General Introduction

For many persons living with spinal cord injury (SCI), motivation is an important and at times challenging aspect of the rehabilitation process. In general, motivation is a complex, goal-oriented process that involves many factors. Although most everyone has some sort of understanding what motivation is, it is difficult to clearly define, measure and shape motivation.

According to Richard Gerrig's book Psychology and Life, motivation is broadly defined as "the process of starting, directing, and maintaining physical and psychological activities; includes mechanisms involved in preferences for one activity over another and the vigour and persistence of responses".1 Another more recent definition offered by Cook and Artino addresses the role that goals play in the motivation process i.e. motivation drives the initiation and continuation of an activity in order to meet set goals.2

Box 1 | Motivation

There are numerous theories and conceptualisations related to the topic of motivation;23 outlining them all would go beyond the scope of this document. Nevertheless, to better understand motivation (of human beings), it would be important to consider some important elements, such as the possible sources of motivation.

In simple terms, possible sources of motivation can be ordered under the following concepts:14

  • Drive: an internal state that is activated in response to basic physiological needs, specifically to reduce stress or deprivation and restore physiological balance
  • Incentives: external factors that are perceived by the person as a reward or something profitable irrespective of physiological needs
  • Learning/Reinforcement: conditioning of a particular behaviour as a result of repeated association between a stimuli in the environment (could be an incentive) and drive, and the person's response
  • Expectations: a person's anticipation that an outcome will occur as a result of his or her behaviour

While these possible sources of motivation help to describe elements that influence specific behaviour, they all fall under two general forms of motivation:12356

  • Intrinsic motivation: the driving force of a specific behaviour is inherent to the person e.g. curiosity, personal interest, experience of enjoyment, desire for self-determination
  • Extrinsic motivation: the driving force of a specific behaviour is external to a person, and is seen as leading to a reward or punishment e.g. financial gain, academic success, or avoidance of a negative consequence

Contemporary models of motivation introduce additional elements. For example, according to attribution theory a person's perception of internal control over the cause of an outcome and the likelihood that a cause will change can influence subsequent behaviour or actions. Another theory, the social-cognitive theory, suggests that a person's decision to initiate a task is influenced by the perception that he or she can perform the task effectively to achieve the goals set. Integrating elements of both the attribution and social-cognitive theories the self-determination theory also emphasises the concepts of autonomy (i.e. opportunity to control one's actions), competence (i.e. ability to master tasks and challenges posed by one's environment), and a relatedness (i.e. sense of belonging or connectedness with others). Introduced by Richard Ryan and Edward Deci, the self-determination theory also suggests that an extrinsic motivational factor can become intrinsic through internalisation, i.e. the process by which a person sub-consciously accepts a value or external factor as his or her own, and that internalisation is fostered by self-determination and autonomy.2357

Having a theoretical understanding of motivation can help lay the foundation for productive planning and undertaking of rehabilitation interventions.8

Motivation and Rehabilitation

While the concepts and theories mentioned in box 1 promote a better understanding of motivation, integrating these elements into one approach on motivation is difficult.3 In the context of rehabilitation, the notion of motivation is seen as important and is embedded in the mind-set of rehabilitation professionals despite the lack of "clinical consensus" on the definition of motivation.89 Siegert and Taylor add that motivation is "difficult to measure objectively and prone to value judgement". Nevertheless, they see the value of integrating elements of motivation in rehabilitation as there is a close link between motivation and goal-setting, an essential activity in rehabilitation practice.8

The link between motivation (based on Ryan and Deci's self-determination theory) and goal-setting is illustrated by Siegert and Taylor in an example of a rehabilitation team and a person with paraplegia who are in the process of planning the person's community reintegration. Together they set goals in the self-determination theory concepts of autonomy, competence, and relatedness. The concept of autonomy is already addressed through the involvement of the person in the goal-setting process. Autonomy is also promoted by setting goals that reflect the active engagement of the person throughout the rehabilitation process. The goals related to competence involve improvements in basic aspects of functioning, such as bladder and bowel functions, mobility, self-care and other activities of daily living. As the person increasingly masters these basic aspects of functioning, goals striving for mastery in more challenging aspects of functioning, such as driving, can be set. Lastly, the goals that address the concept of relatedness focus on developing and strengthening social supports.8

"There is also some scientific evidence for the merits of integrating elements of motivation in healthcare and rehabilitation practice..."

There is also some scientific evidence for the merits of integrating elements of motivation in healthcare and rehabilitation practice, for example in improving compliance to medication and treatment.789 In a study that examined the relationship between motivational patterns and exercise activity of 251 participants of a cardiac rehabilitation programme, Sweet and colleagues found that the study participants with higher and stable levels of motivation elements, including self-determination, were more likely to maintain their exercise levels throughout the 24-month rehabilitation programme.10 In another study that explored the facilitating factors of return-to-work (RTW), Wilbanks and Ivankova conducted semi-structured interviews with four persons with SCI who were employed at the time of the study. The results indicated that intrinsic and extrinsic motivation were the most important factors in influencing RTW, highlighting that family and rehabilitation professionals were the most important extrinsic motivating factors.11 The association between motivating factors and RTW is supported by a recent study by Farholm and colleagues who found an association between a self-determination theory-oriented vocational rehabilitation programme (predominately for persons with musculoskeletal conditions) and increased physical activity and RTW at six weeks post-rehabilitation.12

The results of these studies have implications for rehabilitation, specifically for planning and conducting rehabilitation interventions.

Implications for Rehabilitation Interventions

Given their study results, Wilbanks and Ivankova concluded that rehabilitation professionals have the potential to positively influence RTW. As an extrinsic motivating factor, rehabilitation professionals generally serve as a major support for the person engaged in rehabilitation (patient) during the period of recovery and regaining of independence, often building relationships with patients as a result of extensive time spent with each other during rehabilitation.11 Similarly, the treatment team in the Farholm et. al. study aimed to develop health professional-patient relationships based on mutual trust and respect – reflecting the "relatedness" element of the self-determination theory of motivation.12

The potential of rehabilitation professionals to positively influence rehabilitation outcome, such as RTW, goes beyond their role as a motivating factor. Recognising the influence of various other motivating factors could assist rehabilitation professionals to adapt and refine their intervention approach. Rehabilitation professionals can integrate certain practices in their intervention approach that foster motivation.910

Box 2 | Practices that Foster Motivation in Rehabilitation

Maclean and Pound9 suggest that integrating the following practices in rehabilitation can foster motivation of persons engaged in rehabilitation:

  • Set clear and modifiable goals, including long-term goals beyond the clinical/rehabilitation setting
  • Ensure that the person feels that his or her ideas and opinions regarding the rehabilitation process count and are welcome
  • Accept the diverse characteristics of the person
  • Pursue alignment with the person's value system
  • Interact with the person in a way that promotes the rehabilitation professional as “warm, approachable and competent”
  • Minimise “mixed messages” among the rehabilitation team members
  • Promote a non-moralising approach to rehabilitation i.e. that the person is not solely responsible for his or her recovery
  • Avoid over-protective behaviours toward the person

Complementary to these practices Sweet and colleagues suggest collecting motivation-related information about the person throughout the rehabilitation process in order to identify the persons who may benefit from motivation-facilitating practices and strategies like "collaborative problem-solving, self-monitoring and enjoyment-enhancing strategies".10

This case of Jason illustrates the importance of motivation in the rehabilitation process, as well as the relationship between motivation and goal-setting, and the outcome of rehabilitation. It also highlights the challenges the rehabilitation team may face with regard to motivation in planning and conducting rehabilitation interventions.

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