the client moves beyond his or her personal space and into a novel environmental context, facilitating more exploration. Clients reaching Stage 2 should indicate at least some basic signs of volition, such as hesitantly showing curiosity or initiating actions. Thus, in general, at Stage 2, clients are beginning to feel more connected with their surroundings and more ready to explore the opportunities their surroundings afford. However, they are still very dependent on environmental supports in order to do so. The therapist working with a client at this stage should consider the client’s emerging sense of exploration in providing opportunities. Like Stage 1, Stage 2 consists of different strategies. Stage 2 strategies are:

• Move familiar routines into novel spaces • Facilitate observation of others engaged in activities of interest • Invite through doing things in the presence of the client

These are outlined in Table 5-3 and then further explained in the following discussion.

Table 5-3: Disposition for Environmental Exploration


Move familiar routines into novel spaces

Introduce one change (the setting), allow for exploration, but keep a familiar routine for sense of security amid novelty.

Facilitate observations of others engaged in activities of interest

Expose client to other clients engaging in familiar and significant activities to facilitate new forms of participation and new interests.

Inviting through doing things in the presence of the client

Similar to Validation Stage - ask questions, automatically share parts of activities, or give client ownership of one task.


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Move familiar routines into novel spaces Stage 2 is characterized by the introduction of increasing novelty or change. At this stage the therapist may begin by introducing one change, such as the space in which therapy occurs. This may occur by moving a familiar routine into a new setting, where stimulation will be slightly different and an opportunity for developing exploratory feelings may be facilitated. By keeping the familiar routine, the change is kept manageable and not too overwhelming for the client. The therapist should continue to accompany the client in this routine, offering support as before.

As an example, the therapist, instead of bringing magazines to a client's room for him or her to page through, may invite the client to another room where there are stacks of magazines from which he or she can choose. No expectations should be placed on clients to participate or how long they should remain in the settings. Instead, clients should be free to observe or take part in activities as they feel comfortable. The environments and activities chosen should correspond to what the therapist knows of the client's values and interests. The amount of time spent in the new setting or situation should increase gradually, though flexibility will still be important.

Observation of Others Engaged in Activities of Interest Once the client becomes comfortable with the routine in a new setting, another change may be introduced. For example, the therapist may choose to invite the client to observe others engaged in an activity of interest. These activities can include familiar ones that the client has enjoyed in the past. For instance, if a client enjoys putting together jigsaw puzzles in his or her room, he/she may enjoy a setting where others are putting together a large puzzle cooperatively. Observing others doing this familiar routine may remind the client of his own capabilities for doing the same. Such variations are useful in stimulating curiosity and interest. The client may choose to remain solely an observer in the activity initially. Simply being around others involved in something he/she enjoys can facilitate a very basic sense of belonging and social connectedness. Such a sense, in turn, enhances the developing sense of capacity and personal significance in the client. These opportunities to observe and be among others may also be useful in facilitating more attention to self-care and personal appearance with the goal of raising a sense of capacity. The therapist should gradually increase the exposure to new environments, mixing novel situations with familiar routine in a way that does not overwhelm the client.

Often, clients will need to develop new interests. Therapists frequently encounter clients who can no longer participate in past interests or who are no longer drawn to the same interests. Newly acquired illnesses or impairments or other major life changes may result in this. In such cases, therapists should attempt to determine what elements of past activities of interest attracted the person so as to offer exploration of alternatives for different activities that may have a similar appeal. Attempts should then be made to provide opportunities for the client to observe others in activities within contexts of potential interest to him or her. Such opportunities facilitate adopting new forms of participation or new interests.

Inviting Through Doing Things in the Presence of the Client This is the step at which the client begins to show signs of interest in the new alternatives to familiar routines. Such signs may include spending more time observing these situations, moving closer to


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the area where activity is taking place, smiling, speaking to others involved in the activity, going spontaneously to the place where the activity takes place, etc. At this step, therapists should more enthusiastically promote participation and support whatever attempts are made to participate in activity.

The therapist invites participation through doing, using the strategy discussed in Stage 1. The therapist chooses an activity that is meaningful and interesting to the client and participates in the activity in such a way that the client feels free to observe or join. For instance, a therapist who knows a client is interested in flower arranging may choose to do an arrangement near her. The therapist can involve the client by asking questions like, “Aren’t these carnations beautiful?” or “Could you help me with this?” The client need not answer. By asking the questions, however, the therapist shows an appreciation of the client’s presence during the activity and opens the opportunities for him/her to be more involved. Such questions also convey that the therapist trusts the client’s capabilities to perform different tasks. The therapist might also determine that it is appropriate to give the client ownership of part of the task. This, for instance, may take the form of handing the client flowers to put in the vase or even choosing flowers he/she likes best. Any attempts the client makes to participate should be encouraged and supported.

Again, the amount of time a client spends participating in a new activity may vary from a few moments to a half-hour or more and can change according to the client’s sense of confidence. The therapist should gauge the time that the client is encouraged to spend by carefully observing the client’s verbal or non-verbal indications.

When moving into other contexts, the same approach can be used. Watching how others participate can encourage a client’s own participation. The therapist can assist the client by collaborating with the client on activities or by asking for the client’s collaboration on a given activity. A sense of continuity should be established with these experiences. Allowing the client to take ownership over part of an activity that takes place everyday or following a set schedule for activities can provide this continuity. As always, the client should not feel pressured to participate in any way. Instead, participation and exploration of different activities should be pleasurable and gratifying experiences.

Over time, the client can explore several contexts and activities that have previously been sources of pleasure and enjoyment. The therapist can work with a client to develop a routine based on these experiences. To assure that these experiences remain pleasurable, the therapist can provide the client with a variety of interesting options. Participation in such a variety of activities prepares the client for choice making and the next stage of the Exploration Module.

By the end of Stage 2, clients may begin to show signs of trying new things and increasingly begin to demonstrate interests. They also may demonstrate more curiosity than shown at Stage 1.

The following segment of Lydia’s case illustrates Stage 2 strategies.

Lydia, a Smile of Hope, Part 2: Development of a Disposition for Environmental Exploration Lydia’s experience with Stage 2 of the Exploration Module happened after she had been moved into a new ward. In this ward, the therapist discovered there was a big bathtub available and knew from Lydia’s history that playing with water was an activity that Lydia had loved as a child. So the therapist invited Lydia to leave her room (personal space) and see this bathroom with the big tub. The tub was filled with water. At first she observed the tub in silence.


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The therapist went to the tub and began to move the water with her hands, singing in Spanish to Lydia as she did so. This was a way of inviting Lydia to share in the activity. Lydia simply smiled and listened to the music as she sat at the edge of the tub. She stayed that way for over 20 minutes, indicating to the therapist that the activity pleased her and could be added to her familiar daily routine. The next day, Lydia once again visited the bathroom with the therapist and this time touched the water while sitting on the edge of the tub. The therapist imitated Lydia’s action, reaffirming Lydia’s decision to initiate this action. Lydia smiled and looked at the therapist. This smile was even more significant because it was directed at the therapist and was an indication that for the first time she was acknowledging that they were sharing a meaningful activity. The simple expression indicated that Lydia had improved her personal causation to the extent that she could proudly communicate her enjoyment to another person.

In response to Lydia’s expression, the therapist suggested that Lydia get in the tub and play with water. Though Lydia smiled at this, she covered her face with her hand. The therapist understood this gesture in the following way. Although Lydia wanted to try the tub, she was reluctant. She was attracted to the activity, but her values of modesty made her embarrassed to take her clothes off in front of another person.

So, the therapist asked if Lydia would prefer that she leave so Lydia could undress and get in the tub. But Lydia indicated, “No.” Instead, Lydia got in the tub with her clothes on. She even took the therapist’s hand and moved it through the water. She stayed in the tub for about a half an hour.

Eventually, these interactions over the tub led to Lydia taking morning baths in the tub and washing herself with soap and a sponge. This new activity was so beneficial to her mood that she would go to her room and choose her own clothes. As she showed more initiative and less support to begin this routine, Lydia was introduced to a new member of the nursing staff who began to work closely with her as well. In this way, Lydia began to trust other people in the ward. Her routine became more active as she trusted more people. She listened to music, sang, looked through magazines, and had her daily bath. Lydia smiled more and answered back “hola”. New activities were provided including dancing and going for walks around the ward. A rocking chair was left close to her bed and her roommate in the new ward showed her how to use it, since she had not seen one before. The next step included Lydia taking pride in her appearance. Lydia had not washed or combed her hair since before she was hospitalized and had refused to have anybody do it for her. With encouragement, she managed to wash her hair but was unsuccessful in her attempts to comb it properly. She finally let a nursing aid help her with this task. When the job was done, Lydia immediately went to a mirror and for the first time in years, she looked at herself. She smiled and

said “Linda” (“pretty”). Lydia's VQ scores at this point are shown in Figure 5-4:


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Figure 5-4: Lydia’s Fourth VQ Scores

Stage 3: Choice making By Stage 3, the client takes increasing control over his/her participation in activities. The main objectives in Stage 3 are:

• To continue to facilitate the development of exploratory feelings • To facilitate the process of self-validation by exploring one’s values and interests through

activity • To reinforce a sense of personal significance and capacity through opportunities to choose

activities.

Table 5-4 is an overview of the principal strategies used in Stage 3. They are similar to those strategies used in Stage 2 and include:

• Increase novelty (new settings, people, etc) • Increase invitations for participation

They are described in detail in the following discussion.

Table 5-4: Choice Making

STRATEGY ACTIONS ASSCOCIATED WITH STRATEGY

Similar to Stage 2

• Increase novelty (new settings, people, etc)

• Increase invitations for participation

Encourage the client to choose to engage in familiar and new activities and routines for longer durations. Begin to facilitate reciprocal relationships with other people.

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Once clients have had the opportunity to experiment with different options of activities of interest as in Stage 2, they are ready to proceed to choosing activities in which they would like to participate more often. Generally, a client’s readiness for this is indicated by more spontaneity and autonomy when participating in activities. Indications may take the form of verbally indicating preferred options or simply participating more in certain options.

At this stage, therapists may also attempt to increase clients’ participation in activities like simple grooming tasks that are less appealing to them but may be important in allowing them to take part in situations that they enjoy. For example, attempts to comb one’s hair daily to remain accepted by a group can become an important part of a client’s routine. Therapists should take time to explore what activities are of personal significance to clients and why

Establishing daily and weekly routines are important in helping clients begin to anticipate and plan occupations. Therapists can facilitate this process by providing opportunities for clients to choose activities and decide courses of action. Taking time with clients to plan schedules for the day or week may be one way of doing this. Discussing options with clients may be another way. Some clients may need more assistance such as limiting the number of options to two choices. Therapists should encourage and praise the choices clients make. Similarly, opportunities for clients to express interests and values are important. Remembering to ask clients' opinions, for example, is important, as is commenting supportively on clients’ preferences or engaging clients in conversation over things they enjoy. The more clients exercise choice making, the more they rely on their decision-making capabilities.

Interventions similar to those described in previous stages are used in Stage 3. Therapists should seek to engage clients in meaningful activities for longer durations and with greater frequency.

The process of validation introduced at the very beginning of the Exploration Module should continue to be applied with the goal of the client establishing reciprocal relationships (like that established with the therapist) with other people.

By the end of Stage 3, it is suggested that clients spontaneously show curiosity, indicate interest, stay engaged in activity, and show that an activity is significant. They may also consistently initiate actions though only with substantial support and encouragement. Finally, they may begin to indicate goals. With time, therapists will see more VQ items emerging and higher levels of spontaneity reflected in a client's scores.

The following segment of Lydia’s case illustrates Stage 3 strategies

Lydia a Smile of Hope, Part 3: Facilitation of Choice Making

Lydia began to feel more comfortable in her routine and began to smile more often. Lydia’s exposure to other people increased and she often said hello to others who passed her. Eventually, the therapist invited Lydia to eat in the dining room.

The therapist recommended to other staff that Lydia be allowed to sit by herself of with very familiar friends in the dining room. The therapist also recommended that Lydia be allowed to eat alone or with her roommates with whom she had become comfortable. She was not expected to sit with other people initially. She made the transition to eating in the dining room successfully.


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Lydia’s tolerance for being in the same environment with others continued to increase. She began to take initiative to move about the ward without needing support. At this point the therapist accompanied her off the ward to a patient Clubhouse run by OT’s. Lydia was given a tour of the setting. She responded positively and spontaneously used a rocking chair and a radio, which were familiar elements in the new setting. She walked around the area touching the furniture. And all the while, she smiled. Lydia's VQ Scores at this time are shown in Figure 5-5

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Figure 5-5: Lydia’s Fifth VQ Scores

Stage 4: Pleasure and efficacy in action The strategies of Stage 4 mainly focus on reaffirming the achievements of previous stages as well as facilitating the growing sense of self-efficacy. Objectives for Stage 4 include:

• Reaffirming exploratory feelings, the sense of personal significance and sense of capacity through preliminary participation in roles

• Continuing the process of self-validation • Reaffirming self-efficacy in decision-making • Developing an awareness of one’s skills

The strategies used in Stage 4 are outlined in Table 5-5 and explained in detail in the following discussion. They are:

• Facilitate participation in collaborative projects • Incorporate feedback • Facilitate a sense of life story


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Table 5-5: Pleasure and Efficacy in Action


Facilitate participation in collaborative projects

Facilitate a sense of social belonging by providing opportunities to take part in collaborative projects in any way no matter how small.

Incorporate feedback

Initiate a very simple process of self-evaluation based on concrete experiences in collaborative projects.

Facilitate a sense of continuity in occupational performance

Communicate and share a sense of continuity in experiences through a simple process of interpretation and anticipation of future participation in collaborative projects.

Facilitating Participation in Collaborative Projects In Stage 3, therapists and clients collaborate to develop meaningful daily and weekly routines in accordance with client choices. Such routines should focus first on developing a sense of belonging or being part of common activities. Preliminary participation in roles begins at this stage. This participation can be distinguished from actual role assumption. Though clients may perform activities or carry out functions considered part of a role, they may not participate in the entire range of functions that make up a role, nor yet feel a sense of identifying with that particular role. Recall that roles consist of both the external expectations of the environment for role performance and the client’s expectations and desires within the role (Kielhofner, 2002).

At Stage 4, the focus or role participation is on the meeting of role expectations (i.e., on doing something that is useful, needed, and valued for others). Participation in collaborative projects where each person makes a unique contribution, however small, is one way clients can begin to experience this kind of participation.

A collaborative group project involves the participation of various members who contribute to a series of activities with a common goal. For example, at the Reencuentros Clubhouse such projects provide ongoing, varied opportunities to take part in communal goals that are essential to the operation of the center. Lunch preparation at the clubhouse is an example of this. As a team, members may decide on what to prepare for lunch, but then each member of the lunch preparation team performs a particular function. Tasks are distributed to members according to what is needed – one or two people to shop for ingredients, chop vegetables, stir and mix ingredients, prepare the juice, put table cloths on the tables, etc. Members contribute according to their abilities and no contribution is insignificant. A member, for example, may be able to do no more than put tablecloths on the tables. Nevertheless, the task is a necessary piece in the process of lunch preparation.


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Another example of a collaborative group project is the clubhouse’s monthly magazine. The magazine called “Lazo’s”, is organized and put together by members. In addition to contributing articles, reflections, poetry, artwork, etc. to the content of the magazine, members contribute to the process of putting the magazine together by typing, cutting and pasting, photocopying, collating, etc. The magazine is then sold to members of the community.

Both of the projects just described have goals that are significant and tangible to the members involved (feeding the clubhouse, communicating with the community), and any member, regardless of skill level can take part in these projects.

Thus, when we refer to collaborative group projects we refer to group projects that observe certain principles.

Projects are meaningful and interesting in that they contain a real, tangible goal relevant to each member’s experience. They imply continuity and provide ongoing opportunity for involvement in real life meaningful activity

Participation does not require special skill, only whatever the client is able to unique

contribute. Thus, the emphasis is on social participation and the development of a social identity and not on skill development of any kind (including social skills)

Clients of varying skill level can work together on a project with an equal sense of

belonging. An engineer with an anxiety disorder may contribute an intellectual article to “Lazo’s” while an adolescent with a developmental disability will slowly and deliberately contribute to cutting and pasting elements on paper to prepare for photocopying. Each is a valued and necessary contribution. This is especially important for clients with very low self-esteem who need to feel significant among others. Moreover, this counters one of the myths often believed in occupational therapy that groups should consist of clients with the same skill level in order to be therapeutic

A project is always both planned and carried out in collaboration with others

Through this approach, a client can move from being an outside observer, perhaps timid and

cautious, to becoming an integral part of a group. This can occur even if the client's only role in this group is to assist with part of a task.

When the client is ready, he/she can progress to participating in more and more of the process of the group projects. Participation may begin with planning, organizing, and working with others in collaborative roles until the project is completed. The therapist should continue to promote decision-making within an activity by providing opportunities for clients to choose materials, choose tasks, choose courses of action, etc. As clients become more skilled and spontaneous in decision-making the therapist may supply more challenging situations such as involving the client in collaborative problem solving.

Indications that clients are ready for more challenging situations include: He/she becomes more skilled and spontaneous at decision making He/she shows that such participation is significant to him/her He/she frequently shows initiative He/she indicates goals


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Incorporating Feedback The second strategy used at Stage 4 is the use of feedback, or the initiating of a very simple

process of self-evaluation and participation in volitional processing. After clients have completed participation in a project or some part of a project, therapists can help them begin to reflect on the experience by asking specific, concrete questions. A complete process of interpreting one’s participation does not take place at this point. Instead therapists and client’s focus on examining the client’s expectation going into the project, what the experience had been like, and what specific results were. In this way, therapists reaffirm clients’ experiences within the contexts of their participation. The focus is always on task performance and the concrete accomplishments of projects and does not seek to explore reasons for participation.

The therapeutic use of self is another key element in this process. Therapists should be willing to appropriately share their own stories with clients (similar experiences, mistakes made etc.). This sharing should always have the goal of reaffirming the client’s own experience.

Communicating a Sense of Life Story During the Exploration Module, the client is just beginning to build the volitional process of

experiencing, interpreting, and anticipating participation in occupations. The focus is on the initial part of this process – experiencing – and the links to past, present, and future are not yet fully examined to construct the personal narrative. Nevertheless, therapists remain aware of the fact that they enter clients’ lives as agents for facilitating the continuation of their life stories. This process involves helping to put activity and occupational choices into perspective.

According to MOHO, occupational choices are life choices nested in an unfolding life (Kielhofner, 2002). Such choices link past, present, and future selves and involve the creation of personal narratives.

“Narrating some aspect of one’s life means making one’s experience into a story, even if that story is only for oneself. Stories may also anticipate the future by continuing what has happened in one’s life into some imagined outcome. The life stories we construct carry and integrate the themes of personal causation, values, and interests. Thus the volitional process of making occupational choices is embedded in the narration of an unfolding story – a story through which we make common sense of our circumstances” (Kielhofner, 2002)

During the Exploration Module, the client begins experimenting with activity choices. These choices focus more on immediate circumstances and the near future. As mentioned, the focus of client counseling at this level is on reaffirming these choices and the experience of realizing participation. With increasing reaffirmation and accumulation of experiences, clients will be ready to move on to a process of interpretation of these experiences and examining how they relate to their life stories. At Stage 4 of the Exploration Module, clients begin to view the continuity among their experiences. This process of interpretation is continued and intensified in the next level of the Remotivation Process, the Competency Module.

As discussed earlier, exploration extends throughout the whole rehabilitation process. Once clients have completed the stages corresponding to the Exploration Module in familiar environments (such as the home), the second and third stages are repeated in new environments, such as one’s neighborhood, community centers, relatives’ homes, places of employment, etc.

With each new situation, clients must explore the demands and opportunities presented as well as their own capabilities to function under these new circumstances. The duration of the exploration


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period in each new environment will depend on the supports and demands each poses and the client’s previous experiences. Clients may respond to some situations better than others and thus the time devoted to exploration will vary. Likewise, even a person who has moved through the entire range of Exploration Module stages and moved on to higher levels of the Remotivation Process may still need validation when faced with novel situations.

Clients should never be coerced to participate in environments where they will be rejected. Environments should be carefully analyzed to determine if they are appropriate for a client.

By the end of Stage 4 volitional behaviors are emerging that indicate an increasing enthusiasm and self-confidence in activity. Clients may now spontaneously show initiative and be more involved in indicating goals, though the latter may still need support and encouragement and thus not yet be spontaneous. Also, clients will begin to demonstrate emerging attempts to solve problems and correct mistakes. Finally, an emerging sense of increased energy and emotion in activity should be seen.

The following segment of Lydia’s case illustrates Stage 4 strategies.

Lydia, a Smile of Hope: Developing a Sense of Pleasure Lydia began going to the Clubhouse routinely. She was introduced to and soon became

interested in the kitchen. At first, she just observed others during special baking sessions, joining them in eating cake. She still needed the therapist to accompany her initially in new social situations. However, once she became familiar with the setting and the people in it, she began going on her own. At the clubhouse, she was offered the role of maintaining the living room, which included cleaning furniture, putting music on the stereo, and washing dishes in the kitchen. She accepted this role and was able to successfully complete the required chores.

At this point, Lydia had established a daily routine as follows. Each day she took a walk outside and then spent some time swinging. She took a daily bath in her bathtub and did her hair. She ate all three meals in the dining room. Finally, she did her chores at Our Place. Lydia’s VQ scores at the end of this last stage of the Exploration Module are shown in Figure 5-6.

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The Exploration Module and the Transpersonal Nature of Volition By the end of the Exploration Module, clients have begun to feel a sense of social connection

and a sense of social identity. This is a result of a process that began with the validation and reaffirmation received from one person – the therapist. The use of strategies described in the initial stages and strategies of the Exploration Module (being with and doing with clients) facilitate the sense of self-worth that prepares clients for increased social contact. The therapist thus is an initial key element in helping to develop the client’s volition.

As client begin to experience other people and a sense of their own participation in collaborative efforts with others, further reaffirmation and validation from others is obtained and clients begin to feel a level of confidence in their ability to have an impact on situations and others. The social acceptance communicated by others and the consequent sense of belonging produced for clients, thus, are also key formative elements in clients’ volition.

The Social Environment We have discussed the importance of environmental factors, most notably the social

environment, in volition. The Remotivation Process must include environmental interventions in all possible and relevant ways. The final segment in the case example of "Lydia, A Smile of Hope" outlines strategies taught to Lydia's family, her immediate and most significant social network.

The following illustrates how Exploration Module strategies address the social environment.

Lydia A Smile of Hope, Part 5: Parental Interventions and Outcomes As interventions with Lydia were underway, Lydia's parents also continued to participate in

educational sessions with the occupational therapist who introduced them to new ways of working with Lydia. During these sessions, they learned ways of being physically affectionate with Lydia so that it would not be a negative experience for her. For example, instead of rubbing her back, they were instructed to put their arms firmly over her shoulders and limit verbal expressions to a single comment. Her parents began to notice progress in Lydia's performance and reactions. This gave them comfort as they waited to return home.

Throughout this time, while the therapist was intervening with Lydia, she also worked with Lydia's parents, teaching them how to help Lydia. First, they were taught how to share in Lydia's activities. They participated with Lydia in these activities, gaining a sense of control over these new techniques. Because her parents were illiterate, an album with photos was designed for them to take to Puerto Rico to serve as an instruction manual on how to work with Lydia and share things with her. They also learned how to identify Lydia's medications by color so they would not confuse them. They acknowledged that while it was hard for them, they felt more comfortable refraining from demonstrating affection through physical expressions.

Lydia's parents continued during this time to learn more about supporting Lydia. They were thrilled with her progress. Her father even fabricated a swing for her to use at home. They had also mastered the process of administering Lydia's medications. At this point, the parents and team decided that it was time for Lydia to return home. In preparation for discharge, the therapist instructed the parents about how to provide Lydia with a role at home. She reviewed the routine that Lydia had established and discussed with the parents how to support Lydia to replicate it at home. The therapist also gave the parents simple instructions for observing when Lydia's volitional needs were being met and when she was over-challenged.


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For four months following discharge, the therapist did periodic follow-ups by phone. Lydia's sister gave instructions and money to her parents so that they could go to town where there was a phone and call the therapist at the hospital during prearranged appointments. Lydia's parents informed the therapist that Lydia was maintaining her routine, enjoying helping her mother clean, and swinging in her new swing. They reported that she was smiling.

SUMMARY OF THE EXPLORATION MODULE Clients who complete the Exploration Module have acquired basic volitional strengths. Clients

have gained an increased sense of capacity and personal significance as they also begin to feel increasingly at ease with familiar and new environments. Clients begin by first developing a sense of connection with themselves, things, spaces, and situations. Gradually, continued positive experiences with such connections led to increased interaction with the environment and a sense of their own interests. As interactions began to include more challenging and collaborative situations, clients begin to develop a greater sense of purpose within them. As clients leave the Exploration Module level of the Remotivation Process, they are ready to meet more challenges, responsibility, and opportunities for setting goals.


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CHAPTER SIX

The Competency Module


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CHAPTER SIX THE COMPETENCY MODULE

What Are Goals And Objectives Of The Competency Module? Clients’ participation in routines during the last stage of the Exploration Module become more consistent and continuous. Clients make activity choices with increasing spontaneity. Recall that the main objectives of the Exploration Module were to reaffirm a sense of personal significance, a sense of personal capacity, and a comfortable connection with the environment. As clients move into Level II of the Remotivation Process, the Competency Module, the process shifts. In the previous level, strategies were applied with the idea of facilitating a social connection regardless of the kind of participation involved.

Now, the social expectations for role participation give more emphasis on how the client manages to perform the tasks needed. The quality of the individual’s participation begins to take on more importance. The focus of participation shifts to meeting increased challenges within meaningful roles and/or accepting environmental changes like increased expectations for performance.

During the Competency Module, clients experience changes in performance demands and contexts. It is expected that adapting to these changes, consistent problem solving, and the ability to independently make decisions increase during this module. In other words, the Competency Module is characterized by facing and experiencing circumstances that involve more risk taking than exploration. In the Competency Module, clients continue to test existing capabilities in more challenging situations and/or to acquire new capabilities. A basic sense of capacity (often developed in the Exploration Module) is required to support the process of testing capabilities in these new circumstances. The sense of efficacy continues to develop as the client’s capacities are reaffirmed now in new situations. Likewise, the process of meeting challenges and adapting to change and accompany reflection over these experiences in the Competency Module will support spontaneous engagement in challenges during the final Achievement phase.

As mentioned previously in this manual, therapists take into account "micro" realities of clients when considering volitional change. The micro reality is the way in which clients experience their worlds and also their unique capacities. Thus, during the Competency Module, the experience of new challenges and adapting to changes will involve different processes and different circumstances for each unique client. For a client with a long history of unemployment, the experience of competency may take the form of learning job skills. For a client who longs for acceptance by others, it may mean taking ownership of a chore in a group home. For a client who has become isolated from others, it may mean letting old friends once again visit her home. For a person with a low level of cognitive capacities who lives in a hospital, and has trouble adapting to changes in the environment this may mean accepting a change in the spaces she occupies in the day room. In each of these examples, the key factor in determining the experience of competency is the client's perception of meeting a new and meaningful challenge. Therapists use what they know of their


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clients' life history, interests, and values and work collaboratively with clients to discover the contexts for experiencing competency.

Figure 6-1 shows the Competency Module as the transition between exploration and achievement

Figure 6-1: The Competency Module in the Remotivation Process

While clients are able to take on more at this stage, therapists still need to consider the amount of challenge and responsibility clients can undertake given levels of functioning. Challenge should constantly be adjusted to meet individual needs. Clients will gradually assume more responsibilities as their tolerance allows.

Responsibility may be increased as the client acquires more skills, adjust to new circumstances, or begin to perform different tasks within a significant role. For example, an individual may begin the process of re-assuming that role of mother by first learning cooking skills to help feed her children. Learning new skills may increase to include menu planning, shopping, and budgeting for food. As she increases her abilities to take on more responsibilities associated with the role of mother, her self-confidence and sense of efficacy within this role increases, eventually facilitating the continued assumption of responsibilities extending to areas beyond preparing meals.

The strategies of the Exploration Module (validation, introducing novelty, facilitating choice,) are also applied during the Competency Module when appropriate. In the Competency Module:

Therapists offer more challenging opportunities for increasing sense of efficacy Therapists increase expectations to facilitate skill development.

AUTONOMY


EMERGING SELF-EFFICACY

ACHIEVEMENT

COMPETENCY

EXPLORATION


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Alongside this process, the therapist provides individual counseling to encourage the client’s construction of an occupational narrative that envisions how to move beyond past and present problems and challenges into an acceptable and possible future with an increasing sense of continuity and positive outlook.

The Competency Module: Stages, Goals, and Strategies The stages, goals and strategies of the Competency Module are outline in Table 6-1 and further explained in the next section.

Table 6-1: STAGES, GOALS, AND STRATEGIES OF THE COMPETENCY MODULE

Stage Strategies Goals For Clients

Internalized sense of efficacy Provision of physical or emotional “accompaniment” in new and challenging situations

Facilitation of skill learning when appropriate

Introduction of the counseling process and use of feedback

To Increase emerging sense of efficacy

To begin looking at experiences as they relate to meeting goals

To develop a sense of responsibility with personal and collective projects

Living and telling one’s story Allowance for "moments of reflections" or disorder in change process

Continuation of the counseling process furthering insight through more in depth analysis and questions

To prepare for spontaneous participation in valued roles

To Increase processing of experiences and begin relating them to personal or occupational goals

To increase the process of planning

To increase sense of responsibility and autonomy on meeting the demands of personal projects and/or personal circumstances

Table 6.1: Stages, Goals, and Strategies of the Competency Module


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The Competency Module Stage 1: Internalized Sense Of Efficacy During the Exploration Module, clients begin experiencing a more consistent sense of efficacy within role participation in collaborative projects. Clients also begin to practice the process of making activity choices and begin to reflect on their experiences during participation with guidance from the therapist in individual counseling through the use of feedback.

The emerging sense of efficacy developed in the Exploration Module prepares clients for the emphasis on meeting new performance expectations in the Competency Module. As the performance expectations shift, clients are also given opportunities to increasingly reflect on their experiences. The sense of continuity in experiences further develops, leading to increased anticipation and planning for future experiences.

Additionally, throughout the Competency Module, strategies introduced in the Exploration phase, such as moving routines into new spaces, facilitating choice making, incorporating feedback, and establishing a sense of personal story are continued. There is a shift in emphasis, however, in how these strategies are used. The focus now is on increasing autonomy through increasing change and increasing demands and challenges.

There are several strategies therapists can use in Stage 1 of the Competency Module. These are: Provision of physical or emotional “accompaniment” in new and challenging situations Facilitation of skill learning when appropriate Introduction of the counseling process and use of feedback

The following discussion goes over these strategies.

Provide Physical Or Emotional "Accompaniment" In New And Challenging Situations For some clients, the experience of Competency occurs with adapting to changes in the environment, developing increased tolerance to change, and experiencing self-efficacy in increasingly novel circumstances. These changes can include any combination of new settings, new people, new routines or ways of doing things, new objects, etc.

Therapists assist clients in making these adaptations by providing accompaniment, incorporating strategies used in the Exploration Module when appropriate in accordance to client needs.

Facilitating Skill Learning For some clients, the experience of Competency occurs with developing skills and learning. The following outlines points to consider in the process of skill learning.

Skills The kinds of skills required of clients should also be carefully assessed. Points to consider

include the following: Skills should be relevant to clients and the contexts where they live, work, etc. Skills should also be within each client’s ability to learn. Learning skills should ideally take place within meaningful contexts and roles.


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Facilitating the learning process Ways to facilitate learning include the following:

Shift external expectations of an existing role. Facilitate assuming new roles within meaningful contexts. Identify roles of slightly more responsibility that are in accordance with a client's existing

skills. In each of these instances, changing expectations or contexts creates increased demands and presents clients with the need to adjust performance.

Learning situations should be presented in small increments with attainable goals. Clients should have a clear indication of what is expected in their performance. For some clients, the therapist can facilitate this by explaining what the performance requirements are (arriving on time, meeting deadlines, not leaving a group when frustrated by others, learning to be quiet so others can talk, etc). For others, the therapist may need to rely on specific, concrete instances as opportunities to demonstrate or facilitate skills. These instances may need to be pointed out to the client as they occur or soon afterwards.

Introduce The Counseling Process And Use Of Feedback The development of a sense of efficacy and competence is a gradual process. Clients gradually, increasingly relate participation and activity choices to personal goals.

This is facilitated in individual counseling or in other naturally occurring interactions with the client. In the Exploration Module, the focus of individual sessions with the therapist was on processing the experiencing of participation. This continues in Stage 1 of the Competency Module. Therapists share their observations of the client to help him/her begin examining his experiences and how they may relate to future goals. However, the processing of experiences at this stage is guided by the client’s tolerance, his/her interpretation of experiences, and ability to anticipate other experiences based on these when considering future goals. This may mean that client and therapist focus on immediate, concrete goals. This process prepares the client for later when, in Stage II, the client and therapist begin exploring occupational goals more in depth.

Recommended Assessment Tools for the Competency Module Stage 1 Along with the Volitional Questionnaire, by Stage 1 of the Competency Module, the Occupational Self-Assessment (OSA) (Baron, Kielhofner, Iyenger, Goldhammer, & Wolenski, 2001), the Work Environment Impact Scale (WEIS) (Moore-Corner et al, 1988) are appropriate assessment tools.

Information on ordering the OSA , Role Checklist and the WEIS can be found on the Model of Human Occupation Clearinghouse web site.

For more information on these assessments visit the Model of Human Occupation Clearinghouse

website at: http://www.uic.edu/hsc/acad/cahp/OT/MOHOC

Or go to uic.edu Link to: 1) Academic Departments 2) Applied Health Sciences 3) Occupational Therapy 4) MOHO


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The following briefly describes the use of the OSA and the WEIS in the Remotivation Process. The OSA allows the individual to examine his or her own abilities and on his/her environment

and to begin to prioritize critical areas for change. It provides information on the client's self-perception of his/her occupational competence and may be administered repeatedly throughout the course of therapy.

The OSA is a two part self-rating form. Section one includes a series of statements about occupational functioning to which clients respond by labeling each in terms of how well they do it using a 4-point scale. Clients then respond to these same statements, indicating the importance of each on a 3-point scale. Section two includes a series of statements about one’s environment to which similar responses are given. On the OSA, once clients have completed the ratings, they establish priorities for change. There is a column on the form in which the client selects and ranks the areas for change related to self and environment. When completing the OSA, some clients independently determine their priorities for change and then discuss them with the therapist. Other clients, who need or wish more structure, do this with the therapist. The OSA also includes a form on which the therapist and client together may formally record and review therapy goals and strategies. (Kielhofner et al, 2002, p. 221)

Therapists also continue to assess environmental impact. Environmental impact is the "opportunity, support, demand and constraint that the physical and social aspects of the environment have on a particular individual" (Kielhofner, 2002, p.103). Tools such WEIS (Moore-Corner et al, 1988) can provide examples of criteria to consider when looking at the contexts where clients perform occupations. The Volitional Questionnaire also contains a section for assessing the environment.

The Competency Module Stage 2: Increased Challenges And Responsibilities Within Meaningful Roles At Stage 2 of the Competency Module, clients continue with the “process begun” in Stage 1 and continue to confront increasing demands for role performance. During Stage 1, clients confronted some level of challenge requiring the development of “adjusting to change”. The sense of efficacy continues to grow as these challenges are met with success and clients begin to see continuity in their participation in activities Along with this comes an increased sense of confidence in performing valued roles.

Clients at Stage 2 of the Competency Module prepare to spontaneously seek challenges. This takes form in spontaneously confronting the process of setting long-term goals. Spontaneity, however, is not yet consistently reflected in clients' behavior. At this point, therapists focus on facilitating performance in these areas.

Therapists may need to accompany clients as they meet increased challenges. Recall that this accompaniment refers to the “doing with” and serves to validate the clients’ experiences and to reaffirm their sense of confidence in their abilities. Accompaniment can take many forms. Therapist may “accompany” clients in their search for employment by asking about how the process is going, showing enthusiasm for gains made, listening to doubts, etc. In other circumstances therapists may actually physically visit places with clients as they gather resources and information. The amount of assistance provided by therapists is always carefully calculated to appropriately meet the client’s needs.


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There are two main strategies used by therapists in Stage II of the Competency Module. These are:

Allowing for “moments of reflection” Continuing the counseling process

Change Is Often Disorderly: Allowing For Moments Of Reflections Clients’ volition varies across different roles or areas of occupational performance. Clients’ values and interests, in part, determine this, as do environmental factors and the support or challenge individuals perceive in them.

Furthermore, it is not uncommon during the Competency Module to see clients experience periods of seemingly decreased sense of efficacy. This is especially common as clients confront demands to assume increasing responsibilities in accordance to increasing levels of skill. These periods may be thought of as “moments of reflection”.

What Happens To Clients During “Moments Of Reflection?” During these periods, clients begin to retreat from activity, reject invitations to participate in roles, revert to old behaviors, etc. Clients who may appear to have achieved high levels of competence within roles and who appear ready to take on additional challenges, may seem to suddenly abandon their efforts and instead of pushing forward go back to old patterns of behavior indicative of a lesser sense of efficacy.

In accordance to MOHO, these moments do not mean that clients have not made significant strides and continue to do so. Instead these moments represent a natural need to pause and consider the significance of taking on more responsibility, of deciding to perform more difficult tasks, of moving into an unfamiliar environments, etc. They provide opportunities to reflect on skills and abilities whether or not they match intended challenges, or to consider the real impact of factors like health conditions or limitations.

What To Do During Moments Of Reflection Therapists help to assure that moments of reflection are productive by collaboratively exploring with clients the reasons for these moments and helping to put occurrences that may appear to represent failure in perspective.

Therapists remind clients of all their gains and the progress they continue to show. Therapist reassure clients that the next challenge is within their reach despite the current

pause, and help clients understand the elements of the situation that led to the rejection of or retreat from the performance context.

In this way therapists maintain the process of validation and reaffirmation begun in the early stages of the Exploration Module as clients demonstrated increasing competence in their ability to face responsibility and challenge.

Therapists thus facilitate the continuation of each client’s progression by accepting these moments and by helping the client maintain the vision of attainable long-term goals despite moments of doubt.


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Individual counseling at this stage focuses on setting longer-term goals as clients broaden their perspectives of past, present, and future. Activity choices are now seen in relation to larger occupational choices. Therapist works with clients to see this relation and examine significant life goals for clients.

Continuing the Counseling Process Furthering Insight Through More in Depth Analysis and Questions Now, the focus begins to take on a more interpretative quality as performance and participation are examined in terms of concrete skills developed. During individual counseling at this stage:

Therapists and clients examine how changes are important in terms of clients’ goals. Processing is kept simple, using clear, basic parameters or indicators to evaluate volitional

behaviors, and the volitional process of experiencing, interpreting, anticipating and choosing.

Processing includes reviewing achievements, and recognizing problems and personal strategies to face concrete challenges.

The therapists and clients also consider how choices clients make affect their performance and goals. This can include more specific examinations of activity choices as a means of working towards goals. In this way, clients and therapists engage in a process of co-planning and co-problem solving. This process begins in the Exploration Module when clients and therapists first begin to reflect on participation. In the Competency Module, collaboration between clients and therapists is more purposely linked to the anticipation of goals. Clients begin to explore the slow, gradual process of goal setting and planning, using short-term (weekly, for example) goals to examine progress.

Depending on the needs of clients and the extent of their levels of tolerance for exploring the depths of their life stories, therapists tailor questions to allow for appropriate feedback. Some questions explore more concretely the experience of a particular activity or situation. Others delve more into the relationship between these experiences and the life story.

Table 6-2 is offered as a guide for structuring questions to aid the process of giving feedback. They can be tailored to the level of analysis deemed appropriate with each client at any given moment. The questions are divided into categories for examining the sense of pleasure, values, and personal causation felt within the experience


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Table 6-2: Suggested questions for formulating feedback

Sense of Pleasure Did you enjoy the activity? What were the attractive elements of the

things you found most enjoyable? What moment during the activity stays most

clear in your mind? What did you most enjoy doing during your

participation in this activity?

Values Did you look forward to participating in this activity?

Did the outcomes of the activity affect your own personal experience within participation?

How important is this activity in relation to your personal goals in life?

What the positive and negative aspects about this activity that most affect you?

What has changed for you and what has not?

Personal Causation How did you do? What resulted from your participation? What were these results due to? Was this a familiar situation for you? When things did not work out why did they

not work out? What did you do then? In given situations) What was a result of your

performance? What elements depended more on the

environment and others? What circumstances motivate you to act? Describe the attitude of others involved. Describe what you did to solve problems


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Table 6-3 provides suggested questions for facilitating increased processing of experiences.

Table 6-3: Suggested Questions For Facilitating Reflection On Self And Environment

Personal Analysis Did you meet your objectives? Did you reach your overall goal? Did you perform your role in this situation or

try to? How did you do in accomplishing what you

had intended to? Were you successful or not?

Environment Analysis

Describe the circumstances around your performances.

What was happening at that time? What was the attitude of others involved

about your performance? Did you have all the materials you needed? How did the people present at that time

affect the environment?

Recommended Assessments For The Competency Module Stage 2: Along with assessments mentioned earlier, the Role Checklist (Oakley, Kielhofner, & Barris, 1985) can be a valuable tool at Stage 2 of the Competency Module.

"The Role Checklist (Oakley, Kielhofner, & Barris, 1985) was developed to obtain information on clients' perceptions of their participation in occupational roles throughout their life and on the value they place on those occupational role" (Kielhofner, 2002, p. 231). By the second phase of the Competency Module, clients have a more solid idea of the significance of role participation in certain contexts. They are also solidifying the sense of continuity within their personal narratives working collaboratively with therapists to gain a sense of living and telling their stories with more emphasis on life goals. The Role Checklist can serve as a useful concrete representation of clients’ past, present, and future possibilities Copies of the Role Checklist can be obtained from NIH:

Frances Oakley, MS, OTR/L, BCN, BCG, FAOTA National Institutes of Health Building 10 Room 6s235 10 Center Drive MSC 1604 Bethesda, MD 20892-1604 Email: [email protected]

By the end of Competency Module clients show some indication to try new things, to attempt to correct mistakes, to attempt to solve problems, and to attempt challenges.


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The following case example, the story of Michael, illustrates progress through the Competency Module. The story begins with a summary of Michael's movement through the Exploration Module and then illustrates each of the strategies of the Competency Module

Case Example: Michael

Background and Life-History

Michael, a 40-year-old African American male, was placed at a transitional living facility, a home for people with HIV/AIDS, after years of substance abuse and recurring homelessness. Though short it stature, he had a muscular built and deep gruff voice. At times, he limped due to pain from an old fracture in his right leg. He had been diagnosed with AIDS five years prior. However, he had only recently begun treatment for it, which included taking medications three times a day. Michael came from a large family and grew up in a poor neighborhood on Chicago's West Side. Michael's sister also struggled with substance abuse and a younger brother had as well until he committed suicide. Michael had a learning disability that was undiagnosed through most of his childhood. School was a difficult and sometimes humiliating experience. He eventually left school at the age of 14, having reached the 7th grade. Through the help of his mother, Michael entered into two different vocational training programs but never obtained a job through them. Instead, as a young man, Michael began traveling across the United States, ending up in California. He did odd jobs and worked at car washes. He also sold drugs. He met a woman and had a child with her in San Diego and for a while he worked long hours at a car wash and provided the child with a stable home. The situation, however, turned abusive and Michael found himself in and out of jail for domestic violence charges. Eventually the child was removed from the home by the state. Michael returned to his mother's home in Chicago with the hope of reclaiming his child once he proved he had a stable living environment. When this fell through, Michael returned to a pattern of substance abuse and living on the streets. He finally became so ill that he was hospitalized for several weeks. It was then that he was first placed at the home for people with HIV/AIDS. His first stay lasted one month. During that time he had kept to himself, rarely interacting with other residents and, when he did, he was often confrontational. He was eventually asked to leave when it became clear that he was using drugs again. He spent several months in drug rehabilitation treatment centers and eventually reapplied and was accepted again as a resident in the home.

The transitional living program's hope was that within two years, residents would regain health as well as acquire the skills and financial means necessary for returning to independent living. As part of the conditions for residency, Michael was required to attend a 3 month long outpatient program and continue to attend AA or NA meetings a minimum or 4 times a week.

Summary of Exploration Module

During Michael's absence from the home, a therapist had been hired and had established a small Arts and Crafts room and a Learning Center with a computer lab and other resources. These new environmental factors proved useful in facilitating exploration with Michael. The therapist noticed that during the hours that he was not attending his program, Michael sat idly in the various common areas but did not engage others. She began asking him to assist her with arranging supplies in the Arts and Crafts room and organizing the Learning Center. In their first interactions Michael helped carry paper and stack in on shelves in the Arts and Crafts room. He helped staple and collate


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informational papers in the Learning Center. The therapist and Michael rarely talked during these interactions. However, she noticed that though he would get up and leave the room at times, he would always return and wait patiently for further instruction.

Michael began to show increasing interest in the Arts and Crafts room. He spontaneously showed curiosity towards the different supplies and mediums. Within a couple of weeks, he was spending time in the room drawing and painting. He began to show pride in his work, looking for places in the home where it could be displayed. The therapist supported Michael's new interest by continuing to provide resources and opportunities, by showing genuine interest in his efforts, and by facilitating a collaborative art project between Michael and another resident. This last support was especially significant. It helped alleviate Michael's fears of not having friends in the home. Michael worked collaboratively with a long-time, popular resident who was also a member of the resident council and a natural leader at the home. They created a poster that was part sculpture, part collage. The therapist noticed that during the interaction with the other resident, Michael began to laugh and joke. He would get excited over each new idea. He was investing additional energy in their work together. When the work was finished Michael asked the therapist if they could find a frame for it. They picked out a frame together and Michael selected a spot in the house in the front lobby where it could be displayed to staff, residents,

volunteers, and other visitors to the home. Michael's interest in Arts and Crafts eventually waned but through it, he developed important

volitional behaviors. He began to show initiative, stay engaged, and indicate interests with some support. He also indicated goals and pursued activities to completion with some additional support.

As Michael's interest in Arts and Crafts waned, others developed. The therapist had been working with residents to start a literary magazine. She invited Michael to be part of a small team of residents, staff, and volunteers developing the first issue. Michael sat with the group at the meetings as they brainstormed ideas without joining the conversation. After the meetings, he would ask the therapist to explain more slowly what had been discussed and what the project was about. Eventually Michael understood that they would need written work by residents. He shared with the therapist that he kept a journal. One day, after a meeting he asked her to read an entry and asked if it was the sort of thing they wanted for the magazine. Below is the entry:

Cristal And Caine

San Fransico Ca. I toot cristal than I notice my nose Were bleeding. I ask my self what I’m going to do, so I tried something different shooting up day

after day. I notice tracks on my arm again, I tried something different not facing my problems

running and running trying to find peace and happyness. I found caine I was so hook on caine I gave

up my self respect my family even my conscience, It destroyed my world in the real world caine

world the world of darkness. I never seen the light but the police light, I didn’t wont to come out

during the day people were staring at me. So I came out at night like a vampire sleeping during the

day, finding my prey at night like addicts do. not to mention addicts prey on other addicts,

especially your prey like a pack of wolfs you can here them howling in the night. So be afraid of the

dark side, and ask God to let you see the light and to live with Dignity.


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By Michael

The therapist discovered that Michael, despite his limited skills and vocabulary, had a natural affinity for writing. Michael was visibly pleased and surprised that people seemed to enjoy his writing. Initially, he scoffed when the therapist called it "poetry". However, he began to initiate conversations, asking her questions about what was meant by "poetry". He would show his work to others with reluctant pride, "Someone says this is poetry but I don’t know nothing about that". Thus, Michael showed pride with support from others, relying on their reactions. The affirmation from others fed his motivation to continue writing. He produced several written works for the literary magazine.

Michael was consistently and spontaneously showing initiative, staying engaged, and showing preferences across different environmental contexts. He also indicated goals and pursued activities to completion with some support. A summary Michael's VQ scores at the end of the Exploration Module are shown in Figure 6-2. The scores are a composite from observations taken from variety of contexts.


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Figure 6.2: Summary of VQ Ratings, Michael, Exploration Module

Competency Module Stage 1:Accompaniment in Changes and New Challenges During this time there was also a marked change in Michael's interactions with others in the house. He frequently engaged in lively conversation with residents and staff alike, seeking opportunities to joke and laugh. He gained a reputation for his lively and joking nature, a marked change from the sullen man that had followed the therapist with a stack of paper to the Arts and Crafts room months before. The therapist maintained daily contact with Michael, becoming a significant part of the support network afforded him by the house. The therapist worked with the environment to create opportunities for exploration using material and social resources.

After two months of this routine, Michael began to indicate he was ready to the next challenge.

Skill Learning The therapist had noticed that the computers in the Learning Center fascinated Michael but that he appeared afraid to touch them. She began teaching Michael basic computer skills. He was motivated to learn by a desire to type his original works. Initially, others typed for him, but eventually, Michael developed his computer skills to the point of being able to do it himself with some assistance. The work had spelling and grammatical errors and words and sentences were arbitrarily spaced but Michael was visible proud of his efforts. He shared with the therapist that he would never have imagined that he could work on computers.

The therapist continued to facilitate opportunities for Michael to develop his interests. Michael was included in the small team of residents responsible for the maintenance of the Learning Center and continued to work on the resident literary magazine. By this time, Michael had finished his 3-month outpatient program. His typical daily routine consisted of going to an early morning meeting at 7AM and then returning to bed until about 11AM. After lunch, Michael would go to the Learning Center and help with projects, writing poems, or practice typing using a CD-ROM tutorial. For 2 more months, Michael settled into this routine.


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Michael took much pride in his writing and frequently showed his work to others. Often, people would correct his grammar and spelling errors. Michael became increasingly more critical of his own work and asked questions related to grammar. The therapist and others began to teach Michael some grammatical rules. Part of the process of writing for him now involved trying to make as few mistakes as possible. Similarly, he began to practice typing using the CD-ROM typing tutorial with the goal of increasing his speed and accuracy. Thus, Michael was increasingly trying to correct mistakes, indicating goals, and investing additional energy in the context of his writing. Additionally, he spontaneous showed that this activity was significant to him.

At this point, the therapist still maintained daily contact with Michael, showing genuine interest in his work. Other significant people involved in Michael's daily routine included the Activities Coordinator, volunteer, and other residents.

The therapist worked with Michael to establish attainable learning objectives. Michael's computer skills were developed to the point where he could create flyers and greeting cards with some assistance from the therapist or another person. In addition to his role providing assistance in the Learning Center, Michael took on the role of creating flyers and greeting cards when needed. The therapist developed a work order form that staff and residents filled out to request a flyer or greeting card specifying the kind of message they wanted in varying detail and always providing a deadline. Michael created flyers announcing house activities of events and made holiday and birthday cards as requested with assistance from others.

Prior to this new role, Michael would arrive at the Learning Center when he chose, usually after lunch. With this new role, however, Michael was expected to help other residents in the Learning Center starting at 11AM. Michael inconsistently arrived on time, often oversleeping. Also, he often needed to be reminded of deadlines by the therapist.

Beginning the counseling process The therapist provided feedback. Each week they would review his performance. They looked at his role in the Learning Center and also at his other commitments (AA, medical, house meetings). Eventually, Michael began monitoring his arrival times and when he met deadlines. This process involved learning the habit of using an alarm clock and monitoring the times he went to bed. The processing of experiences and the feedback provided by the therapist remained focused on these concrete goals. Together the therapist and Michael examined the effectiveness of different strategies Michael incorporated and how he felt about the small changes he attempted.

Michael also continued the process of skill learning. At this point in the Competency Module, Michael was learning in two key areas: computer and typing skills and habits of timeliness. In the meantime, the work begun in the Exploration Module continued. Michael continued to develop self-efficacy with his increasing involvement in occupations he valued.

Michael was increasingly trying to solve problems and seeking additional responsibility. His VQ scores at this stage are shown in Figure 6-3:


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Figure 6.3: Summary of VQ ratings, Michael, Competency Module

Living and telling a story Throughout their work together, the therapist and Michael discussed his accomplishments, his fears, and his goals. Initially, they discussed only Michael's current projects and the activities of the house. The therapist processed with Michael the difficulties of creating the collaborative piece of artwork, learning to type, and his writing.

In time, Michael began to show indications of future goals, beginning with his interest in going to school. As Michael began to relate more about his past, the therapist began asking him more about his past experience related to his present experiences, and what he envisioned in the future. At this stage, Michael was still pessimistic about the future. The therapist noticed that Michael appeared to retreat at the mention of "skills". He stated that he had no skills. The therapist noted that Michael often compared his performance to others. He was often discouraged, for example, when others learned or completed a task faster or when residents who had entered the house before him found jobs. When this happened, the therapist would ask Michael to talk about the accomplishments of recent days or weeks and the possibilities he saw for the future.

Despite the roles he took on in the house, Michael's sense of self-efficacy was still low with respect to other areas. The role of student or worker remained for Michael as important as they were absent in his life. Furthermore, Michael was beginning to reflect increasingly on the role of father. As more time passed without the use of drugs and alcohol, he reflected increasingly on the regrettable aspects of the past and worried about the future. The issues that presented themselves at this time would continue to unfold over future months.

The therapist and Michael worked together to explore the hope amid his increasing worries, and to determine the next progressive step to take in his life story.

The following are poems Michael wrote during this time.

Lost in Darkness

No where to go no, nowhere to live? Don’t know Where I’m going to get my next meal


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Can’t Find room in my heart to love I’ve tried living an honest but darkness got in my way I’m lost in the system I’m trying to find some one who cares but can’t… I’m asking is it me? Why doesn’t someone care? I’ve thought of ending my life but the faith of a mustard seed keeps me alive By: Michael

From the dark side When you lose faith in God, you will be in darkness. He gave us life the way we want to live it. But he wants us to live an honest and respectful life, and call on him in all situation. It may not come when you want it to be but he will provide you with your needs. have faith if you lose the faith you will be in darkness the devil will come in your life and your heart, you can’t feel nor touch someone heart I was like a wolf howling in the night, following my prey, I’ve been bitten by darkness It’s poisonous and deadly most of all it’s unforgettable.

By Michael

Living With HIV

Living with this disease is a hard thing to live with. Some will turn their backs and that is a fear in itself. Not getting support, not knowing if people will accept you and your illness. Sometimes you feel strong and healthy sometimes you don’t, mentally and physically. It’s an everyday thing that I live with. When I first found out that I had the virus, I wanted to die. I couldn’t see myself getting smaller. There would be times that the medication would make you sick, when they don’t work. That’s when the fear comes, but faith over come fears. I thank God that I’m alive and strong to deal with my

disease. I do believe that there would be a cure. I might not hear about it, but I will know about it.

P.S. People who live with this disease, be strong and thank God that you’re alive.

By Michael 5/ 21 / 2001

Approaching the next challenge In time, Michael began to appear less energetic in his routine and more pensive. Because Michael could clearly articulate his thoughts, the therapist began exploring long-term goals with Michael through conversations about the things that he enjoyed or valued. The therapist noted that Michael wanted to continue his education and eventually obtain a job. The therapist and Michael determined


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that a logical next step for Michael was to try participating in a class outside of the home. Michael was both eager and frightened to be in a structured learning environment. He associated a classroom environment with repeated failure. However, he agreed that it was time to explore an environment outside the home.

The therapist found a literacy program that provided individual tutoring but also held a Wednesday night creative writing class. The therapist accompanied Michael to the center for an initial visit. Dressed all in white holding on to a large shoulder bag with notebooks of his writings, Michael said almost nothing on the train ride to the center. When he finally spoke, he said, "You know I'm nervous, right?" He feared the teacher would lose patience with him, as had been the case often when he was a child. The therapist acknowledged his fears. She reminded Michael of his reasons for wanting to look at the program. The program had skilled teachers and tutors who could guide him toward getting his GED. Moreover, Michael could opt not to attend the literacy program. The choice, ultimately, was his. In this way, the therapist put the process into an exploratory context, lessening the potential for failure.

When they arrived at the center where the program was held, the director, a pleasant woman with a welcoming smile, greeted them. She gave them a tour and took time to read the poetry Michael had brought. The number of computers the center had visibly impressed Michael. He told the director that he knew "a little" about computers and wanted to learn more. The director told Michael that he could work with a tutor at the center to help him learn more. She also made encouraging remarks about Michael's writings. Michael decided that he would try attending the program.

Michael enjoyed the literacy program. He received individual tutoring on Monday, Tuesday, and Thursday evenings. On Wednesday, he participated in the creative writing program. He left on time to catch the train to the center without any reminders from the therapist. He began to make friends with people in the program. Eventually, he was invited to participate in an open-mike poetry reading at a local coffeehouse. A couple of people from the home went to watch as Michael "debuted" some of his poems. Attending the coffeehouse readings became an additional part of Michael's routine.

Through his writing, Michael found a tool for validating his experiences. The people at the literacy center and the coffeehouse provided him with increasing affirmation. Through interactions with them, he began to see the ties between his writing, his identity ("where I've been, what I've seen"), and social causes ("what's out there"). He began to feel as if he had something to say to the world. He wrote dozens of poems, many of which he read at the coffeehouse gatherings. Among them were the following:

Life in the Ghetto Babies having babies confused that they blows sometimes don’t have a father, they see the anger in their mother’s eyes. Wondering if they would ever get out the ghetto. So they go out to hustle selling rocks dummies bags. The fast money catches their eyes not knowing what life has in store for them. Dodging bullets seeing bodies lying, bleeding on the sidewalk like Vietnam but it’s not Vietnam its life in the ghetto.


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By Michael 8/31/01 Living sober

Living Sober is a wonderful feeling; I haven’t lived sober for a long time. I forgotten how to live sober, I been hiding my real feeling’s .I was like Dr. Jackal hiding Michael not letting people knows me. When you don’t open up u lose in the long run, Even if you get hurt don’t shut down. If you open Up too god, he will answer your prayers. He’s my savor my father most of all He love’s me.

By Michael

In other areas of his life beyond his writing, Michael struggled for a sense progress. Michael initiated more conversations with the therapist about the future. Increasingly, he expressed fear that he would never be able to find a job, that he would never be able to afford living on his own, that he would never establish contact with his son. Saving money became a priority for him. However, before the end of every month, he had spent his entire SSI check of $530.

The therapist explored with Michael several possibilities for steps to take towards the goals of employment and saving money. Based on their discussions and with assistance from the therapist, Michael filled out an application for a job at the house where he lived working in the kitchen. The position was one of four resident-employee positions supervised by the chef in collaboration with the therapist. The therapist also investigated two other community resources. One was a job training and placement center for people with disabilities. Michael would qualify for their services. The other was another nearby social service agency that provided services to children and elderly. Michael could volunteer there. The therapist sat by Michael as he made calls to both places requesting appointments for an initial visit.

Michael began demonstrating behaviors indicative of seeking challenges and seeking additional responsibility with lots of support from the therapist.

In the meantime, Michael and the therapist also examined Michael's monthly expenses. Together, they identified areas where he could cut costs (dry cleaning, cable TV). Michael's mother was his payee. She received his check each month and then turned it over to him in cash. Michael said he wished to receive his check directly and have his own back account. The therapist asked Michael to speak with his case manager about the steps necessary to do this. In the meantime, the therapist paid a visit to a nearby bank and spoke with the branch manager. The branch manager agreed to let residents from the home open savings accounts at the bank with no minimum balance requirements. This would help Michael and other residents.

With the help of the case manager and Michael's mother, Michael came his own payee. His check would be directly deposited into his own back account. Michael had never had a bank account. The therapist went with Michael to open the account. Before going to the bank, they reviewed the kinds of questions he might want to ask.

Michael opened a savings account. The therapist showed him how to use his bankcard, to write money orders for bills, and to track his expenditures. The bank account was a significant step in increasing Michael's sense of autonomy.


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At this point, Michael was showing high indicators of volition in activities that involved his writing. However, in other areas, like banking, calling the vocational training program, etc his behavior indicated a need for continued support from the environment. Figure 6-4 compares Michael's VQ score reading his poetry at the coffeehouse with withdrawing money at the bank using the teller.

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Figure 6.4: Summary of VQ Ratings, Michael, Poetry


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Figure 6-4 Comparison of Michael’s VQ Scores in 2distinct contexts

VQ RATINGS - Michael: Poetry Recitation

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VQ RATINGS – Michael: Banking

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Moments of Reflection Michael decided to withdraw his application for the job in the house kitchen. He processed the decision with the therapist and maintained that he did not wish to pursue the job for fear of rejection. The therapist respected Michael's decision and supported another decision to go for an assessment at the job training and placement center. He was placed in a janitorial training program. A week before he began the program, he got sick and landed in the hospital with PCP pneumonia. Michael spent three weeks hospitalized and was near death at one point. The therapist visited Michael in the hospital. He admitted that he had not been taking his AIDS medications. They had been causing him digestive problems so he had decided not to take them. Together with Michael, the therapist talked with a nurse that explained to Michael the importance of taking his medications and maintaining communication with his doctor over side effects.


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Michael returned from the hospital shortly before Christmas. He had to suspend his plans to start the janitorial training program and his attendance at the literacy program while he recovered his health. He worked with the therapist to devise a plan for taking his medications and for monitoring the side effects he experienced. Michael was visible happy to be back. He joked and talked with staff and residents with more than his usual exuberance.

In two weeks, Michael returned to his routine at school. However, shortly afterwards, Michael began to spend periods of time in his room or outside of the house. He missed required house meetings and stopped going to his classes. The therapist received a call from a trainer at the vocational program that Michael had missed two appointments. When he was seen, he was sullen and avoided eye contact with others. One evening he left the house and did not return until 7 the next morning. Staff was concerned that he might have returned to using drugs. He spent that day sick in bed with a fever. This was his pattern for almost two weeks. The therapist would check on him briefly and express concern without pushing him talk.

Finally, one day Michael shared with the therapist that he was feeling like he had "stepped into quicksand". When the therapist asked if he had been using drugs, Michael replied that he had not but that he had frequent thoughts about doing so. He was thinking more and more about his son and reflecting on the time he spent with him and the abuse that had surrounded it. In tears, he spoke of wanting to reconnect with his son but not knowing what the first step might be or where his son even was. Finally, he shared that he felt he was "never going to make it" - that all the effort he had put forth in the past year was not worth it. The possible endings he saw for his story included returning to drug use and dying on the streets or dying from AIDS in the near future.

The therapist and Michael talked for a long time. Together, they linked Michael's current feelings to the scare of nearly dying in the hospital and the reality of his deteriorated health. Michael acknowledged that the holiday season also contributed to his increasing despondency. He missed his son and longed to regain contact with him but was fearful of his son rejecting him. Months prior, he had written the following letter for his son but was torn over whether or not to look for where to send it.

A Son of Mine

You are the most beautiful person on earth. I miss the your laughter, I miss not knowing you better. I wish I could tell you, how much drugs interfered with our relationships. I left you when you needed me the most, I ran from my responsibility as a father, went in and out of jail because of drugs. I will have to live with that guilt for the rest of my life. You will always be in my heart no matter how you fell about me, I will always’ love you. Yours truly Michael Sr. 9/20/01


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As they talked, the therapist and Michael identified concrete steps he could take with regards to his son and talked out different scenarios for what might happen if he chose to take them. Michael decided to wait to send the letter. Finally, they began reassessing his abilities and goals and formulating a new plan.

The new plan eventually meant that the janitorial program would be replaced with a less physically demanding option. Michael, the therapist, and vocational counselor at the program would work as a team to investigate alternatives. In the meantime, Michael resumed his activities in the Learning Center continuing to learn new skills. It was apparent to the therapist, however, that Michael continued to be troubled and seemed to seek more solitude. Ironically he joked and laughed more than ever when he was around other people. The following are two of the poems that Michael wrote during this time.

Slavery of Cocaine

Stuck in the bottom like quicksand can’t find happiness in my heart. nothing but hatred running from whitey but it seems it always caught me. whipping me whipping me and whipping me until I’m dead. By Michael 12/24/01

Quick Sand

Sinking sinking and sinking’ into the world of darkness. struggling to get on my feet, not going nowhere. but standing in quicksand waiting for someone to throw me a rope, but the rope is to short like lifeel, trying to live a honest and respectful life and that’s the good life.

By Michael 1/17/02

Shortly after Christmas, Michael once again disappeared overnight. Upon his return this time he admitted to the therapist that he had gone back to his old neighborhood, hooked up with some old friends and used cocaine after almost one full year of sobriety. Michael was bitterly disappointed in himself. Also, he ran the risk of once more being asked to leave the house. Michael agreed to go to an outpatient program once again to deal with his addiction and in return he could continue living in the house. For several weeks, Michael took a break from most of his activities to reassess with the therapist and others in his addiction program what had occurred. His need to participate in an outpatient addictions program once again meant postponing a commitment to a job-training program. He began attending AA meetings with more frequency and processing with the therapist the importance of these meetings in his life.

As the months went by, Michael began the process of making occupational choices with slow deliberation but with increasing autonomy. He approached his role as student and the potential role as worker with new seriousness. Independently, he called a local GED program to see about enrollment in more structured classes. A job opening in the kitchen was again made available and Michael chose to go through with the application process. This involved practicing his interviewing skills with the therapist and putting together a resume. When he did not get the job the first time, he was disappointed but continued to look for ways he could develop the skills he needed to land a job.


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A second opportunity to apply for the job presented itself and Michael was hired. The new job presented a series of new challenges from testing his physical stamina to being consistent and reliable in his attendance and performance. Having worked hard for his job, Michael met these challenges with enthusiasm often seeking challenges on his on, like taking on double shifts to test his abilities.

Throughout, he kept writing and maintained his ties with the creative writing group and the coffeehouse. Even as he struggled towards his goals towards increasing his education and resuming the roles of worker and father, he became at ease calling his writing poems and himself a poet. Michael's poetry continues to be a vehicle to both explore his identity and tell his life story. Month after his relapse with cocaine, Michael wrote the following:

After Darkness

After darkness is a good feeling of life. seeing the beauty of life, in it self knowing people love you no matter what the circumstance was in the past. people do forgive and that’s love, I thank God for giving me light after darkness.

By Michael

Lost in a Storm

Sailing in the night, dark clouds ahead the storm is coming get down below, the captain said. looking for a tower in the storm three days past no luck no hope nothing but the sound of thunder lightning over there heads not knowing if they are going to live or die. A light ahead circling around it self. being helpful for sight. in darkness the tower of life. At last on land, at last on land.

By Michael

Figure 6-5 provides a summary of Michael's VQ scores taken in across different contexts at this

stage in the Competency Module:

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CHAPTER SEVEN

The Achievement Module


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CHAPTER SEVEN THE ACHIEVEMENT MODULE

Throughout the Remotivation Process, therapists strive to give clients increasing sense of control over their lives. Previously outlined strategies (facilitating choice making, facilitating the process of negotiating environmental demands, etc.) contribute to this. By the Achievement Module, clients generally feel in control when confronted with most occupational challenges. Their sense of personal causation has developed to an extent that they feel they can overcome difficulties.

The Achievement Module is the phase where clients seek to integrate new areas of occupational participation in all aspects of their lives. Typically, clients will do this by practicing skills and abilities discovered in earlier modules in more challenging contexts. Examples of this may include moving beyond having roles in a therapeutic setting to taking on roles at home or in the larger community.

Figure 7-1 shows the Achievement Module in the Remotivation Process.

AUTONOMY


EMERGING SELF-EFFICACY

ACHIEVEMENT

COMPETENCY

EXPLORATION


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Goals and Objectives of the Achievement Module When clients reach the Achievement Module, they have the necessary self-efficacy to function and perform in a variety of relevant situations. Many of the strategies incorporated in the Competency Module are continued in the Achievement Module but with the clients taking increased ownership for choices made in their involvement in occupational roles. Continuing support from the therapist now takes the form of monitoring performance and occasionally reaffirming the client’s ability to make decisions, establish new goals, solve problems, and manage stress. At this level, clients have increased volitional autonomy and significant role performance. Clients also begin the process of self-monitoring and self-evaluation. Therapists, in turn, step back to let clients be more autonomous, learning to “let go” of the client as they show increasing capacity to negotiate with environmental demands and constraints and take advantage of environmental resources and opportunities. The two main objectives of the Achievement Level are:

To facilitate autonomy in setting and striving for personal goals, making occupational choices, and seeking new challenges in relevant occupational environments (a process begun in the Competency Module)

To facilitate the continued learning of critical skills and the application of new strategies and tools for seeking and confronting new challenges

The Achievement Module is not further broken down into different stages, but as with the Exploration and Competency Modules, specific strategies are suggested for facilitating the Achievement Module goals. Therapists serve as counselors or consultants to clients, supporting clients to find their own ways to realize these goals.


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Table 7-1 outlines the Achievement Level

TABLE 7-1 The Achievement Module Goals and Strategies

GOAL STRATEGY

Autonomous person-environment negotiation; autonomy in setting and striving for personal goals, making occupational choices, and seeking new challenges in relevant occupational environments (a process begun in the Competency Module)

Continued learning of critical

skills and the application of new strategies and tools for seeking and confronting new challenges

Advising to facilitate interpretation and choosing

courses of action in new challenges by maintaining objective perspective and an awareness of client's subjective experience

Giving Feedback to facilitate client's insight into

personal causation and interpretation of environmental elements

Providing information and resources: give tools

and strategies for self-monitoring

Stepping back: let the client practice autonomy, encourage self-help groups, etc.

Reflection Moments and Moving Towards Achievement Recall that during the Competency Module, as clients begin to apply newly acquired skills in new situations, they experience moments of doubt in their own abilities and often retreat from or reject involvement in these new situations. In the Achievement Module, clients face such moments of doubt with increased understanding of their significance. Thus, instead of automatically retreating from a new challenge, clients undertake the natural process of reflecting on the elements of the new challenge, taking into consideration both the environmental demands for performance and their own skills, values, expectations, etc. In other words, clients now use knowledge from past experiences to understand and have expectations of new ones.

Moments of reflection are necessary when individuals are confronted with difficult occupational choices. These often occur with the need to make a decision that will greatly impact one’s life, for example, taking a new job, leaving a home environment for a new one, deciding to return to school, etc. These moments thus represent natural events that all individuals face when confronted with such significant possibilities for change within their life stories. Learning to recognize these moments and use them to grow is a part of the process of moving from Competency to Achievement. This can be a difficult process. Occupational therapists can assist clients through identifying, advising, and providing feedback.


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What Strategies do Therapists Use in the Achievement Module? When the client approaches a level of Achievement, the occupational therapist's role must change accordingly. Initially, therapists may be more involved as clients bridge competency and achievement. Then, as clients naturally begin to explore areas of occupation with increasing spontaneity, the occupational therapist is less actively a part of the client's life but remains available as a resource as needed.

Because clients at this phase must exercise their autonomy, the therapist must carefully assess the moments when intervening is necessary as the client confronts challenges and makes negotiations. Therapists, for example, may see clients for monthly follow-ups and eventually progress to seeing clients only on an as needed basis. During these sessions, the therapist serves as a consultant, continuing when needed to facilitate clients' living and telling of their stories. This narrative process is now occurring in a more complete manner as clients are moving through a range of volitional processing according to their capabilities. By the Achievement Module, clients have experienced many of the processes of change detailed by Kielhofner (2002). Clients, for example, have explored new activities, planned courses of action, practiced chosen courses of action, and re-examined their experience to determine future courses of action. Therapists use this base of experience to continue supporting clients in new and increasingly challenging contexts. The following are strategies an occupational therapist may use with a client in this final phase of the Remotivation Process:

Advising Giving feedback Identifying information and resources Stepping back

Each of these strategies is discussed in detail below.

Advising The experience and skill of therapists in understanding and using elements of environment, occupation, and the individual serves as a valuable resource for clients. During the Achievement Module, therapists advise clients as needed, for example, when clients appear to experience moments of reflection. Advising may include recommending courses of action base on a clear understanding of clients' volition and realistic opportunities, pointing out the value of one course of action over another or explaining the value of adopting additional or new strategies in approaching challenges. The therapist’s ability to both understand the subjective experience of the client and maintain an objective perspective is crucial here.

Giving Feedback Feedback is a strategy continued in the Achievement Module. Therapists draw on previous experiences with clients and previous feedback to continue to give feedback when opportunity arises. Ongoing feedback supports clients’ increased insight into their personal causation and sense of efficacy as they confront new challenges. This, in turn, supports the ease in which clients choose suitable courses of actions toward their goals.


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Identifying Information and Resources Again, at this stage, therapists shift their focus from a heavy emphasis on validation to being a consultant. Therapists often have knowledge of community resources, techniques and strategies, and informational sources, tools, etc that clients are not aware of. Also, by the time that clients reach the Achievement Module, they are ready to use methods of self-monitoring and self-evaluating to guide and determine their continued volitional development process. Therapists have tools that serve this purpose.

Throughout the Remotivation Process, the therapist strove to give the individual an increasing sense of control over their lives by facilitating opportunities for choice making, by facilitating an understanding of environmental demands and personal capacities, and in general by facilitating the process of negotiation with the environment. By the Achievement Module, the individual feels in control when confronted with most occupational challenges, with a sense that he/she can overcome difficulties that may arise.

In addition to the strategies and tools the therapist has helped the individual acquire in other levels of the Remotivation Process, now the therapist can provide the individual with concrete ways and instruments to examine their own volitional process. The therapist can help the individual identify personal strategies that work best for him/her when confronting challenges. The therapist can also teach the individual to use MOHO assessments. For example, the therapist can instruct the individual on use of the Volitional Questionnaire, teaching the individual how to critically interpret his/her behaviors and attitudes in different contexts and increase awareness of how different situations affect his/her volition. Use of the Work Environmental Impact Scale (Moore-Corner et al, 1988) to examine environmental factors and their relevance to the individual’s occupational choices, etc is also recommended. Self-monitoring along with the use of identified strategies for confronting challenges helps to maintain the individual’s autonomy.

Thus, therapists use the strategy of identifying in the following ways: Identifying relevant pieces of information from their knowledge and resource base and

sharing them with clients Teaching clients to use occupational therapy assessments on themselves. Therapists can

teach clients the basic principles underlying the use of assessments like the VQ and go over the use of indicators to understand volition. For example, clients can use the VQ, to critically interpret their own behaviors and attitudes in different contexts and increase awareness of how different situations affect their volition. They can use the Environmental Impact Scale to examine environmental factors and their relevance in occupational choices

Helping the client identify elements that impact positively or negatively on their abilities to problem-solve and make decisions and evaluate their own capacities when faced with certain external demands, etc.

In these ways, therapists contribute to giving clients increased autonomy in making occupational choices, setting occupational goals, practicing and sustaining courses of action, etc.

By this stage in the Remotivation Process, many different assessment tools can be used as the therapist deems appropriate. Table 7-1A provides a quick overview of the specific assessment tools used during various stages of the Remotivation Process.


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TABLE 7-1A ASSESSMENT TOOLS USED IN THE REMOTIVATION PROCESS

Tool Description

Stages introduced

Volitional Questionnaire (VQ) (de las Heras 1993, de las Heras, 1997, de las Heras et al 1998, Chern et al, 1997)

Evaluators use 14 indicators to assess volition by observing the client in a series of activities. Clients are rated on a 4-point scale. The VQ also includes a section for assessing the environmental context in which activities are performed.

Exploration – the VQ is used repeatedly throughout the entire Remotivation Process

Occupational Performance History Interview II (OPHI-II) (Kielhofner et al, 1998)

Evaluators conduct a semi-structured interview with the client, caregiver, or others that can provide insight into the client’s past and present occupations. Rating scales measure occupational competence, occupational identity, and the impact of behavior settings.

Exploration – The OPHI-II can be used as an initial assessment tool together with the VQ.

Occupational Self-Assessment (OSA) (Baron, et al 2001)

Evaluators may assist clients in completing the 2-part self-rating form. Clients rate their occupational functioning in various areas and their perceived importance of these areas. They similarly rate elements of their environment.

Competency – Stage 1

The Role Checklist (Oakley, Kielhofner, & Barris, 1985)

Clients review a list of 10 occupational roles and indicate whether they have engaged in the role in the past, are engaged in the role presently, and/or anticipate being engaged in the role in the future. Finally, they rate how much they value the role.


The Work Environment Impact Scale (Moore-Corner et al, 1988)

Evaluators conduct a semi-structured interview with client about how they experience their work environments, The WEIS examines 17 environmental elements and rates them on a 4-point scale.


Stepping back Perhaps the biggest challenge for the therapist at this level of the Remotivation Process is determining whether or not the client continues to need intervention and how much intervention to continue to supply and in what form. According to the MOHO, therapy is an event that comes into a life in progress and must be understood and undertaken in that context (Kielhofner, 2002). Therapists serve as agents for change but not protagonists in the lives of clients. As clients begin to more actively resume control over the progress in their lives, therapists need to step back and allow for this.


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Let us review the stages in the client-therapist relationship leading to this point: 1) Exploration - Therapists negotiate with the environment

Clients and therapists begin the process of Remotivation with an exploration of how to negotiate between environmental demands and client needs and expectations. Therapists at the beginning of this process, in the Exploration Module, play a major role in structuring the environment to facilitate positive experiences for clients. Once clients develop a basic level of confidence and security, they feel capable and ready to begin negotiating with the environment through their own activity.

2) Competency - Collaboration between client-therapist

In the Competency Module, clients and therapists are involved in a collaborative relationship: co-problem solving, co-planning, and in general co-negotiating with environmental demands. During this process, clients increase skills and competency in different contexts and begin to consider life goals.

3) Achievement - Client autonomy, therapist steps back

Now, at the Achievement Module, the client is ready to begin to assume total responsibility for the process of negotiating with the environment.

What began with the transpersonal nature of volition where therapists, and later others within

collaborative group projects, reaffirmed and validated clients' capabilities, now culminates in each client's ability to self-validate and rely on an internal sense of one's capabilities. In other words, now the “person goes to the environment, instead of the environment coming to the person” (de las Heras, 1999).

As clients at the Achievement Module become more and more efficient and effective in confronting new situations and determining how to adjust behavior to conform to the expectations of social situations, they need less support of therapists. Eventually, the support of the therapist is replaced by natural supports in the clients' relevant environments.

What are Natural Alternatives to Therapy? According to MOHO, “Volitional change means finding a direction for one’s personal narrative” (Kielhofner, 2002) Therapists must be able to recognize the gains clients make in finding such direction and respect their ability to rely on their own volitional process to continue the living and telling of their personal stories.

A necessary part of this is to expect and encourage the client to look for natural alternatives for advice and support apart from the therapist. The use of friends or self-help groups, for example, may become primary resources for the client. These resources facilitate the process of information gathering, reflection, and re-examination needed to make occupational choices or to sustain a level of satisfaction in life.

One way therapists can facilitate this without unnecessary intervention is by providing spaces for these kinds of support networks to take place. At the Reencuentros Clubhouse, for example, therapists provide a space for ex-members to get together one Saturday a month and discuss issues and problems, providing mutual support for one another without therapists or other professionals. The Clubhouse's only role thus was to provide the space and time for such support. The clients do the rest.


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The final phase of the Remotivation Module is illustrated through the use of a case example, the story of David. The story of David begins with a summary of his movements through the Exploration and Competency Modules. David moved relatively quickly through these modules. A discussion of David's progress through the Achievement stage follows.

Case Example: David, Striving for Achievement

Summary of Exploration and Competency Stages

Progress through Exploration David was 47 years old when he arrived at the transitional home for people with AIDS. He had

been in the hospital for a month prior for an infection that affected his digestive system. He had lost close to 60 pounds. He had neuropathy, which made walking difficulty. Before being hospitalized, David had lost his job and was consequently unable to maintain his apartment. He had been living with HIV/AIDS for seven years. He also struggled with alcoholism and substance abuse.

The therapist at the home did an OPHI-II on David when he first arrived. David was very articulate and enjoyed talking about himself. He was highly intelligent and openly referred to himself as such. When he spoke, he often used big words and alluded to famous people that he knew. David was raised in an upper middle class family in the northern Chicago suburbs. Though he never finished college, his ability to learn things quickly allowed him to secure professional jobs. He took much pride in this. He worked at an insurance company, eventually moving up to a high paying position where he supervised many employees. He was with the company for ten years. David claims that job stress contributed to his developing an ulcer and exacerbated his drinking. After this job, he worked several others, mostly as a computer consultant but also in accounting. The therapist eventually learned that many of his jobs were lost due to conflicts with others, including his supervisors. In fact, among David's contacts few, if any, could be counted on for references. David blamed others, including past supervisors, for his current situation. They had been too demanding, stupid, or uncaring, and thus he was now sick and homeless. David's interests included cultural arts and computers. He had also been a member of the Gay Men's Chorus of Chicago when he could afford to pay dues. He followed local and national politics and was well informed on HIV/AIDS issues.

The therapist determined that the Role Checklist was an appropriate assessment to use with David. She learned that, though David placed importance on many roles, he had been unable to sustain nearly all of them. Figure 7-2 shows David's Role Checklist at this Exploration stage.

ROLE Past Present Future Not at all valuable

Somewhat valuable

Very valuable

Student X X Worker X X X

Volunteer X X Caregiver

Home Maintainer

X X X

Friend X X X X Family

Member X X


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Religious Participant

X

Hobbyist/ Amateur

X X X

Participant in Organiza-

tions

X X

Other

David was quick to tell the therapist that he did not believe he had anything in common with the other residents, many of whom had never finished high school or worked for significant lengths of time. The therapist noticed that initially David spoke only to staff members and never to residents. He liked to engage staff in long conversations about his past accomplishments when he could. The therapist also noted that things in the house easily frustrated David. When dinner was late, he would mutter angrily under his breath. He would yell and curse when someone neglected to give him a phone message. However, he rarely spoke directly with the resident at fault. He spent most of his time in his room or talking on the telephone. He ate meals alone. At house meetings or support groups he would never speak aloud but often made scornful facial expressions or muttered sarcastic comments under his breath.

The addictions counselor at the home and the therapist were the staff members who worked closely with David. Though David had expressed a desire to return to employment he was unsure of his ability to do so because his physical health. Instead, David and the therapist examined ways he could get involved in house activities. In sobriety support groups and individual counseling, the addictions counselor began talking with David about his short frustration tolerance and his need to be more accountable for his actions and his situation. Initially, David was resentful of this and refused to acknowledge any of these observations. Because of David's computer skills, the therapist invited him to help out in the house's learning center in the computer lab. David agreed to try it. On David's first day in the learning center, he sat at a table away from the computers and told stories about his past to the therapist. The therapist finally asked him to type a project, a simple sign to post in the family room. David sat at a computer station and began analyzing the computer. He scoffed at how "outdated" it was, and it was Microsoft, while he preferred Macintosh. He began typing. Soon, he was swearing at the computer and declaring the task hopeless. As he was getting up to leave, the therapist went to investigate the problem. She learned that, though David had excellent

technical knowledge about computers, he was not as familiar with programs like Microsoft Word. The therapist taught David some functions on Word. David learned quickly, all the while

insisting that he would not have any problems using WordPerfect. David completed the sign. Another resident, who was learning basic computer skills, noticed and said, "Hey man, that's cool!" David said thank you and chatted with the resident briefly, offering to help him with his learning. This was the first agreeable encounter David had with another resident. He was smiling as he left to place the sign in the family room.


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FIGURE 7-3: VQ RATINGS - David - Exploration

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Progress through Competency David returned to the learning center the next afternoon and afternoons afterwards for two months. He began by making signs and flyers. Through this, he learned to use Microsoft Word. Residents noticed his skill and asked him for help on occasion. Eventually, David spent most of his time in the learning center assisting residents. He helped them type letters, learn to use the Internet, and set up e-mail accounts. He was patient and thorough in his explanations, often going on tangents to explain the origins of a floppy disk or other bits of trivia. He was nicknamed "The Professor" by other residents. David was proud of this nickname. It meant he was accepted. He stated to the therapist, "I think some people here actually like me!"

As David experienced new acceptance and new roles within the house, the addictions counselor and the therapist gave David feedback on his interactions with others and his continued bouts of anger. Slowly, David began to see a connection between the way he acted toward others and his past and current problems. The therapist gave him concrete examples of behaviors that would support change, such as asking questions when he needed help and refraining from sarcastic remarks at meetings. These changes were difficult for David but with ongoing feedback, they grew easier. David's motivation stemmed from a deep need to be accepted by others. He had always believed that others should accept and appreciate him for his intelligence and knowledge and was repeated disappointed when he this proved not the case. With his work in the Learning Center and his interactions in the house, he was learning to see other ways in which he could be accepted. At the same time, he grew increasingly aware of behaviors that posed barriers to this. The therapist continued her feedback. Other residents used humor or sometimes outwardly confronted David on these behaviors.

David continued to take on more responsibility in the learning center and in the house. He was rarely in his room or on the phone. He spoke at house meetings, giving voice to many concerns other residents were reticent to vocalize. In support groups, he slowly began talking about his struggle to "learn humility" and how the house was helping him. During this time, David's health improved greatly. He had gained weight and his doctors noted that his viral load was virtually undetectable.


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After being a resident for six months, David ran for resident council and was not elected. He was bitterly disappointed and went to the therapist with a tirade of complaints about the other residents and "their ignorance", stating that he needed to leave the house because he obviously did not fit in. The therapist validated David's disappointment, but also encouraged him to see that blaming other residents and the other conclusions he was making were not constructive. The therapist advised David, helping him sort through his emotions, the realities of the situation, and the best courses for future action. Later on that day when another resident said he was sorry David had not won, David responded by saying, "No big deal - I'll get them next time." Three months later, when the new resident council was elected, David won a seat. At this point David's VQ scores were as shown in Figure 7-4.

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From Competency toward Achievement As David grew more secure in his roles at the house, he showed increasing interest in returning to work or doing volunteer work outside of the house. In his discussions with the therapist, David revealed that he did not wish to return to work similar to what he had done in the past. In college, he had worked at a radio station briefly and talked about going into broadcasting. He had a friend that worked at a radio station, and he hoped to use this friend as a resource. This however proved unsuccessful. Meanwhile, the therapist contacted a not-for-profit organization that produced HIV-related informational excerpts for various talk radio networks. They frequently recruited interns. David interviewed and obtained a position as an intern. The therapist advised David to take things slowly and not be scornful of the daily tasks they might assign him at first. David understood that he would need to work his way up. At first it was hard for David to stuff envelops and work the copy machine. But the therapist talked with him and helped him see this time as an opportunity to prove himself to the others who worked there. David was learning that getting along with others was as important a skill as any technical one.

One day, David came to the therapist's office after his day at his internship. He proudly declared to her that they had entrusted him with doing an interview with a well-known HIV activist. It was his first opportunity to be on the radio!


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David continued to take on increased responsibility at his internship site and maintain his roles at the house. At this point, he was bridging Competency and Achievement.

Achievement Module: Autonomously Choosing Courses of Action After months of working at his internship site, David shared with the therapist that his boss mentioned giving him a stipend for his work. David had increased his hours from two days a week to four eight-hour days. His responsibilities matched those of the other paid employees. Weeks went by and there was no mention of the stipend again. Angrily, David complained to the therapist about his boss. The therapist advised David to speak calmly with his boss and reminded David of the very real possibility that his boss may have simply forgotten. David went to his boss the next day and they spoke about the stipend. The boss agreed that David's work merited financial compensation. However, the boss stated that the organization currently lacked the funds to compensate David. He asked David to stay on for another month and then they would revisit the possibility of the financial compensation. David was disappointed but willing to work another month without compensation. When, after a month, it was clear that there was still going to be no stipend, David chose to cut back his hours at the radio station to one day a week. His boss, however, insisted that David work on projects to the extent that he had been. David eventually decided to resign from his internship altogether. The decision was difficult, but David, with advice from the therapist, made this transition free of hostile conflict with his supervisor. This marked a significant departure from the way David often left jobs in the past. David felt he had left his internship on good terms and with a sense of closure. Leaving the internship relieved a large source of stress for David and allowed him to concentrate on looking for other opportunities.

David's next opportunity was one that he obtained independent of any assistance from the therapist. He chose to volunteer for a local politician's campaign. This role merged many of David's interests. He was involved in politics, networking with HIV activists, and making friends with educated and intelligent people that shared many of his passions. The therapist was aware of David's actions and was supportive of them. At this point, she stepped back and let David make these decisions. David was autonomously choosing courses of actions that aligned with his interests and values and provided adequately stimulating challenges for him.


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Achievement Module: Continuing to Learn Critical Skills For months, David worked long hours. He was rarely in the house anymore. He had been run for a second term on resident council and was once again elected. However, he was rarely present at their meetings. Likewise, he missed many mandatory house meetings and often neglected to lock the learning center at night, his one remaining responsibility in the learning center.

When the therapist finally had the opportunity to talk with David, she gave him feedback about his lack of consistency in meeting house responsibilities. She advised him to relinquish some of his responsibilities in the house to others to free himself up to carry on his commitments outside of the house. David became angry and refused to give up any of his responsibilities. He stated that the responsibilities of the house were very simple and it was nothing to manage them along with his outside commitments. He blamed other residents for failing to remind him of meeting times or to cover his learning center shift when he had asked them to.

A week later, after neglecting his responsibilities to the house yet again, David went to the therapist and apologized for his previous behavior. He returned the key to the learning center and admitted that, in fact, he no longer had the time and energy to do everything he had signed on to do. The therapist and David talked at length about his progress. The therapist reminded David of when he first began working in the learning center and the kind of person he was then. David acknowledged that he was arrogant and yet afraid of being rejected by other residents. The acceptance he received in the house had given him the confidence to go out and do the things he was currently involved with in the community. The therapist also talked with David about the moments when his old behavior would resurface. She gave him feedback on what that behavior looked like to another person and the feelings it stirred in others. These were observations that had been made in the past, but they served to remind David again of how to monitor his behavior as he moved into new contexts and his life continued to unfold. David acknowledged that the behavior surfaced most when he felt stressed or overworked. He knew that along with working on getting along with others, he needed to work on setting limits on how much he took on. He realized that this would be an ongoing task for him. The therapist had given him some tools for which to monitor himself and strategies for sustaining positive change. Through such interaction with the therapist, David reinforced the skills he had learned and the insight he achieved.

After a year at the transitional home, David moved out to live in his own apartment. His work with the local politician had led to a paid position. He worked to advance the causes of people with HIV/AIDS. Through his work and his other interests, he had a supportive network of friends. He maintained relationships with residents, however, and continued to attend the same AA support groups as they did. Before he moved out, he had several more conversations with the therapist about his progress and the critical skills that he continued to develop.

At this point, David had regained many of his former roles with new insight into how to sustain them. Figure 7-5 of the follow-up Role Checklist scores for David reflect this.


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Role Checklist: David - Achievement

ROLE Past Present Future Not at all valuable

Somewhat valuable

Very valuable

Student X X Worker X X X X Volunteer X X X X Caregiver Home Maintainer

X X X X

Friend X X X X Family Member

X X X X

Religious Participant

X X

Hobbyist/ Amateur

X X X X

Participant in Organiza-tions

X X X X

Other


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