This thesis investigated the important topic of impaired motivation for rehabilitation and the negative effect this can have on individuals’ recovery and community reintegration following an Acquired Brain Injury (ABI). ABI affects hundreds of thousands of individuals in Australia and is considered to be a leading cause of disability. The recovery process following ABI is often painful and lengthy with individuals often experiencing a range of physical, cognitive, emotional, behavioural and social difficulties. Motivation for rehabilitation has been found to be an important determinant in rehabilitation and lifestyle outcomes following ABI, with reduced motivation being found to significantly impede the rehabilitation process. A multitude of neurological/neuropsychological, psychological and socio-demographic factors have been suggested in the literature to help explain the motivation difficulties experienced by individuals following an ABI and the impact these factors can have on rehabilitation and lifestyle outcomes for individuals. Several different theories of motivation have been proposed over the years with suggestions on how to increase motivation and goal setting, some of which have more recently been applied to individuals with an ABI.
This thesis provides a biopsychosocial approach to problems of motivation after ABI through discussion and examination of neurological/neuropsychological and psychological factors such as: type of injury, frontal lobe involvement, executive functioning, self awareness, depression, anxiety, self esteem, denial and locus of control, and their independent and combined relationships with motivation and goal setting. Key socio-demographic factors such as age, pre-injury education, post-injury employment, post-injury driving and time since injury were also discussed and their independent and combined relationships with motivation and goal setting examined.
Using a longitudinal design the influence of these factors on motivation and goal setting, goal achievement and psychosocial outcome was examined over a 12 month period. Five studies were conducted involving 52 individuals with an ABI and a control group of 21 undergraduate students. Thirty of the fifty-two participants with an ABI took part in the 12 month follow up study. The aim of these studies were as follows: Study 1: the development and standardisation of a new measure for assessing motivation and goal setting after ABI; Study 2: investigation of relationships between motivation and goal setting and neurological/neuropsychological factors; Study 3: investigation of relationships between motivation and goal setting and psychological factors; Study 4: investigation of relationships between motivation and goal setting and socio-demographic factors and Study 5: investigation of neurological/neuropsychological, psychological and socio-demographic factors that predict motivation and goal setting, goal achievement and psychosocial outcomes over time.
Chapter 1: provides a critical review and evaluation of past research and highlights the need for future research into the factors underlying and influencing motivation for goal setting after ABI and the effects of motivation and goal setting on goal achievement, motivation and goal setting and lifestyle outcomes over time. Conclusions drawn from the literature review support a biopsychosocial approach to the assessment and rehabilitation of motivation and goal setting after ABI and highlight the need for a new measure to be developed to assess motivation and goal setting after ABI.
Chapter 2: outlines Study 1 which involved the development, standardisation and application of a new valid and reliable semi-structured interview for assessing motivation and goal setting (MAGS) after ABI.
Chapter 3: details Study 2 which investigates the relationships between neuropsychological factors and motivation and goal setting after ABI and the role time-since- injury plays in these relationships. Key findings were as follows: an association between the importance placed on goals and error scores on the Controlled Word Association Test (COWAT) and association between realistic goal setting and total scores on the Tower Test and the Key Search Test; individuals with injuries involving the frontal lobes being found to place less value on their goals and doing less to achieve their goals than those with injuries not involving the frontal lobes; individuals with a traumatic brain injury (TBI) being found to be doing less towards achieving their goals, than individuals with a non traumatic brain injury (NTBI); time-since-injury was found to be an important factor with individuals, who sustained their injury more than two years earlier, placing less importance on their goals than those whose injury occurred within two years of the study. Support was also provided for research suggesting executive functioning is not limited to frontal lobe involvement and the need for a biopsychosocial approach to assessment of motivation and goal setting after ABI.
Chapter 4: details Study 3 which investigates the relationships between psychological factors and motivation and goal setting after ABI and the role time since injury plays in these relationships. Key findings were as follows: confidence in achieving goals was associated with self awareness, self esteem, depression, chance locus of control and level of personality related denial; importance of goals was associated with level of personality related denial and doctors locus of control; realistic goal setting was associated with level of self awareness; action towards goal achievement was related to levels of doctors locus of control. In addition interrelationships were also found between psychological factors and motivation and goal setting and psychological factors and time since injury and the effects these interrelationships had on motivation and goal setting. A biopsychosocial approach to motivation and goal setting was further supported by the results of this study.
Chapter 5: details the findings of Study 4 which investigates the relationships between socio-demographic factors and motivation and goal setting after ABI and the role time-since-injury plays in these relationships. Key findings were as follows: an association was found between realistic goal setting and employment status; action towards achieving goals was associated with age and driving status. This study also provided further support for a biopsychosocial approach to assessment of motivation and goal setting.
Chapter 6: outlines Study 5 a longitudinal study which investigated what neuropsychological, psychological and socio-demographic factors predict motivation and goal setting, goal achievement and psychosocial outcomes over time. Key findings were as follows: performance on subscales of the MAGS remained relatively unchanged for 30 of the participants with an ABI from time 1 to time 2 (12 month follow up); neurological/neuropsychological, psychological and socio-demographic factors at time one directly influenced scores on the MAGS 12 months later as follows: goal selection and goal oriented behaviour at time 2 was found to be associated with time one frontal lobe involvement and pre-injury education; confidence in achieving goals at time 2 was associated with number of design fluency errors at time 1; complexity of goals at time 2 was associated with time 1 other people locus of control, self awareness and type of injury (TBI Vs NTBI); realistic goal setting at time 2 was associated with time 1 coping related denial; importance in achieving goals at time 2 was associated with time 1 other people locus of control and current action towards achieving goals at time 2 was associated with time 1 scores on the Health and Safety Questionnaire and Design Fluency Test. No individual time 1 factor influenced goal achievement, but rather a combination of factors was found to be important and interestingly no neurological/neuropsychological factors played an influential role in goal achievement, however interrelationships between psychological factors did. Scores at time 1 on the confidence in achieving goals and realistic goal setting subscales of the MAGS were found to predict scores on the Sydney Psychosocial Reintegration Scale at time 2. Again this study provided further support for adopting a biopsychosocial approach to the assessment of motivation and goal setting after ABI. Finally,
Chapter 7: provides a summary of the key findings of the empirical studies as noted above, discusses implications for the field, limitations of the research and provides suggestions for future research, in particular: further examination and standardisation of two of the subscales of the MAGS (Importance and Current Action) to improve the internal consistency and reliability of these subscales, the use of different clinical populations and control groups and larger groups to improve the generalisability of the MAGS and ability for it to be turned into a psychometric test; investigating whether differences in gender influence performance and responses on the MAGS, an increase in the number of participants who take part in follow up studies and finally, finding ways to measure the impact of external treatment/therapy on follow up results.