Discussion

Among persons working in a rehabilitation setting there is a general understanding that motivation has an impact on the achievement of rehabilitation goals and ultimately on long-term outcome. However, evaluating a person's motivation and targeting interventions that address motivation is an inexact science.

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:

• Individualistic approach: Motivation is a personality trait of the person receiving clinical interventions that is unaffected nor explainable by social factors.
• Social approach: Motivation is affected by the extent the person and rehabilitation professional(s) share values in the therapeutic encounter, by the way clinicians communicate with and behave toward the person, and the person's social networks.
• Combined individualistic-social approach: Motivation is influenced by both internal traits of the person as well as by diverse social factors, include those mentioned in the description of the social model.

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:

• Psychological and emotional factors: Jason gradually overcame the psychological shock caused by the trauma of incurring a SCI. This psychological shock not only impaired his emotional functioning, impacting on how he perceived his life situation post-SCI compared with his life before his SCI, it also stunted his motivation. The passing of time, as well as improvements in functioning and the prospects for regaining a “normal life” all contributed to increasing Jason's awareness and acceptance of his life situation post-SCI.
• Social factors: Before the injury, Jason had been an accomplished and disciplined athlete. After the injury and early in the rehabilitation process, Jason often felt “mothered” and that he was being treated like a child – this was demotivating for him. As rehabilitation progressed, the communication between Jason and his rehabilitation team improved, possibly due to the interventions of the psychologist and the patience and support provided by the other rehabilitation team members. Jason also benefited from the strong social support provided by his friends. In addition, the other patients in the rehabilitation centre, who improved in functioning and were discharged home, served as role models; they helped Jason to imagine a life beyond the rehabilitation centre.
• Factors related to goal-setting: Having to give up his goal of playing competitive sports the way he did prior to his injury produced a demotivating effect on his participation in rehabilitation. However, being able to play wheelchair basketball compensated for the inability to reach his pre-SCI goals in sports. This, in turn, helped Jason to accept his limitations and adapt accordingly. Subsequently, he redefined his personal goal from participating in competitive sports to maximising his walking ability. This showed that Jason had internalised the cycle goal of re-gaining walking ability, that he may have initially perceived as imposed by his rehabilitation team. Better communication between Jason and the rehabilitation team additionally facilitated the clarification of conflicting goals.

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