By Les Willis, Student Dietitian
Motivation is a nebulous concept which has been the subject of extensive investigation by psychologists (Gross, 1987). The link drawn with behaviour is usually a reflection of the particular theoretical approach of the writer. O'Gorman (1975) sees the concept of motivation as 'the most important yet the most difficult part of the work of the therapeutic professions'. Yet, there is considerable disagreement amongst clinicians (and psychologists) over what constitutes motivation (King and Barraclough 1989). King and Barraclough see this disagreement amongst clinicians as sufficient grounds for the rejection of motivation because it is a clinically unhelpful concept.
Despite conceptual difficulties, motivation has proved an important principle for care professionals on a number of grounds. Motivation is consistently linked to 'better' therapeutic results (Simpson, Joe, Rowan-Szal and Greener, 1997; Shen, McLellan and Merill, 2000; MacLean and Pound 2000; Tupper and Henley, 1987), and has been a powerful predictor of those results when measured before intervention occurs (Pitre, Danserau, Newbern and Simpson, 1998).
In a critical review of 'the concept of patient motivation' MacLean and Pound (2000) identified how health care professionals consistently rate the motivation levels of their patients and draw firm links between patient motivation and positive therapeutic outcomes, while employing very loose definitions of the term 'motivated'. In their review MacLean and Pound identified how clinicians tend to identify motivation as a personality trait. Motivation is seen as an integral component of the individual and their behaviour. Kaufman and Becker (1986) found that clinicians stressed individual responsibility, a finding repeated by Griffiths and Hughes (1993), who also noted a focus on patient character. MacLean et al (2001) observed that patient demeanour was widely used as an indicator of motivation. In addition complicity with the intervention was directly correlated with motivation, the unmotivated being those who did not follow the instructions of clinical staff.
The way that clinicians define motivation is problematic, Lane and Barry (1970) summarise the situation, "when a counsellor describes a client as unmotivated, this can usually be taken to mean that the client's goals and aspirations are not the goals the counsellor has for him". An individualistic focus shifts responsibility for the success or failure of treatment on to the patient (Hoffman, 1981; Becker and Kaufman, 1995; MacLean et al 2001), and often leads to moralistic judgements by clinicians (MacLean and Pound, 2000; Becker and Kaufman, 1995; Hoffman, 1981). Deitchman and McHargue (1973) and Wright (1980) both identified motivation as a contextual variable within the health care setting, as opposed to it being a constant. Resnick (1999) highlighted patient motivation as being dependent upon a supportive, empathetic relationship with the health care practitioner (Myers 1965; Weiss, 1966; Rigoni 1969).
Patient motivation is a complex phenomenon, and it is important to focus on those theoretical aspects which link directly to beneficial therapeutic outcomes. No theoretical consideration of motivation would be complete without an appreciation of Maslow's (1970) "Hierarchy of Needs". Maslow identified two types of need, deficiency and growth; deficiency needs have to be met before growth needs can be fulfilled. After his initial work, Maslow, modified his Hierarchy and recognised that is possible to attempt to fulfil higher needs while lower ones go unsatisfied. Maslow's Hierarchy of Needs in its fullest form is thus:
- Physiological; hunger, thirst, etc
- Safety and Security
- Belongingness and Love
- Cognitive; understanding, knowledge
- Aesthetic; order, beauty
- Self Actualization; fulfilment and realisation of potential
- Self transcendence; connection with something beyond the ego or to help others fulfil their potential
This hierarchy is helpful to health care practitioners because it delineates and defines human motivations into identifiable and manageable factors. Fulfilment of higher needs is not dependent on the satisfaction of lower ones.
For example, a patient with anorexia nervosa can fulfil their needs for esteem and self actualization while their most basic physiological need goes unmet (Vitousek, Watson and Wilson 1998). If as practitioner we are going to embark upon a successful therapeutic relationship with an anorexic patient we need to appreciate their motivation, and our treatment program needs to meet their requirements for self-actualization and esteem if it is to prevent their disordered eating behaviour from returning. By embarking upon a program our patient may be relinquishing satisfaction of their need for safety and security, this need should consequently be addressed as part of their therapeutic program. To meet their needs, patients seek out information (Norwood 1999), the type of information that is most appropriate is dependent upon the need it is required to fulfil. For example, patients in need of safety and security are best served by helping information, while people seeking esteem require empowering information. Our anorexic patient would be best served by the provision of both empowering and edifying information.
McClelland (1985) identified that needs are learned as well as being 'genetically programmed'. This identification builds upon the work of Bandura (1977) and social learning theory from Vygotsky (1978). In terms of patient motivation MacLean et al (2001) see social context as being of primary importance. In terms of motivation in a clinical setting, social context provides support (Klingemann et al 2001), defines acceptable behaviour (Durkheim 1985), influences behaviour (Bond, 1982; Matlin and Zajonc, 1980; Geen, 1981) and provides an important stimulus for change (Baumeister and Tice, 1990). Social context is important in determining the success and continuation of change, as well as in terms of practitioner – patient relations. The presence of others motivates extra effort, while also heightening the sense of embarrassment when an individual fails (Carver and Scheier 1981). Experience of success is important, because when performing tasks in the presence of others, success leads to success and failure leads to further failure (Seta and Hassan 1980). When seeking successful therapeutic outcomes it is incumbent upon the practitioner to create a safe environment that engender success.
Elster (1989) reminds us; "the elementary unit of social life is the individual human action". There are some individual characteristics that are important in patient motivation. Piaget (1958) illustrates how children have a desire to maintain what he terms equilibration. In other words, individuals seek to organise and balance their view of the world and their place in it. New experiences are either assimilated into an existing scheme or accommodated via modification. The desire to attain equilibration combines with the need for achievement (Atkinson, 1964), and for control over the environment (Stipek, 1993; White, 1959). Individuals are inherently active and self directed (Deci and Ryan, 1985), and it is this, along with equilibration, that gives individuals a perception of control (Gurin and Brim, 1984; Brim, 1976). Perceptions of control are linked to outcomes by Bandura (1977) as self efficacy. Self efficacy forms a partnership with self esteem. Individual self efficacy and esteem form the foundations of individual motivation (Fox, 2000; Fox and Corbin 1989; Sonstroem, 1998). When individuals perceive they are in control more successful therapeutic outcomes are the result (Deci, Vallerand, Pelletier and Ryan, 1991; Ryan and Connel, 1989; Vallerand and Bissonnette, 1992; Nentwig, 1978).
These three theoretical approaches to motivation can be used to inform a practitioner's model of patient change. Motivation is the interplay of inherent, learned, and social factors. The individual combines these to produce their own way of seeing the world, which they seek to confirm (Kelly 1963). Festinger's (1957) cognitive dissonance theory describes how, when there is a discrepancy between an individual's beliefs and their actions they seek to reconcile the two; either by changing their cognition to justify the behaviour or, by altering their view of themselves. As practitioners it is important to note that the dissonance effect is greatest when behaviour threatens self image. Often patients experience changes that directly impact upon their self beliefs. This can be used to help drive the process of change through the practitioner highlighting the disjunction between belief and action. This model of change is embodied in the Motivational Interviewing technique (Rollnick, Heather and Bell, 1992; Miller and Rollnick, 2002; Wagner and Sanchez, 2002). Motivational interviewing has proven effective in a number of settings, such as increasing treatment involvement (Lincourt, Kuettel and Bombardier, 2002; Marhno, Carroll, O'Malley and Rounsaville, 2000), and lowering patient dropout (Daley, Salloum, Zuchiff, Kinsci and Thase, 1998).
Weinreich (1999) identifies the essential elements required to achieve effective and lasting behavioural change:
- An individual must believe there is a problem which has severe consequences
- An individual must believe that the proposed behaviour will address the problem and prevent the consequences
- The individual benefits must be perceived as outweighing the costs
- An individual has to have the skills required for the new behaviour
- They must believe they have the skills required (self efficacy)
- The behaviour has be consistent with self image
- An individual needs to perceive greater social support or pressure for the changed behaviour as opposed to the status quo
- There need to be less barriers to the new behaviour than there are to the old behaviour
- The individual must intend to make the required change to their behaviour
Practitioners can utilise the powerful integrated stages of change model developed by DiClemente and Prochaska (1982). By identifying which stage the patient is at, understanding that patients can move back and forth through the stages, and spend different amounts of time at each stage, the practitioner is better able to meet the needs of the individual. Appropriate solutions are built through an effective working partnership. The change process is solutions orientated, and those solutions are patient, not practitioner driven, and hence, are more effective (Heijn and Granger, 1974; Wressle, Oberg and Henriksson, 1999; Hesse and Campion, 1983).
Patient motivation is essential for the achievement of beneficial therapeutic outcomes. The health care professional uses theory to inform practice, and to build an effective partnership with the patient. Goals are formulated through a dialogue and, if necessary, negotiation, so that they take into account the wider context of the patient - practitioner relationship. Used effectively patient motivation is part of an empowered patient – practitioner partnership where it is possible to achieve outcomes that better meet patient needs, rather than the needs of health care providers (McGuire, 2000; Miller and Rollnick, 2002).
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