This case study of Jason, a young man who sustained a spinal cord injury (SCI) after a 50-metre fall into a quarry and who completed a rehabilitation programme in a specialised SCI centre, illustrated that there are various factors, both internal and external, that seem to affect motivation and how motivation, in turn, influences the rehabilitation process and outcome.
The role of motivation in rehabilitation, as demonstrated in Jason' case, is highlighted in several studies.89101112 Of particular relevance to Jason's case are the approaches of motivation that Maclean and Pound outlined based on a review of 50 rehabilitation-focused studies spanning a period of thirty years.9 According to Maclean and Pound these studies are characterised by the following three approaches of motivation in clinical settings:
According to the individualistic approach, motivation in the context of rehabilitation is linked with expectations of participation in the rehabilitation process. A low level or lack of motivation, characterised in one study as involving “apathy, dependency, and the refusal to accept responsibility for recovery” is considered a personality defect. Behaviours stemming from this low level or lack of motivation is even labelled by some supporters of the individualistic model as “Abnormal Illness Behaviour (AIB)”. Interestingly, the same researchers who established the term AIB later acknowledged that AIB may be provoked if the person and the rehabilitation professional(s) do not share the same rehabilitation goals. In other words, some external factors – in this case rehabilitation professionals – may play a role in prompting negative behaviours. The individualistic approach has been criticised by many as promoting a moralising attitude by placing the sole responsibility of rehabilitation success on the person, i.e. this attitude may consequently manifest itself in moralising behaviours toward the person.9
Jason's case seems to reflect the combined individualistic-social approaches, exemplified by the change in Jason's involvement in the rehabilitation process. After three weeks of what the rehabilitation team considered a lack of motivation, Jason became more actively involved in his rehabilitation, including doing extra physical exercises and intensifying the training of his wheelchair basketball skills. While the reasons for Jason's shift in behaviour were unclear, the rehabilitation team suspected that the following factors may have played a role in increasing Jason's motivation and consequently the change in his behaviour:
The fact that the rehabilitation team connected Jason's introversion and passive communication during interventions with a possible lack of motivation could be seen as reflective of the individualistic approach. However, the rehabilitation team did recognise their (social) role in facilitating Jason's motivation, consequently adjusting their communication approach toward Jason. The efforts of the rehabilitation team to improve their communications with Jason echoes the “relatedness” element (connectedness with others) of the self-determination theory of motivation,2357 specifically, the importance of developing trusting and mutually respectful health professional-patient relationships.12
While Jason's case illustrated the importance of motivation in the rehabilitation process, it also showed the difficulty in clearly defining the scope of motivation, and that integrating the aspect of motivation in rehabilitation interventions is not clear-cut. This was evident in the decision of the rehabilitation team to define only the personal factor of ‘personal motives’ as an intervention target instead of also including the body function category b1301 Motivation. In addition, beyond psychological counselling to address Jason's emotional functioning and communication issues, and ‘personal motives’, the rehabilitation team decided to address Jason's motivation issues predominately through indirect means, such as by showing patience and encouragement, rather than providing additional concrete interventions.
"...there is value in integrating practices in rehabilitation that optimises a person's motivation..."
The lessons learned from Jason's case has some implications for rehabilitation of persons with SCI – there is value in integrating practices in rehabilitation that optimises a person's motivation, especially practices that are person-centred, foster shared goal-setting and decision-making, enhance clear communication between the person and rehabilitation team, and promote a mutual understanding of needs, processes and goals.891012
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