Neurogenic Disorders: Assessing/Managing Patient Motivation Michael Biel, CScD, CCC-SLP 1 Motivation 1 Disorders of diminished motivation 2 Motivation and Rehabilitation Assessment Management 3 4 5 2
Most of us rely on an intuitive sense of what motivation is 3 Why study motivation? 4
Because we believe it s important to outcomes (Kaufman & Becker, 1986; Maclean et al., 2002) Because we make treatment decisions based on it (Enderby & Petheram, 1992; Mackenzie et al., 1993) 5 Not a new concern Darley (1972), Eisenson, (1949) and Wepman (1953) made understanding motivation a prominent part of aphasia treatment 6
What do we believe? Age, stroke severity, cognition, personality and depression influence motivation Cultural factors, including religious beliefs influence motivation Kaufman & Becker, 1986; Maclean et al., 2002 7 More beliefs... Maclean et al. (2002) Motivated Unmotivated Asks questions about therapy Asks for more therapy Demonstrates understanding of the purpose of therapy Initiates therapy Passive Pessimistic Lack of interaction with staff Little overt interest in rehab Does exercises alone 8
Viewing motivation as a personality trait can lead to moralizing Maclean et al. (2002) 9 Two basic aspects There is an urge/desire to act Which is goal directed WHO (2001) ICF definition... Mental functions that produce the incentive to act; the conscious or unconscious driving force for action Goals can be external (e.g. food) or internal (e.g. self-esteem, autonomy, competence, and relatedness) (Lequerica & Kortte, 2010; Marin & Wilkosz, 2005) 10
Motivation does not imply action or participation in therapy 11 Motivation 1 Disorders of diminished motivation 2 Motivation and Rehabilitation Assessment Management 3 4 5 12
Disorders of diminished motivation (DDM) Diminished overt behavior Diminished goal-related thought content Diminished emotional response to goal related events Marin & Wilkosz (2005) 13 Apathy Abulia Akineti c mutism Diminished motivation Poverty of behavior, lack of initiative, loss of emotional responses Total absence of spontaneous behavior and speech Marin & Wilkosz (2005) 14
Marin & Wilkosz (2005) 15 Marin & Wilkosz (2005) 16
Dx criteria for Apathy in AD Robert et al. (2009) Diminished overt behavior, diminished goalrelated thought content, and diminished emotional responses to goal-related events Symptoms of apathy should cause significant impairment in personal, social, occupational or other areas of functioning Should not be attributable to physical or motor disabilities, depressed consciousness, or due to the effects of substances such as drug abuse or medications 17 Apathy Assessment Clark et al. (2011) Reviewed 15 apathy scales and subscales Apathy Evaluation Scale (AES) and the apathy subscale of the Neuropsychiatric Inventory (NPI) were psychometrically the strongest and covered a broad range of disease processes 18
Apathy Evaluation Scale (AES-C) Marin (1996) 19 Apathy Prevalence van Reekum et al. (2005) Alzheimer s disease - 60% TBI - 61% Basal Ganglia (focal lesions, PD, HD, and PSP) - 41% Vascular dementia - 34% Cortical stroke - 35% 20
Apathy - Associated Outcomes van Reekum et al. (2005) Decreased functional level (ADLs) Caregiver (but possibly not patient) distress Poorer outcome of illness Poorer treatment response 21 Motivation 1 Disorders of diminished motivation 2 Motivation and Rehabilitation 3 Assessment Management 4 5 22
Lequerica & Kortte (2010) 23 Lequerica & Kortte (2010) 24
Bandura s Self-efficacy Theory Different experiences shape our beliefs in our abilities to do different behaviors Past performance Vicarious experience Verbal persuasion Physiological states Bandura (1986;2000) 25 Types of self-efficacy Task self-efficacy Belief in ability to complete a specific task Self-regulatory efficacy Belief in ability to complete a task in the face of some barrier Bandura (1986;2000) 26
Self-efficacy and outcomes Self-efficacy post-stroke is an important variable in outcomes, such as quality of life, depression, ADLs, and, to a lesser degree, physical functioning (Jones & Riazi, 2010) Elderly adults with high memory self-efficacy maintained a more consistent level of practice on inductive reasoning tasks (w/ greater improvement) than low memory self-efficacy adults (Payne et al.,2012) 27 Outcome expectancies Judgement that a certain outcome will result from a certain behavior Self-efficacy is our belief in our ability to do the behavior, outcome expectancies are our beliefs about the results Bandura (1986;2000) 28
Subjects may have high self-efficacy but if they do not believe in the outcomes associated with a therapy then it is unlikely that they will persist, this is particularly true for the elderly Resnick (1996); Resnick et al. (2005); Shaugnessy et al.(2006) 29 Lequerica & Kortte (2010) 30
Engagement is "a deliberate effort and commitment to working toward the goals of rehabilitation interventions, typically demonstrated through active, effortful participation in therapies and cooperation with treatment providers" Lequerica & Kortte (2010) 31 Throughout the engagement phase, patients are assessing the costs and benefits of treatment and deciding whether to continue to engage or not. Lequerica & Kortte (2010) 32
Motivation 1 Disorders of diminished motivation 2 Motivation and Rehabilitation 3 Assessment 4 Management 5 33 Assessing Awareness 34
Background awareness can be domain specific or global Individuals post-cva and TBI appear to acknowledge motor/sensory impairments more often than cognitive, social, and emotional changes (Fleming & Strong, 1999; Toglia & Kirk, 2000; Trahan, Pepin, & Hopps, 2006) Higher levels of awareness on the Self- Awareness of Deficits Interview (SADI) were associated with higher levels of motivation in TBI (Fleming et al., 1998) 35 Direct Assessment Self-family/friend discrepancy Performance-based discrepancy Structured interviews Clinician ratings 36
Indirect Assessment Verbal reports from staff/family Ability to set realistic goals Presence or absence of use of compensatory strategies Compliance with therapy (both medical and rehab) 37 Measurement instruments Awareness Questionnaire-AQ (Sherer et al., 1998) Patient Competency Rating Scale-PCRS (Prigatano et al., 1990) Self-Awareness of Deficit Interview-SADI (Fleming et al., 1996) Visual-Analogue Test Assessing Anosognosia for Language Impairment-VATA-L (Cocchini et al., 2010) 38
VATA-L For persons with aphasia 39 Assessing Self-Efficacy 40
Background Self-awareness and self-efficacy are interrelated when deficit awareness is poor, beliefs and judgements about what one is capable of may become distorted (Toglia & Kirk, 2000) Overestimation of abilities can lead to unexpected difficulties performing a task and erode self-efficacy 41 Assessment process Self-efficacy scales are typically done via confidence ratings on a 0-10 or 0-100 scale (Jones et al., 2008) Should be task specific, contain different levels of challenge, and contain contextual conditions (Bandura, 1997) Contextual conditions that impose some challenge or barrier to doing a behavior can be added to improve the predictive ability, e.g. "How confident are you that you can do your practice when you are home alone?" 42
Van Leer & Connor (2012) 43 Assessment process cont Wording: "can do" asks for a judgement of capabilities (i.e. self-efficacy), "will do" asks for a judgement of intention Make sure clients are judging their capabilities now, not in the future or in the past May need to use a very concrete example of self-efficacy before asking about speech, language or cognitive abilities/tasks, e.g. "How confident are you that you can lift a 10 lb weight? A 50 lb weight? etc. 44
Communication Confidence Rating Scale for Aphasia-CCRSA Can be used to assess generalization of self-efficacy beliefs Babbitt & Cherney (2010) 45 Assessing Participation and Engagement 46
Rehabilitation Therapy Engagement Scale-RTES Designed to help rehabilitation therapists... Quantify the level of observed engagement during rehab Identify factors contributing to reduced engagement Serve as a basis for thinking about interventions to improve engagement High correlation between higher engagement scores and better motor and cognition FIM scores in a group of 75 acute rehab patients with ABI Lequerica et al. (2006) 47 Pittsburgh Rehabilitation Participation Scale-PRPS Measures observed patient participation in a therapy session Doesn t measure different aspects of participation/engagement Once those areas are identified by other means, the scale may be useful in tracking change over time to evaluate the effectiveness of interventions designed to improve participation in therapy. Lenze et al. (2004) 48
49 Motivation for Traumatic Brain Injury Rehabilitation Questionnaire (MOT-Q) Likert scale questionnaire developed to assess motivation to participate in post-acute rehabilitation 31 items in 4 subscales: (lack of denial, interest in rehabilitation, lack of anger, reliance on professional help) Chervinsky et al. (1998) 50
Motivation 1 Disorders of diminished motivation 2 Motivation and Rehabilitation 3 Assessment 4 Management 5 51 Bandura's 4 determiners of selfefficacy Bandura & Locke (2003); Shaughnessy & Resnick (2009) Mastery experience Vicarious experience Verbal persuasion Physiologic feedback 52
Mastery experiences Client-centered goal-setting Success on meaningful goals can promote setting more challenging goals in order to experience greater reward (Bandura, 1986), while failure to achieve goals can erode self-efficacy (Bandura & Jourden, 1991) Individuals tend to discount the intensity of the value of goals the further out in the future they are (Green & Myerson, 2004) 53 Mastery experiences cont. Rosewilliam et al. (2011) systematic review - patient-centered goal setting has the following positive psychological outcomes, leading to greater participation in rehab Self-efficacy and confidence Sense of autonomy Motivation Reduction of anxiety 54
Mastery experiences cont. Rosewilliam et al. (2011) systematic review cont. Need to educate patients about the concept and the process of patient-centered goal setting, provide clear information regarding the condition, its prognosis and time course in order to avoid unrealistic expectations 55 Vicarious experience Self-efficacy increases when watching others successfully complete a similar task (Bandura, 1986) Peer mentorship, one-on-one (Coles & Snow, 2011) or via group therapy Video self-modeling (Cream et al., 2010) 56
Verbal persuasion Appropriate persuasion builds task self-efficacy (Bandura, 1986) Closely aligned with goal-setting...need to make sure that clients are placed in a context in which they will succeed Can include a review of past successes 57 Physiologic feedback Physical and emotional (e.g. anxiety) experiences associated with task self-efficacy or regulatory self-efficacy (Bandura, 1986) Help clients understand common experiences, such as anxiety, stress, or fatigue associated with therapy and provide strategies to counteract them. 58
Apathy treatment Lane-Brown & Tate (2010) 59 Motivational interviewing a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Miller & Rollnick, 2002) Four guiding principles to create the conditions for change: express empathy, develop discrepancy, roll with resistance, and support self-efficacy (Miller & Rollnick, 2002) 60
Medley & Powell (2010) 61 Thank you! 62