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Rehabilitation: an ‘everyday’ motivation model
ELSEVIER
Patient Education and Counseling 28 (1996) 69-77
Rehabilitation:
an ‘everyday’ motivation
model
Ronald J.G.M. Geelena’*, Paul H.G.M. Soonsb “Verpleeghuis
Lucia, Liesboslaan hSt. Annaziekenhuis.
6, 4813 EC Breda The Netherlands Geldrop. The Netherlands
Received 2.5 January 1995: revi’sed 20 September 1995; 24 September 1995
Abstract
In this article a model is presented to deal with motivational problems of rehabilitation patients. The problem of motivation is not covered yet in relevant psychological disciplines like rehabilitation psychology, neuropsychology and health psychology. An important source of the model is cognitive psychology. Applications are presented in the communication between rehabilitation workers and the patient. The model can be put into practice in a wide range of patients with physical and/or cerebral handicaps. Keywords:
Motivation;
Rehabilitation;
Communication
1. Introduction
In institutions like nursing homes, rehabilitation centres and general hospitals, the somatic approach has traditionally played a central role within rehabilitation. The psychological view at rehabilitation is emerging over the last 25 years [l]. Neuropsychology has become an important development in the field of rehabilitation, especially for patients with cerebral dysfunction. In respect of specific diagnosis and the formulation of rehabilitation prognosis, it is now a commonly accepted principle that questions related to concentration capacity, information processing and understanding of language require professional attention. In many cases neuropsychological in* Corresponding
author.
formation is included in the treatment plan as a contribution to the formulation of diagnoses, and to clarify limitations and stagnation in the rehabilitation process. The disciplines of rehabilitation and health psychology stress the problems of acceptance of handicaps, and the means of coping with physical and psychological limitations. The mentioned approaches from psychology are important in relation to diagnosis and from a therapeutic point of view. The range of possible psychological treatment methods is expanding, including cognitive restructuring, training of cognitive functions such as attention and memory, learning how to cope with specific cognitive disabilities (strategy training) or how to improve on specific tasks (skill-training), behavior modification, counselling and psychotherapy [l]. Despite the variety in covered topics, certain aspects
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in rehabilitation literature seem somewhat ‘forgotten’. One aspect is the way in which the patient experiences and interprets his or her own efforts. In other words, the subjective perception and evaluation of one‘s own chances of successful rehabilitation [2], also known in literature as cognitive appraisal [3]. We must keep in mind that even a perfect rehabilitation programme can fail, when the patient does not believe in its potential or in his own potential to complete it. When the treatment process stagnates, often the patient is verbally forced to practice more or to increase his efforts. If the problem is fear of failure, the pressure means a further threat to his motivation. When the misunderstanding is not rapidly illuminated, a circular negative interaction pattern can soon be established. The ‘solution’ put forward by the rehabilitation worker in fact becomes the core of the problem [4]. At first glance, the cognitions of the patient and the patient-carer communication appears to be easier to influence than physical handicaps, neuropsychological shortcomings or personality traits, but this aspect has as mentioned received little attention in the literature. The aim of this article is to present a theoretical model for dealing with motivational problems of rehabilitation, in the context of patientcarer communication. The illustrated model is applicable to a wide range of patients with cerebral and/or physical handicaps: patients with CVA, head trauma, amputations, mild dementia, heart diseases, etc. Consequences for daily practice in working with these patients will be dealt with.
2. A motivation
model for rehabilitation
Atkinson [5-81 carried out experimental studies into the relationship between achievement motive and risk taking behavior. His students competed with one another, for example via shuffle boards or imaginary bets. They could determine themselves the risk/reward ratio. For example, the choice of a longer shuffle board meant - in the case of a good performance - a larger monetary reward.
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According to Atkinson, motivation is not a stable personality trait. Achievement motive behavior is determined by three variables: the subjectively estimated chance of a successful completion (assuming that action is undertaken), the perceived value of a positive result, and the perceived costs of taking the action (for example in the case of failure, the felt shame and humiliation). In brief [6]: Motivation = F (Expectancy x Motive X Incentive). His model is applicable only when an individual knows that his effort will be evaluated (by himself or others) in terms of some standard of performance, and that the consequence of this action will be either a success or a failure. Atkinson found that depending on their need for achievement, persons differ in their risk taking behavior. Persons with a high need for achievement prefer tasks of medium difficulty. This is not so with people who have a low need for achievement. Their motive to prevent failure (and to avoid the task for self-protective means) will be stronger. When they have to engage in the game, they will select tasks of very high difficulty (by which failing is not upsetting), or more probable very low difficulty. When they win, the pride in the accomplishment will be less than by the ‘high-achievers’. To use his model in standard experimental situations, Atkinson has strictly operationalized it. In this article, however, we will take it as an imaginary framework for rehabilitation situations in which variation is inherent. Although the gap between a game situation and the rehabilitation process appears wide, there are a number of points of concordance. In both situations the person in question takes an action (effort) of which the result is uncertain, and the chance of success depends on the formulated target. The performance will be noticed by the person and others, painfully experienced failure can not be ruled out. For the more insecure individual, rehabilitation can bring about an ‘approach-avoidance conflict’. Birren and Schaie [9] posit that Atkinson‘s model is eminently suitable in the rehabilitation setting. They reformulate the model as follows: M = (P( OS) X V) : C where M = the motivation for
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rehabilitation, often characterized by conflicting motives to achieve success and to avoid failure. Motivation is determined by the following factors. P(Os) = the subjective perception on the part of the patient of the likelihood of a successful outcome of the rehabilitation, assuming that he or she makes the required effort. V= the individually perceived utility or value of a successful rehabilitation process, assuming that the objectives laid down are achieved. C = the perception of the cost of the outcome and the costs of the rehabilitation process itself for the patient. Possible costs can be financial and material, physical, social and psychological. In the case of the latter three, costs could be pain and tiredness, feelings of threatened self-esteem, confrontations with incapacity, lessened interest and compassion on the part of others. According to the model, motivation increases proportionately, as the numerator ( = P(Os) X V) increases and the denominator (C) decreases. The person undergoing rehabilitation is highly motivated if he or she is convinced that the chance of a successful outcome is high, and attaches considerable value to the outcome of the rehabilitation, without experiencing expectations of seriously negative effects as a result of the undertaking. Also important is the fact that the three elements of the numerator and denominator mutually influence one another. The reason for this is the dynamic character of the patients‘ perception: change within one element may have consequences for each of the other elements. We shall give a simplified example. A 64-year-old man with atactic walking difficulties is eager to improve his walking ability, because he values his independence (V). Highly motivated, he exercises vigorously every day. At a given time, the exercises advance less rapidly. He still considers improved walking an important aim (V), but is frightened because the chance of a successful outcome of the rehabilitation process seems for him to be less than expected (P(Os)). This tension results in considerable fear of failure and insecurity (C), as a consequence of which he falls more often both during his exercises and
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outside the rehabilitation process. By way of selfprotection he plays down these failures, as a consequence of which the carers incorrectly believe that he is not taking the rehabilitation seriously. They hope to alert him to the problem, by making pointed comments, ‘If you don ‘t make more effort, there are plenty of others who can take your place’. For him, the result is anger at the carers, and self-rejection. He does not discuss his feelings with his carers, thus confirming them in their opinion. Due to the concurrence of these events and his perception of them, the rehabilitation process has for him an increasingly aversive character (C), in which he reduces both the chance of success (P(Os)) and the value of it (v). Eventually, he refuses to continue with his exercises (M).
Of course, this example does not deal with all the complexities of the perceptions of the patient, but it is an illustration of the processrelated character thereof. We are now ready for a more extensive discussion of the various components of the model. Practical advice is given when motivation is a problem, in relation to the theoretical model.
3. Motivation
as a dependent
variable
In Atkinson‘s model a wide range of mutually influencing variables determine motivation. These include expectations, values, situational and social factors, and perceived costs. It must be mentioned that within the various movements in psychological ideas and theories, there is one common point: the concept of motivation does not fully explain or predict behavior [lo]. In other words, the effort of the rehabilitation patient is not solely determined by his ‘motivation’. A range of other factors also play a role. Motivation is no ‘homunculus’ or independent factor within a person, rather it is something created within the person himself and in interaction with their environment. Motivation is targeted, and related to someone‘s circumstances, needs, expectations and interpretations, values and fears. It is therefore incorrect to label those people
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refusing rehabilitation as unmotivated [11,12]. The key question is to determine why this particular patient in this particular respect and in these speciJic circumstances appears to be insufficiently motivated. In practice, after all, we often see that patients can be motivated in other activities (or that their behavior differs in other circumstances). Symptoms of motivational problems can be: anger reactions towards carers, argument in the rehabilitation team about the patient, stagnation of the progress of rehabilitation goals, stopping the programme, an overly critical attitude to the carers or the programme. A number of blocks which can occur may be derived from the elements in the motivation model. Practical advice will be given on how to deal with these blocks
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(Table 1). We will now deal with this question in more detail.
4. The subjective perception of the chances of success
P( OS) represents the patients’ subjective calculation of the outcome, assuming that he or she makes the necessary effort for rehabilitation. In other words, the patient asks him or herself how great the chance is that rehabilitation will provide him or her with that which may be expected. This estimation may differ from the ‘objective’ chance of a good recovery [2]. Amongst others, Thomae [2] suggests that the perception of a
Table 1 Practical advice General
advice
Before the start of the rehabilitation, it is important to have an impression of how the patient perceives his situation and prognosis. Keep psychosocial factors in view during the rehabilitation process and try to incorporate them in the program. Try to make the patient an active participant, and give him options and responsibility in the design of the program. l Be alert to blockades in motivation; such as anger reactions, poor cooperation and lessened initiative, self-downing or an overly critical attitude towards himself, carers or the rehabilitation program, and/or the rehabilitation team is divided in the opinion of an individual patient. View these signals not as proof of unsuitability of the patient for rehabilitation, but as a starting point for targeted communication. The following three factors of Atkinson‘s model can be a point of departure here: P(Os), V and C. l
Subjective
perception
of the likelihood
of a successful
outcome
of rehabilitation
(P(Os))
Do not give only medicaUneuropsychologica1 objective information, but also tune in on the frame of reference of the individual patient. l When explaining the situation to the patient, keep in mind that he can selectively remind, neglect and/or distort information. l Detect expectations, if irrational try to correct them. l Set small short-term objectives. l Re-label the patient‘s critical attitude, behavior, performance and the rehabilitation in a convincing, positive way. l
Perceived
value
of a successful
rehabilitation
(V)
Detect commitments of the patient, and look for possible translations of these in the rehabilitation program. Try to make the patient an active partner in the rehabilitation program, by explaining how this can be a fruitful undertaking for his own priorities. If necessary, seek alternative routes of help to fulfil the commitments of the patient. l
Perception
of costs (C)
Costs of the rehabilitation hamper motivation quickly. Talk openly and empathically with the patient about possible inhibitory factors. Focus on a realistic estimation of costs, be aware of the possibility that the patient exaggerates them. When the patient tends to avoid participation in the rehabilitation, for example because of fear of failure, seek ways to make the rehabilitation less emotionally demanding. l Be alert to the possibility that there can be hidden costs for the patient when he improves. Find out how these can be prevented or worked out, in active contact with the patient. l Seek ways to make rehabilitation less emotionally demanding. For example by building in pleasant distraction, or focussing the patient on daily pleasant experiences during exercise. l
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situation determines behavior far more than the objective characteristics of the situation. The role of this subjective assessment is expressed in Bandura‘s ‘self-efficacy’ theory [ll]. Self-efficacy means the expectation of someone that he himself can correctly carry out a given action. This differs from the point of departure generally assumed by carers in the case of rehabilitation: namely the average chance of success of a given therapy in a specific problem situation. A specific elderly person may well be convinced that people with a collum fracture in general can fully recover, but despite this knowledge believe that this will not be so for himself. This means that simply giving general medical information about diagnoses and prognoses is often insufficient to encourage the patient to make the necessary efforts. Even if, from an ‘objective point of view’, the chances of functional recovery are extremely favourable. The patient does not automatically believe that a general rule will apply especially for himself. It is important to ask the patient about his ideas in this area. Further, it may help if the information is not provided on a one-sided medical or technical level, but in a way which fits in with the particular patient‘s world and experience. Metaphorical images which intermesh with the areas of interest of the person can prove useful. A possible example would be a retired car mechanic, with arthrosis in the knee joints. An explanation to him could be that his knees are no longer functioning correctly, by comparing them with poor shock absorbers in a car. The problem regularly makes walking painful, just as driving in a car with faulty shock absorbers is not the smoothest of rides. However, if he decides to avoid walking (or simply ‘park the car’), independent walking will probably become impossible (‘Your wheel bearings will seize up’). It is therefore important to accept some of the pain, in order to maintain the capacity to walk (‘If you want to keep your car going, despite the poor shock absorbers, you will have to keep driving’). It is also important to tune in on the expectations of the patient and to get him involved. By taking his expectations seriously, and if they cannot be met by explaining this to the patient, one can
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prevent the patient becoming merely the object of the rehabilitation process. Requesting the active cooperation of the patient in specifying the exact structure of the rehabilitation programme, sometimes enhances motivation. Of course, in such a situation the alternatives put forward must be both plausible and in principle equal to one another. And the patient‘s decision needs to be honored. One possibility is the choice between a short-term intensive programme, or a somewhat longer-term less intensive programme. If the patient himself selects an alternative, this will often become more attractive [13]. In fact, by presenting this ‘selection menu’, the rehabilitation patient is being subjected to the illusion of freedom of choice [4], whereby the decision of whether or not to cooperate with the rehabilitation becomes secondary. For rehabilitation patients, expectations can often be stimulated by setting small, short-term objectives. Starting from short-term objectives can reduce the fear of failure and humiliation. It seems however important to describe these objectives as serious work targets, especially to persons who have a high need for achievement. If patients have a strong fear of failure, an option can be to describe the initial weeks of the rehabilitation process as a period of information gathering [14]. If the patient fails to complete a given exercise, it is possible on each occasion to mark such failures as helpful in correctly establishing the ‘final’ programme (or in other words, as a means of increasing the chance of a good outcome). Another method is to reformulate in the rehabilitation stage, for example as an exercise in willpower. The actual implementation of the process and the result to be achieved, are thus for the time being made explicitly subordinated to the willpower exercise. After all, not only the chance of a good outcome is subjective; equally subjective are the specific standards of a good outcome. It is important to put the greatest emphasis on those matters to which the patient seems most receptive. Furthermore, it is important to keep in mind that patients are often very sensitive to signals and information which are in concordance with their fears. The depressed patient is prone to selectively notice signals and
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to remember information which confirms his negative emotional and cognitive state. When there is fear of failure, one can put less emphasis during the rehabilitation exercises on performance and focus more, for example, on effort or the experience of movement. An inherent aspect of rehabilitation is the sometimes embarrassing and confusing confrontation with one‘s own incapacities. Both for the well-being of the patient him or herself and for the good of the working relationship, it is sometimes necessary for the carer to place the patient‘s behavior in the best possible believable light. The patient who despite best attempts repeatedly fails, is not a loser but a stayer. However, excessively positive reinterpretations are advised against, since they undermine credibility [15]. The carer will often have a long-term aim or even the final objective in mind. This can sound very unrealistic and fear-arousing for the patient who directly experiences his disabilities. ‘I will never succeed with this program!’ An excessively high level of arousal can be the result. This can not only negatively influence motivation [12] and cooperation, but also hamper the execution of exercises. Remember Atkinson, who found that even ‘normal healthy’ people tend to avoid undertaking tasks if dominated by fear. If long-term objectives are the point of departure, the person can further feel he is required to, as it were, write out a ‘blank cheque’ to his carers. He will have to make an endless effort, without a guarantee whatsoever that any positive outcome will be the return. Understandably, this reduces motivation. Additionally, encouraging contact with fellow sufferers who have already advanced further in the rehabilitation process can prove positive. Examples set by other persons who have experienced the same problems, but despite this have come through it all relatively well, can increase the perceived chance of a positive outcome. If the patient disparages the knowledge and skills of the carer, the carer can develop a defensive attitude. However, this will merely make him less believable. A more positive approach generally has a better result. An example of this would be to suggest that the critical attitude of the patient
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can be an asset during the rehabilitation process. Instead of overplaying your own hand by guaranteeing a successful recovery, it may be better to indicate that there are indeed’no guarantees for a successful outcome, but that the chances of success are too large to dismiss a serious attempt. One can follow up by suggesting examining together the value of a longer-term rehabilitation program. For example, the patient can be asked to put in 100% effort for a month, with a promise of looking into further steps after this period. This approach may also prove worthwhile if the patient has excessively high aspirations. Instead of a ‘verbal battle’ about what can be achieved, the carer can simply adopt a neutral position, and suggest that after the ‘trial period’ matters may become clear of their own accord.
5. The individual rehabilitation
meaning
or value of the
For the patient the core question is, ‘What will rehabilitation provide of importance to me?’ The carer will place the value of rehabilitation in the ‘objective’ context of better functional skills, or increased self-sufficiency. For the patient this aspect will often be important too, but other factors will ‘color’ the level of importance. If the patient sees his sickness as a punishment (for example from a religious perspective, punishment for previous sins), this may understandably hamper motivation. The patient can further experience disadvantages with better self-sufficiency as the loss of interest or sympathy from important persons. Or the prospect of having to bear responsibilities or assume obligations can become a burden, when it is at the moment unclear if this will really be possible. The diverse consequences of the rehabilitation may itself diverge considerably in personal importance, and sometimes - for the patient to - unwittingly and unexpectedly act as cost and thus become an obstacle. It is important to find out to what themes the patient feels ‘connected’, what really matters to him [2,9,12]. Literature describes these as ‘commitments7. Examples of commit-
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rnents are acting as a committee member in a local sports club, bringing up and maintaining good contacts with one‘s children, thinking and living according to Christian moral standards, accruing wealth, etc. Patients differ in the quantity, depth and variety of their commitments, and as their lives progress, such commitments will alter. Commitments are not purely individual, but develop in a social context. There may be threats to motivation from this social environment. For example if the family behaves as if the patient is incompetent, or expresses excessive sympathy, placing him/her in a dependent role. Naturally, positive influences are just as possible. In general, a cerebra vascular accident (CVA) or a physical dysfunction forces the patient to reorient his or her commitments, especially when these block the current commitments. Think, for example, of the effects of aphasia on social contacts. If the patient is unable to carry out this reorientation alone, counselling may also be advisable, in addition to the rehabilitation. It is also important to clearly describe the commitments of the patient for the rehabilitation itself. Since they form part of the patient‘s experiences, and can be of importance for recovery. Together with the elderly patient, a determination must be made as to the way in which and why the rehabilitation could or would be worthwhile for him. A number of questions can serve as a starting point, such as: l In what matters did the person show an interest, and is he or she still showing an interest? l What hindrances to this interest have now arisen, due to the dysfunction? l To what extent can these hindrances be removed by rehabilitation or other efforts? l How are the existing hindrances experienced, in terms of commitments? What tensions are they generating? l How can you convince the patient in a language he or she understands? l What options for involvement are present, which have not (yet) been called upon? In discussions with the patient, the expressed needs are sometimes strictly speaking not within
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the field of rehabilitation (for example finding a mate). If a specific desire expressed by the patient cannot be directly met, this impossibility will have to be explained. The patient generally values receiving a concrete explanation, during which he or she is at least able to express his or her wishes. A ‘contract’ can be entered, whereby the patient agrees he will give his best efforts in achieving the objective of rehabilitation. In return the carer will arrange help for the patient‘s main concern.
6. Perceived
costs of rehabilitation
In the explanation of the motivation model, the costs (C) are the denominator; the greater the costs, the less the motivation (assuming that P(Os) and V remain constant). C, just like the other elements, can be very diverse. Possibilities are the effort to be provided, tiredness, pain, (acceptance of) suffering humiliation, or as already mentioned reduction in attention and care (for example from family) in the case of increased independence. These costs vary in nature, and are valued differently by each individual. Something experienced by many people as a cost (C: effort, having to work hard and long at something), may actually increase the value of the rehabilitation for other individuals (V: e.g. seeing the rehabilitation process as a personal challenge). For this reason, the costs cannot simply be ‘added together’ to provide an index. Knowing that costs reduce motivation, carers often tend not to discuss them with the patient. Or they dismiss them as unimportant. However, this in no way guarantees that they will no longer play any role for the patient. Indeed, the costs may even be overestimated by the patient. Generally speaking, creating an open atmosphere and giving a realistic overview of what will have to be invested, stating at the same time that this will occasionally prove extremely difficult, proves the better option. It is in any case important to prevent the costs being overestimated. In summary, subjective estimations and considerations also play a role in relation to the costs of
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rehabilitation. The carer has to elucidate these perceptions and cognitions, and wherever appropriate correct them. Instead of working against them, it will sometimes be possible to use them as a motivator. Let us illustrate this with an example from a different field. Bodybuilders train for years with discipline and high intensity, in order to achieve the desired physical appearance. Through intensive training, with short periods of rest, the muscles rapidly begin to swell, and exhibit slight pain; this phenomenon is described by bodybuilders as being ‘pumped up’. Bodybuilders do not see these physical feelings as negative; on the contrary, they are an indication of effective training. This is expressed in the slogan ‘No pain, no gain’. A cost (physical discomfort) is reinterpreted here as a gain. Being able to withstand the physical discomfort increases the chance of a positive outcome. When slightly altered, this same type of reinterpretation can be applied to rehabilitation. For example, ‘When carrying out this exercise, you may experience a painful or niggling feeling in your legs. Most people don‘t like this. It is important to remember that this discomfort is all part of the rehabilitation process. Eventually, things will go easier for you’. The subject of the reinterpretation may clearly change, due to the fact that it should be aimed specifically at what acts as a barrier for the patient. Rehabilitation patients are often prone to ambivalent feelings. For example on the one hand there is sadness about the loss of functional ability; the patient is afraid that this will be permanent. On the other hand there is fear that improved mobility will bring about less attention from the family and carers. In addition to counselling, indirect interventions can be of help here. The carer talks for example especially after the exercise with the patient, and prevents a relapse of attention when the patient improves. During the exercise less emphasis can be laid on the performance itself, and more on matters not closely related to the rehabilitation process. Rehabilitation means for the patient not only a physical, but also a psychological burden. Between the exercises or immediately after training
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resting is therefore important, possibly in conjunction with relaxation exercises. Pleasant distractions during or after the sessions (such as a short conversation or drinking a cup of coffee together) may serve as positive affirmations. The advantage of this approach is that it counters the aversive character and monotony of the rehabilitation process. The principles of behavioral therapy appear to be highly successful in the rehabilitation setting [7,15,16]. One concrete example is the Premack Principle [17], where frequently displayed behavior of the patient can be used to amplify the desired rehabilitation behavior. For example, the patient may undertake to do some walking exercises every time he or she drinks a cup of coffee.
7. Recommendations
for everyday
praxis
From the somatic and neuropsychological viewpoint, it is frequently possible to estimate the maximum gains of the rehabilitation of a patient with certain dysfunctions. Whether the rehabilitation program will be accepted, and if and how fast the goals can be arrived at, depends partly on the patient-carer communication and the patient‘s cognitive and affective characteristics. To improve these conditions, it is necessary to make use of communicative techniques which are tuned in on the individual patient. Motivation for rehabilitation calls for empathy and good communicative abilities from the carers. Because there is no generally effective ‘recipe for motivation’, the carer needs to address the perceptions, cognitions, values and (social) situation of the patient. Atkinson‘s model can serve as a framework for establishing a goal-directed individual strategy. When the rehabilitation process stagnates, workers should ask themselves why this is happening. Psychosocial know-how can better be employed before the rehabilitation process begins to stagnate. After all, a policy active from the start can prevent miscommunication and distrust between carers and patient. So it is advisable that the coordinating doctor should
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from the start interview the patient on the subject of motivation. It should be a standard aspect of rehabilitation programmes that motivation-related aspects are evaluated on a routine basis. One of the consequences of this is that, more than currently is the case, psychologists will have to be closely involved in the day-to-day rehabilitation process. A further conclusion is that all carers need to be alert to how they establish contacts with their patients. This is not a process which will take place automatically. However this seems a reasonable request, if we consider the consequences which the shortfall in functional capacity and the rehabilitation process can have on the capacity of the patient to adjust. When the rehabilitation workers do not succeed in detecting the reasons for the stagnation, a psychologist should be consulted. When this consultation is not enough, referral to the psychologist for counselling and cognitive behavior therapy may be indicated in addition to the rehabilitation programme. The following statement was published more than 20 years ago, but has lost none of its power [18]: ‘What leads more than anything to a rehabilitation approach is a constant closeness to the actual problems of the deprived and disabled in everyday life, requiring not only intellectual understanding but emotional understanding of the character of the problems’.
References [l] Moor de JMH, Balen van HGC, Beers KA,Vos de LAJ. Revalidatiepsychologie. Assen/Maastricht: Van Gorcum, 1990. [2] Thomae H. Theory of ageing and cognitive theory of personality. Hum Dev 1970; 13: 1-16.
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[3] Folkman S, Schaefer C, Lazarus, RS. Cognitive Processes as Mediators of Stress and Coping. In: Hamilton V, Warburton DM, editors. Human Stress and Cognition. Chichester: John Wiley & Sons, 1979. [4] Watzlawick P, Weakland JH, Fisch R. Het kan anders, over het onderkennen en oplossen van menselijke problemen. Deventer: Van Loghum Slaterus, 1987. [S] Atkinson JW. An Introduction to Motivation. Toronto: D. van Nostrand Company, 1964. [6] Atkinson JW, Bastian JR, Earl RW, Litwin GH. The achievement motive, goal setting, and probability preferences. J Abn Sot Psycho1 1960; 60: 27-36. [7] Beck, RC. Motivation: Theories and Principles. New Jersey: Prentice-Hall Inc., 1978. [8] Jung J. Understanding Human Motivation, A Cognitive Approach. New York: Macmillan Publishing Co. Inc., 1978. [9] Birren, JE, Schaie. KW. Handbook of the Psychology of Aging. New York: Van Nostrand Reinhold Company, 1985. [lo] Reber AS. Woordenboek van de psychologie. Amsterdam: Uitgeverij Bert Bakker, 1989. [ll] Snoek FJ. Psycho-sociale determinanten van reactivering: een introductie. In: Ribbe MW, Snoek FJ, editors. Amstelhof, hedendaagse verpleeghuiszorg in een historische omgeving. AmsterdamlMeppel: Druk Krips Repro, 1987. [12] Wright B. Physical Disability, a Psychological Approach. New York: Harper, 1983. [13] Beck RC. Motivation, Theories and Principles. Englewood Cliffs, NJ: Prentice-Hall Inc., 1978. [14] Velden van der K, editor. Directieve therapie I. Deventer: Van Loghum Slaterus, 1977. [15] Egmond van JJ. Theorie en toetsing in de revalidatie psychologie. Gedrag Gezondheid 1986; 14: 19-26. [16] Shapiro D. Surwitt RS. Operant Conditioning, A New Theoretical Approach in Psychosomatic Medicine. In: Lipowsky ZJ, Lipsitt DR. Whyprow PC, editors. Psychosomatic Medicine. New York: Oxford University Press, 1977. [17] Premack, D. Toward empirical behavior laws, 1: positive reinforcement. Psycho1 Rev 1959; 66: 219-233. [18] Dembo T, Diller L, Gordon WA, Leviton G, Sherr RL. A view of rehabilitation psychology. Am Psycho1 1973; 28: 719-722.
Patient Education and Counseling 28 (1996) 69-77
Rehabilitation:
an ‘everyday’ motivation
model
Ronald J.G.M. Geelena’*, Paul H.G.M. Soonsb “Verpleeghuis
Lucia, Liesboslaan hSt. Annaziekenhuis.
6, 4813 EC Breda The Netherlands Geldrop. The Netherlands
Received 2.5 January 1995: revi’sed 20 September 1995; 24 September 1995
Abstract
In this article a model is presented to deal with motivational problems of rehabilitation patients. The problem of motivation is not covered yet in relevant psychological disciplines like rehabilitation psychology, neuropsychology and health psychology. An important source of the model is cognitive psychology. Applications are presented in the communication between rehabilitation workers and the patient. The model can be put into practice in a wide range of patients with physical and/or cerebral handicaps. Keywords:
Motivation;
Rehabilitation;
Communication
1. Introduction
In institutions like nursing homes, rehabilitation centres and general hospitals, the somatic approach has traditionally played a central role within rehabilitation. The psychological view at rehabilitation is emerging over the last 25 years [l]. Neuropsychology has become an important development in the field of rehabilitation, especially for patients with cerebral dysfunction. In respect of specific diagnosis and the formulation of rehabilitation prognosis, it is now a commonly accepted principle that questions related to concentration capacity, information processing and understanding of language require professional attention. In many cases neuropsychological in* Corresponding
author.
formation is included in the treatment plan as a contribution to the formulation of diagnoses, and to clarify limitations and stagnation in the rehabilitation process. The disciplines of rehabilitation and health psychology stress the problems of acceptance of handicaps, and the means of coping with physical and psychological limitations. The mentioned approaches from psychology are important in relation to diagnosis and from a therapeutic point of view. The range of possible psychological treatment methods is expanding, including cognitive restructuring, training of cognitive functions such as attention and memory, learning how to cope with specific cognitive disabilities (strategy training) or how to improve on specific tasks (skill-training), behavior modification, counselling and psychotherapy [l]. Despite the variety in covered topics, certain aspects
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in rehabilitation literature seem somewhat ‘forgotten’. One aspect is the way in which the patient experiences and interprets his or her own efforts. In other words, the subjective perception and evaluation of one‘s own chances of successful rehabilitation [2], also known in literature as cognitive appraisal [3]. We must keep in mind that even a perfect rehabilitation programme can fail, when the patient does not believe in its potential or in his own potential to complete it. When the treatment process stagnates, often the patient is verbally forced to practice more or to increase his efforts. If the problem is fear of failure, the pressure means a further threat to his motivation. When the misunderstanding is not rapidly illuminated, a circular negative interaction pattern can soon be established. The ‘solution’ put forward by the rehabilitation worker in fact becomes the core of the problem [4]. At first glance, the cognitions of the patient and the patient-carer communication appears to be easier to influence than physical handicaps, neuropsychological shortcomings or personality traits, but this aspect has as mentioned received little attention in the literature. The aim of this article is to present a theoretical model for dealing with motivational problems of rehabilitation, in the context of patientcarer communication. The illustrated model is applicable to a wide range of patients with cerebral and/or physical handicaps: patients with CVA, head trauma, amputations, mild dementia, heart diseases, etc. Consequences for daily practice in working with these patients will be dealt with.
2. A motivation
model for rehabilitation
Atkinson [5-81 carried out experimental studies into the relationship between achievement motive and risk taking behavior. His students competed with one another, for example via shuffle boards or imaginary bets. They could determine themselves the risk/reward ratio. For example, the choice of a longer shuffle board meant - in the case of a good performance - a larger monetary reward.
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According to Atkinson, motivation is not a stable personality trait. Achievement motive behavior is determined by three variables: the subjectively estimated chance of a successful completion (assuming that action is undertaken), the perceived value of a positive result, and the perceived costs of taking the action (for example in the case of failure, the felt shame and humiliation). In brief [6]: Motivation = F (Expectancy x Motive X Incentive). His model is applicable only when an individual knows that his effort will be evaluated (by himself or others) in terms of some standard of performance, and that the consequence of this action will be either a success or a failure. Atkinson found that depending on their need for achievement, persons differ in their risk taking behavior. Persons with a high need for achievement prefer tasks of medium difficulty. This is not so with people who have a low need for achievement. Their motive to prevent failure (and to avoid the task for self-protective means) will be stronger. When they have to engage in the game, they will select tasks of very high difficulty (by which failing is not upsetting), or more probable very low difficulty. When they win, the pride in the accomplishment will be less than by the ‘high-achievers’. To use his model in standard experimental situations, Atkinson has strictly operationalized it. In this article, however, we will take it as an imaginary framework for rehabilitation situations in which variation is inherent. Although the gap between a game situation and the rehabilitation process appears wide, there are a number of points of concordance. In both situations the person in question takes an action (effort) of which the result is uncertain, and the chance of success depends on the formulated target. The performance will be noticed by the person and others, painfully experienced failure can not be ruled out. For the more insecure individual, rehabilitation can bring about an ‘approach-avoidance conflict’. Birren and Schaie [9] posit that Atkinson‘s model is eminently suitable in the rehabilitation setting. They reformulate the model as follows: M = (P( OS) X V) : C where M = the motivation for
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rehabilitation, often characterized by conflicting motives to achieve success and to avoid failure. Motivation is determined by the following factors. P(Os) = the subjective perception on the part of the patient of the likelihood of a successful outcome of the rehabilitation, assuming that he or she makes the required effort. V= the individually perceived utility or value of a successful rehabilitation process, assuming that the objectives laid down are achieved. C = the perception of the cost of the outcome and the costs of the rehabilitation process itself for the patient. Possible costs can be financial and material, physical, social and psychological. In the case of the latter three, costs could be pain and tiredness, feelings of threatened self-esteem, confrontations with incapacity, lessened interest and compassion on the part of others. According to the model, motivation increases proportionately, as the numerator ( = P(Os) X V) increases and the denominator (C) decreases. The person undergoing rehabilitation is highly motivated if he or she is convinced that the chance of a successful outcome is high, and attaches considerable value to the outcome of the rehabilitation, without experiencing expectations of seriously negative effects as a result of the undertaking. Also important is the fact that the three elements of the numerator and denominator mutually influence one another. The reason for this is the dynamic character of the patients‘ perception: change within one element may have consequences for each of the other elements. We shall give a simplified example. A 64-year-old man with atactic walking difficulties is eager to improve his walking ability, because he values his independence (V). Highly motivated, he exercises vigorously every day. At a given time, the exercises advance less rapidly. He still considers improved walking an important aim (V), but is frightened because the chance of a successful outcome of the rehabilitation process seems for him to be less than expected (P(Os)). This tension results in considerable fear of failure and insecurity (C), as a consequence of which he falls more often both during his exercises and
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outside the rehabilitation process. By way of selfprotection he plays down these failures, as a consequence of which the carers incorrectly believe that he is not taking the rehabilitation seriously. They hope to alert him to the problem, by making pointed comments, ‘If you don ‘t make more effort, there are plenty of others who can take your place’. For him, the result is anger at the carers, and self-rejection. He does not discuss his feelings with his carers, thus confirming them in their opinion. Due to the concurrence of these events and his perception of them, the rehabilitation process has for him an increasingly aversive character (C), in which he reduces both the chance of success (P(Os)) and the value of it (v). Eventually, he refuses to continue with his exercises (M).
Of course, this example does not deal with all the complexities of the perceptions of the patient, but it is an illustration of the processrelated character thereof. We are now ready for a more extensive discussion of the various components of the model. Practical advice is given when motivation is a problem, in relation to the theoretical model.
3. Motivation
as a dependent
variable
In Atkinson‘s model a wide range of mutually influencing variables determine motivation. These include expectations, values, situational and social factors, and perceived costs. It must be mentioned that within the various movements in psychological ideas and theories, there is one common point: the concept of motivation does not fully explain or predict behavior [lo]. In other words, the effort of the rehabilitation patient is not solely determined by his ‘motivation’. A range of other factors also play a role. Motivation is no ‘homunculus’ or independent factor within a person, rather it is something created within the person himself and in interaction with their environment. Motivation is targeted, and related to someone‘s circumstances, needs, expectations and interpretations, values and fears. It is therefore incorrect to label those people
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refusing rehabilitation as unmotivated [11,12]. The key question is to determine why this particular patient in this particular respect and in these speciJic circumstances appears to be insufficiently motivated. In practice, after all, we often see that patients can be motivated in other activities (or that their behavior differs in other circumstances). Symptoms of motivational problems can be: anger reactions towards carers, argument in the rehabilitation team about the patient, stagnation of the progress of rehabilitation goals, stopping the programme, an overly critical attitude to the carers or the programme. A number of blocks which can occur may be derived from the elements in the motivation model. Practical advice will be given on how to deal with these blocks
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(Table 1). We will now deal with this question in more detail.
4. The subjective perception of the chances of success
P( OS) represents the patients’ subjective calculation of the outcome, assuming that he or she makes the necessary effort for rehabilitation. In other words, the patient asks him or herself how great the chance is that rehabilitation will provide him or her with that which may be expected. This estimation may differ from the ‘objective’ chance of a good recovery [2]. Amongst others, Thomae [2] suggests that the perception of a
Table 1 Practical advice General
advice
Before the start of the rehabilitation, it is important to have an impression of how the patient perceives his situation and prognosis. Keep psychosocial factors in view during the rehabilitation process and try to incorporate them in the program. Try to make the patient an active participant, and give him options and responsibility in the design of the program. l Be alert to blockades in motivation; such as anger reactions, poor cooperation and lessened initiative, self-downing or an overly critical attitude towards himself, carers or the rehabilitation program, and/or the rehabilitation team is divided in the opinion of an individual patient. View these signals not as proof of unsuitability of the patient for rehabilitation, but as a starting point for targeted communication. The following three factors of Atkinson‘s model can be a point of departure here: P(Os), V and C. l
Subjective
perception
of the likelihood
of a successful
outcome
of rehabilitation
(P(Os))
Do not give only medicaUneuropsychologica1 objective information, but also tune in on the frame of reference of the individual patient. l When explaining the situation to the patient, keep in mind that he can selectively remind, neglect and/or distort information. l Detect expectations, if irrational try to correct them. l Set small short-term objectives. l Re-label the patient‘s critical attitude, behavior, performance and the rehabilitation in a convincing, positive way. l
Perceived
value
of a successful
rehabilitation
(V)
Detect commitments of the patient, and look for possible translations of these in the rehabilitation program. Try to make the patient an active partner in the rehabilitation program, by explaining how this can be a fruitful undertaking for his own priorities. If necessary, seek alternative routes of help to fulfil the commitments of the patient. l
Perception
of costs (C)
Costs of the rehabilitation hamper motivation quickly. Talk openly and empathically with the patient about possible inhibitory factors. Focus on a realistic estimation of costs, be aware of the possibility that the patient exaggerates them. When the patient tends to avoid participation in the rehabilitation, for example because of fear of failure, seek ways to make the rehabilitation less emotionally demanding. l Be alert to the possibility that there can be hidden costs for the patient when he improves. Find out how these can be prevented or worked out, in active contact with the patient. l Seek ways to make rehabilitation less emotionally demanding. For example by building in pleasant distraction, or focussing the patient on daily pleasant experiences during exercise. l
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situation determines behavior far more than the objective characteristics of the situation. The role of this subjective assessment is expressed in Bandura‘s ‘self-efficacy’ theory [ll]. Self-efficacy means the expectation of someone that he himself can correctly carry out a given action. This differs from the point of departure generally assumed by carers in the case of rehabilitation: namely the average chance of success of a given therapy in a specific problem situation. A specific elderly person may well be convinced that people with a collum fracture in general can fully recover, but despite this knowledge believe that this will not be so for himself. This means that simply giving general medical information about diagnoses and prognoses is often insufficient to encourage the patient to make the necessary efforts. Even if, from an ‘objective point of view’, the chances of functional recovery are extremely favourable. The patient does not automatically believe that a general rule will apply especially for himself. It is important to ask the patient about his ideas in this area. Further, it may help if the information is not provided on a one-sided medical or technical level, but in a way which fits in with the particular patient‘s world and experience. Metaphorical images which intermesh with the areas of interest of the person can prove useful. A possible example would be a retired car mechanic, with arthrosis in the knee joints. An explanation to him could be that his knees are no longer functioning correctly, by comparing them with poor shock absorbers in a car. The problem regularly makes walking painful, just as driving in a car with faulty shock absorbers is not the smoothest of rides. However, if he decides to avoid walking (or simply ‘park the car’), independent walking will probably become impossible (‘Your wheel bearings will seize up’). It is therefore important to accept some of the pain, in order to maintain the capacity to walk (‘If you want to keep your car going, despite the poor shock absorbers, you will have to keep driving’). It is also important to tune in on the expectations of the patient and to get him involved. By taking his expectations seriously, and if they cannot be met by explaining this to the patient, one can
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prevent the patient becoming merely the object of the rehabilitation process. Requesting the active cooperation of the patient in specifying the exact structure of the rehabilitation programme, sometimes enhances motivation. Of course, in such a situation the alternatives put forward must be both plausible and in principle equal to one another. And the patient‘s decision needs to be honored. One possibility is the choice between a short-term intensive programme, or a somewhat longer-term less intensive programme. If the patient himself selects an alternative, this will often become more attractive [13]. In fact, by presenting this ‘selection menu’, the rehabilitation patient is being subjected to the illusion of freedom of choice [4], whereby the decision of whether or not to cooperate with the rehabilitation becomes secondary. For rehabilitation patients, expectations can often be stimulated by setting small, short-term objectives. Starting from short-term objectives can reduce the fear of failure and humiliation. It seems however important to describe these objectives as serious work targets, especially to persons who have a high need for achievement. If patients have a strong fear of failure, an option can be to describe the initial weeks of the rehabilitation process as a period of information gathering [14]. If the patient fails to complete a given exercise, it is possible on each occasion to mark such failures as helpful in correctly establishing the ‘final’ programme (or in other words, as a means of increasing the chance of a good outcome). Another method is to reformulate in the rehabilitation stage, for example as an exercise in willpower. The actual implementation of the process and the result to be achieved, are thus for the time being made explicitly subordinated to the willpower exercise. After all, not only the chance of a good outcome is subjective; equally subjective are the specific standards of a good outcome. It is important to put the greatest emphasis on those matters to which the patient seems most receptive. Furthermore, it is important to keep in mind that patients are often very sensitive to signals and information which are in concordance with their fears. The depressed patient is prone to selectively notice signals and
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to remember information which confirms his negative emotional and cognitive state. When there is fear of failure, one can put less emphasis during the rehabilitation exercises on performance and focus more, for example, on effort or the experience of movement. An inherent aspect of rehabilitation is the sometimes embarrassing and confusing confrontation with one‘s own incapacities. Both for the well-being of the patient him or herself and for the good of the working relationship, it is sometimes necessary for the carer to place the patient‘s behavior in the best possible believable light. The patient who despite best attempts repeatedly fails, is not a loser but a stayer. However, excessively positive reinterpretations are advised against, since they undermine credibility [15]. The carer will often have a long-term aim or even the final objective in mind. This can sound very unrealistic and fear-arousing for the patient who directly experiences his disabilities. ‘I will never succeed with this program!’ An excessively high level of arousal can be the result. This can not only negatively influence motivation [12] and cooperation, but also hamper the execution of exercises. Remember Atkinson, who found that even ‘normal healthy’ people tend to avoid undertaking tasks if dominated by fear. If long-term objectives are the point of departure, the person can further feel he is required to, as it were, write out a ‘blank cheque’ to his carers. He will have to make an endless effort, without a guarantee whatsoever that any positive outcome will be the return. Understandably, this reduces motivation. Additionally, encouraging contact with fellow sufferers who have already advanced further in the rehabilitation process can prove positive. Examples set by other persons who have experienced the same problems, but despite this have come through it all relatively well, can increase the perceived chance of a positive outcome. If the patient disparages the knowledge and skills of the carer, the carer can develop a defensive attitude. However, this will merely make him less believable. A more positive approach generally has a better result. An example of this would be to suggest that the critical attitude of the patient
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can be an asset during the rehabilitation process. Instead of overplaying your own hand by guaranteeing a successful recovery, it may be better to indicate that there are indeed’no guarantees for a successful outcome, but that the chances of success are too large to dismiss a serious attempt. One can follow up by suggesting examining together the value of a longer-term rehabilitation program. For example, the patient can be asked to put in 100% effort for a month, with a promise of looking into further steps after this period. This approach may also prove worthwhile if the patient has excessively high aspirations. Instead of a ‘verbal battle’ about what can be achieved, the carer can simply adopt a neutral position, and suggest that after the ‘trial period’ matters may become clear of their own accord.
5. The individual rehabilitation
meaning
or value of the
For the patient the core question is, ‘What will rehabilitation provide of importance to me?’ The carer will place the value of rehabilitation in the ‘objective’ context of better functional skills, or increased self-sufficiency. For the patient this aspect will often be important too, but other factors will ‘color’ the level of importance. If the patient sees his sickness as a punishment (for example from a religious perspective, punishment for previous sins), this may understandably hamper motivation. The patient can further experience disadvantages with better self-sufficiency as the loss of interest or sympathy from important persons. Or the prospect of having to bear responsibilities or assume obligations can become a burden, when it is at the moment unclear if this will really be possible. The diverse consequences of the rehabilitation may itself diverge considerably in personal importance, and sometimes - for the patient to - unwittingly and unexpectedly act as cost and thus become an obstacle. It is important to find out to what themes the patient feels ‘connected’, what really matters to him [2,9,12]. Literature describes these as ‘commitments7. Examples of commit-
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rnents are acting as a committee member in a local sports club, bringing up and maintaining good contacts with one‘s children, thinking and living according to Christian moral standards, accruing wealth, etc. Patients differ in the quantity, depth and variety of their commitments, and as their lives progress, such commitments will alter. Commitments are not purely individual, but develop in a social context. There may be threats to motivation from this social environment. For example if the family behaves as if the patient is incompetent, or expresses excessive sympathy, placing him/her in a dependent role. Naturally, positive influences are just as possible. In general, a cerebra vascular accident (CVA) or a physical dysfunction forces the patient to reorient his or her commitments, especially when these block the current commitments. Think, for example, of the effects of aphasia on social contacts. If the patient is unable to carry out this reorientation alone, counselling may also be advisable, in addition to the rehabilitation. It is also important to clearly describe the commitments of the patient for the rehabilitation itself. Since they form part of the patient‘s experiences, and can be of importance for recovery. Together with the elderly patient, a determination must be made as to the way in which and why the rehabilitation could or would be worthwhile for him. A number of questions can serve as a starting point, such as: l In what matters did the person show an interest, and is he or she still showing an interest? l What hindrances to this interest have now arisen, due to the dysfunction? l To what extent can these hindrances be removed by rehabilitation or other efforts? l How are the existing hindrances experienced, in terms of commitments? What tensions are they generating? l How can you convince the patient in a language he or she understands? l What options for involvement are present, which have not (yet) been called upon? In discussions with the patient, the expressed needs are sometimes strictly speaking not within
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the field of rehabilitation (for example finding a mate). If a specific desire expressed by the patient cannot be directly met, this impossibility will have to be explained. The patient generally values receiving a concrete explanation, during which he or she is at least able to express his or her wishes. A ‘contract’ can be entered, whereby the patient agrees he will give his best efforts in achieving the objective of rehabilitation. In return the carer will arrange help for the patient‘s main concern.
6. Perceived
costs of rehabilitation
In the explanation of the motivation model, the costs (C) are the denominator; the greater the costs, the less the motivation (assuming that P(Os) and V remain constant). C, just like the other elements, can be very diverse. Possibilities are the effort to be provided, tiredness, pain, (acceptance of) suffering humiliation, or as already mentioned reduction in attention and care (for example from family) in the case of increased independence. These costs vary in nature, and are valued differently by each individual. Something experienced by many people as a cost (C: effort, having to work hard and long at something), may actually increase the value of the rehabilitation for other individuals (V: e.g. seeing the rehabilitation process as a personal challenge). For this reason, the costs cannot simply be ‘added together’ to provide an index. Knowing that costs reduce motivation, carers often tend not to discuss them with the patient. Or they dismiss them as unimportant. However, this in no way guarantees that they will no longer play any role for the patient. Indeed, the costs may even be overestimated by the patient. Generally speaking, creating an open atmosphere and giving a realistic overview of what will have to be invested, stating at the same time that this will occasionally prove extremely difficult, proves the better option. It is in any case important to prevent the costs being overestimated. In summary, subjective estimations and considerations also play a role in relation to the costs of
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rehabilitation. The carer has to elucidate these perceptions and cognitions, and wherever appropriate correct them. Instead of working against them, it will sometimes be possible to use them as a motivator. Let us illustrate this with an example from a different field. Bodybuilders train for years with discipline and high intensity, in order to achieve the desired physical appearance. Through intensive training, with short periods of rest, the muscles rapidly begin to swell, and exhibit slight pain; this phenomenon is described by bodybuilders as being ‘pumped up’. Bodybuilders do not see these physical feelings as negative; on the contrary, they are an indication of effective training. This is expressed in the slogan ‘No pain, no gain’. A cost (physical discomfort) is reinterpreted here as a gain. Being able to withstand the physical discomfort increases the chance of a positive outcome. When slightly altered, this same type of reinterpretation can be applied to rehabilitation. For example, ‘When carrying out this exercise, you may experience a painful or niggling feeling in your legs. Most people don‘t like this. It is important to remember that this discomfort is all part of the rehabilitation process. Eventually, things will go easier for you’. The subject of the reinterpretation may clearly change, due to the fact that it should be aimed specifically at what acts as a barrier for the patient. Rehabilitation patients are often prone to ambivalent feelings. For example on the one hand there is sadness about the loss of functional ability; the patient is afraid that this will be permanent. On the other hand there is fear that improved mobility will bring about less attention from the family and carers. In addition to counselling, indirect interventions can be of help here. The carer talks for example especially after the exercise with the patient, and prevents a relapse of attention when the patient improves. During the exercise less emphasis can be laid on the performance itself, and more on matters not closely related to the rehabilitation process. Rehabilitation means for the patient not only a physical, but also a psychological burden. Between the exercises or immediately after training
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resting is therefore important, possibly in conjunction with relaxation exercises. Pleasant distractions during or after the sessions (such as a short conversation or drinking a cup of coffee together) may serve as positive affirmations. The advantage of this approach is that it counters the aversive character and monotony of the rehabilitation process. The principles of behavioral therapy appear to be highly successful in the rehabilitation setting [7,15,16]. One concrete example is the Premack Principle [17], where frequently displayed behavior of the patient can be used to amplify the desired rehabilitation behavior. For example, the patient may undertake to do some walking exercises every time he or she drinks a cup of coffee.
7. Recommendations
for everyday
praxis
From the somatic and neuropsychological viewpoint, it is frequently possible to estimate the maximum gains of the rehabilitation of a patient with certain dysfunctions. Whether the rehabilitation program will be accepted, and if and how fast the goals can be arrived at, depends partly on the patient-carer communication and the patient‘s cognitive and affective characteristics. To improve these conditions, it is necessary to make use of communicative techniques which are tuned in on the individual patient. Motivation for rehabilitation calls for empathy and good communicative abilities from the carers. Because there is no generally effective ‘recipe for motivation’, the carer needs to address the perceptions, cognitions, values and (social) situation of the patient. Atkinson‘s model can serve as a framework for establishing a goal-directed individual strategy. When the rehabilitation process stagnates, workers should ask themselves why this is happening. Psychosocial know-how can better be employed before the rehabilitation process begins to stagnate. After all, a policy active from the start can prevent miscommunication and distrust between carers and patient. So it is advisable that the coordinating doctor should
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from the start interview the patient on the subject of motivation. It should be a standard aspect of rehabilitation programmes that motivation-related aspects are evaluated on a routine basis. One of the consequences of this is that, more than currently is the case, psychologists will have to be closely involved in the day-to-day rehabilitation process. A further conclusion is that all carers need to be alert to how they establish contacts with their patients. This is not a process which will take place automatically. However this seems a reasonable request, if we consider the consequences which the shortfall in functional capacity and the rehabilitation process can have on the capacity of the patient to adjust. When the rehabilitation workers do not succeed in detecting the reasons for the stagnation, a psychologist should be consulted. When this consultation is not enough, referral to the psychologist for counselling and cognitive behavior therapy may be indicated in addition to the rehabilitation programme. The following statement was published more than 20 years ago, but has lost none of its power [18]: ‘What leads more than anything to a rehabilitation approach is a constant closeness to the actual problems of the deprived and disabled in everyday life, requiring not only intellectual understanding but emotional understanding of the character of the problems’.
References [l] Moor de JMH, Balen van HGC, Beers KA,Vos de LAJ. Revalidatiepsychologie. Assen/Maastricht: Van Gorcum, 1990. [2] Thomae H. Theory of ageing and cognitive theory of personality. Hum Dev 1970; 13: 1-16.
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[3] Folkman S, Schaefer C, Lazarus, RS. Cognitive Processes as Mediators of Stress and Coping. In: Hamilton V, Warburton DM, editors. Human Stress and Cognition. Chichester: John Wiley & Sons, 1979. [4] Watzlawick P, Weakland JH, Fisch R. Het kan anders, over het onderkennen en oplossen van menselijke problemen. Deventer: Van Loghum Slaterus, 1987. [S] Atkinson JW. An Introduction to Motivation. Toronto: D. van Nostrand Company, 1964. [6] Atkinson JW, Bastian JR, Earl RW, Litwin GH. The achievement motive, goal setting, and probability preferences. J Abn Sot Psycho1 1960; 60: 27-36. [7] Beck, RC. Motivation: Theories and Principles. New Jersey: Prentice-Hall Inc., 1978. [8] Jung J. Understanding Human Motivation, A Cognitive Approach. New York: Macmillan Publishing Co. Inc., 1978. [9] Birren, JE, Schaie. KW. Handbook of the Psychology of Aging. New York: Van Nostrand Reinhold Company, 1985. [lo] Reber AS. Woordenboek van de psychologie. Amsterdam: Uitgeverij Bert Bakker, 1989. [ll] Snoek FJ. Psycho-sociale determinanten van reactivering: een introductie. In: Ribbe MW, Snoek FJ, editors. Amstelhof, hedendaagse verpleeghuiszorg in een historische omgeving. AmsterdamlMeppel: Druk Krips Repro, 1987. [12] Wright B. Physical Disability, a Psychological Approach. New York: Harper, 1983. [13] Beck RC. Motivation, Theories and Principles. Englewood Cliffs, NJ: Prentice-Hall Inc., 1978. [14] Velden van der K, editor. Directieve therapie I. Deventer: Van Loghum Slaterus, 1977. [15] Egmond van JJ. Theorie en toetsing in de revalidatie psychologie. Gedrag Gezondheid 1986; 14: 19-26. [16] Shapiro D. Surwitt RS. Operant Conditioning, A New Theoretical Approach in Psychosomatic Medicine. In: Lipowsky ZJ, Lipsitt DR. Whyprow PC, editors. Psychosomatic Medicine. New York: Oxford University Press, 1977. [17] Premack, D. Toward empirical behavior laws, 1: positive reinforcement. Psycho1 Rev 1959; 66: 219-233. [18] Dembo T, Diller L, Gordon WA, Leviton G, Sherr RL. A view of rehabilitation psychology. Am Psycho1 1973; 28: 719-722.