The role of client motivation in workplace rehabilitation

Motivation has been recognised as an essential component in managing medical issues, adjusting to physical disability, cognitive impairment, returning to work, and improving psychosocial functioning. Rehabilitation aims to reduce the impact of impairments on activities of daily living and social role functioning, promoting both independence and social inclusion. This research explores the role of client motivation in workplace rehabilitation and demonstrates the implications for rehabilitation counselling practice. The research focuses on understanding the concept of motivation, reasons for its presence or absence, and why motivation is important to the workplace rehabilitation process. This study also explores significant influencing factors that may be utilised to increase motivation and promote more successful return to work outcomes, as well as considering the implications for rehabilitation practice and research.


Introduction
Rehabilitation counselling can be understood as a process that aims to enhance and improve the personal, social, and functional potential of clients through individual, environmental, vocational, and social resources. A Rehabilitation Counsellor works with individuals experiencing disability, injury, or social disadvantage to achieve a range of goals. In order to support the client in their return to work, Rehabilitation Counsellors work with individual strengths to facilitate change in the person and their environment (Rehabilitation Counselling Association of Australasia [RCAA], 2012). To reach the desired return to work outcome, the Rehabilitation Counsellor is required to identify social, economic, and environmental factors that may adversely affect a client's motivation toward rehabilitation (Matthews, Buys, Randall, Biggs, & Hazelwood, 2010).
Motivational practices incorporate a broad range of strategies, including screening nonmotivated clients and maintaining high client motivation in the return to work process (Ryan, Lynch, Vansteenkiste, & Deci, 2010). Ryan et al. (2010) also emphasise that a Rehabilitation Counsellor needs to be able to actively support, facilitate, and produce change in a client to promote motivation and return to work.

Method
This study utilised a comprehensive review of journals, published books, Australasian peak body websites, and government and legislative publications focused on motivation and rehabilitation practice. The following databases were reviewed: SAGE research methods online; RehabData; Informit health collection; SAGE journals online; Proquest; and Scopus. To analyse implications for practice and research, publications from authorities such as WorkCover NSW and Heads of Workers Compensation Authorities (HWCA) were reviewed, as well as data from Comcare.

Motivation
Motivation is a difficult concept to define. Lai (2004) suggests that motivation could be a purely internal 'personality trait' that exists unaffected by external factors. Alternatively, Miller (1999) suggests that motivation should not be considered an intrinsic personality trait, but a critical implication of client-counsellor interaction in rehabilitation. Meanwhile, Ryan et al. (2010) take a more behavioural approach and broadly define motivation as that which moves people to act and involves energy and direction. Rijk, Janssen, Lierop, Alexanderson and Nijhuis (2009) enhance this behavioural approach by stating that motivation is focused through the internal process that influences the direction, persistence and strengths of a person's goal-directed behaviour. The definition of motivation that will be used throughout this discussion is a combination of the above interpretations, taking the view that it is too simplistic to say people are motivated or not; rather, that people are motivated by different things and this can be influenced. In this paper, motivation refers to the underlying internal and external influences on behaviour that determine whether a person will achieve the desired rehabilitation goals. A key focus of this definition of motivation is the implied behaviour and actions undertaken in order to achieve these objectives.
Immediately after the onset of work disability, the return to work aspect of rehabilitation may not be a priority; however as the rehabilitation and return to work process develops, priorities change and motivations to reach personal goals are highlighted. Motivation can be measured or closely linked with the client's readiness to change and the work readiness scale (Young et al., 2005). During the rehabilitation process, work demands and individual capacities need to be stabilised in relation to each other to achieve a sustainable fit between work demands and the capacity to meet those demands . Grahn, Borgquist and Ekdahl (2000) indicate that rehabilitation aims to help the client return to an active and independent life. They state that multidisciplinary rehabilitation, which focuses not only on physical restrictions but also emotional and social factors, has an important effect on the health-related quality of life for a client. In linking this concept, Ryan et al. (2010) suggest that motivation is not a focus at any one point in the rehabilitation process, as it should be maintained throughout the return to work process. As a result Ryan et al. (2010) recommend that positive and lasting results most likely occur when a client becomes motivated, actively engaged, and invested in change in all aspects of their life. Guthrie and Harvey (1994) state that there is a significant relationship between motivation for recovery and the rehabilitation outcome. Understanding what medical, personal, social, and psychological factors influence the outcome of the return to work plan is of key relevance to a successful return to work process. There are many significant factors that have the ability to influence a client's level of motivation. In analysing the literature the following key factors were identified: internal motivation; key stakeholders; social supports; external regulation; perceived costs and benefits; hope and individual beliefs surrounding working identity.

Factors that influence motivation
Internal motivation has been identified as a key factor, suggesting that a client needs to have the willingness, readiness, and desire to change in order to achieve the desired outcome. Larsson and Gard (2003) suggest that the client's capacity to respond positively is underpinned by an individual's belief about themself and their potential. The Royal Australasian College of Physicians (2010) support this by stating that employees who are confident about their situation and active participants in the return to work process are more likely to return to work. The critical question is whether the client's self concept is essentially stable or can be influenced in a way that not only brings about an objective or goal, but also direction, incentive and effect . Young et al. (2005) state that the key stakeholders in a return to work plan have an ultimate influence on the return to work outcome for the injured worker and in turn, have the ability to influence motivation for the client. They define return to work stakeholders as any person, organisation, or agency that stands to gain or lose based on the results of the return to work process. The stakeholders that are directly involved in a rehabilitation plan include the injured worker, employer, insurer, and healthcare and rehabilitation providers. Other stakeholders that influence the process include the injured workers' families, co-workers, labour union groups, government agencies, local communities, as well as the socio political environment (Franche, Baril, Shaw, Nicholas, & Loisel, 2005). Secure, gainful employment positively influences health, well-being, social prestige and social inclusion, benefiting both individuals and other stakeholders (Geisen, 2011). It is important that all stakeholders have the potential to gain from the worker successfully returning to work to ensure each stakeholder has an interest in motivating the client to strive for the return to work outcome. For many clients, the absence of a direct relationship between diagnoses, clinical measures of injury or illness, function at home, and ability to work has been recognised as a barrier to motivation (Franche et al., 2005). Effective rehabilitation requires that the different stakeholders are able to cooperate and act in the same direction. This notion suggests that it is important for all stakeholders in the return to work process to formulate their goals and to coordinate them for an effective rehabilitation outcome and increased level of motivation for the client (Gard & Larson, 2003). Supporting the need for client consultation, WorkCover NSW (2005) research concludes that there are key principles underlying the safe, early, and durable return to work of injured workers which include: having systems in place to ensure everyone at the workplace agrees; everyone understands and knows what to do in the event of an injury; early reporting of injuries and early intervention; and, having the key parties working together and communicating effectively.
Social support and a strong network of good relationships play an important role in client motivation and have a generalised positive effect on health and good prognosis after illness or injury (Guthrie & Harvey, 1994). Guthrie and Harvey (1994) found that motivated clients in their research were sufficiently supported by social networks and their rehabilitation plan consisted of sufficiently ambitious goals. Further, it has been established by Ryan et al. (2010) that stakeholder involvement and the participation of caregivers in supporting the client to sustain commitment towards their goals is crucial to motivation in rehabilitation and return to work.
Perceived costs and benefits for the client are another key influencing factor in motivation to participate in a return to work plan. Wagner and McMahon (2004) propose that the client might be more willing to participate in the rehabilitation process if they are able to see the benefits and payoffs in the future. Possible costs within a workplace rehabilitation plan include the required effort to participate fully, as well as the associated tiredness or pain. These costs vary in nature and are valued differently by each individual. Geelan and Soons (1996) state that rehabilitation clients are prone to ambivalent feelings about returning to work. In considering this in rehabilitation counselling practice, Wagner and McMahon (2004) suggest that it may be beneficial for the rehabilitation professional to focus on clients' assets and de-emphasise limitations and other negative aspects of their situation. Encouraging clients to take small steps towards change and directly involving clients in all aspects of the rehabilitation process has been proven effective in influencing the motivation levels of the client. An evidencebased benefit is that health improvement is directly caused by re-employment. The security of the new job, as well as the person's motivation and job satisfaction, also influence a person's health following their return to work. In many instances, work can play an important role in rehabilitation because 'doing' promotes recovery and therefore increases motivation (The Royal Australasian College of Physicians, 2010).
A worker's employment status and earning potential are related to their motivation to return to work. Re-establishing one's sense of self, if work has previously been a major part of their life, and gaining a desired place in society or the ability to participate in other life goals, such as community and family priorities are all potentially key motivations for an injured worker. Although this may not be of importance immediately after the onset of work disability, in the long term, successful work resumption will financially benefit most workers (Young et al., 2005). Work content and 'working identity, affect motivation to return to work. People have increased motivation to return to work if their job is meaningful and they have a sense of belonging and being appreciated (The Royal Australasian College of Physicians, 2010).
Evidence-based practice presented by Bezyak, Kubota, and Rosenthal (2010) holds rehabilitation professionals accountable in an increasingly expensive healthcare system. This accountability is necessary because healthcare systems are moving from provider-driven to payer-driven systems (Leahy, Chan, & Saunders, 2003). In nearly all contexts of rehabilitation, the health professional is limited by funding mandates imposed by the insurer, government agency, or other departmental organisations.
Pressure from these agencies and third party payers in many settings dictates a shortterm and limited funding approach to change, which makes motivation more critical. It also makes motivation more difficult to establish as clients have less control (Ryan et al., 2010).
An insurer's primary motivating factor is the return to work of injured workers for the least cost. This paradigm of cost containment and cause determination sets the stage for close interactions with healthcare providers. The insurer, guided by legislation, may take a medical perspective that requires the injured worker to be assessed by a physician to determine cause of injury and capacity to work. Treatments deemed necessary to achieve return to work are then approved for coverage. This approach is based on the assumption that disability outcomes are predictable once the diagnosis is made and does not take into consideration the psychosocial context (Franche et al., 2005). When an injured worker does not proceed according to these norms, the insurer may activate additional resources, such as professional case managers, to attempt to clarify and resolve obstacles to return to work. Given these motivating factors, insurers are most likely to respond to return to work interventions that reduce disability costs (Ryan et al., 2010).
In addition to the factors commonly discussed in the rehabilitation literature: internal motivation, stakeholder influence, social support and perceived costs and benefits; Kortte, Stevenson, Hosey, Castillo and Wegener (2012) suggest that hope buffers against negative influences because the individual believes their goals can be achieved despite the obstacles. "Hope is the perceived ability to achieve goals by generating routes to those goals and the associated motivated thoughts to access those routes" (Kortte, et al., 2012, p. 249). Human traits, such as hope, build on existing strengths and facilitate greater engagement with all life domains, including work (Kortte, et al., 2012).

Implications for practice
In identifying motivation as a key influence in a successful return to work process, it has been recognised that internal and external influences are major contributors, which extend to behavioural consequences for client motivation. It is the role of the Rehabilitation Counsellor to gauge this level of motivation within a client and direct the behavioural manifestations of motivation.
A significant contributing factor that not only affects the motivation levels in clients, but also equally influences the return to work process on a broader scale, is the pressure and impact from third parties. On a micro system scale, this can be defined as being controlled or pressured to change behaviours or attitudes (Ryan et al., 2010), which could result from the counsellor-client relationship and the interventions and strategies implemented to return the client to work. However, on a macro system scale, the impact can be linked to larger third party organisations such as insurers, government payment and welfare systems, and policy and legislation guidelines. These stakeholders have ultimate control over the way in which rehabilitation guidelines can be developed and implemented, and the services and funding available for Rehabilitation Counsellors and their clients to utilise in the return to work process (The Royal Australasian College of Physicians, 2010). Leahy, Muenzen, Saunders and Strausser (2008) suggest that although clients demonstrate motivated behaviour, some actively oppose the idea of changing their actions internally. The idea that a client may be forced by a system or by pressure from surrounding networks, to attend counselling or receive treatment has been a reported issue in return to work (Ryan et al., 2010). The client may act with compliance based on the desire for approval from someone, rather than a true personal desire to return to work. As a result, the client's underlying actions represent unwillingness to cooperate (Chan et al., 2010). The idea of internal regulation can be positively influenced by Rehabilitation Counsellors through their use of mutually agreed goals and strategies presented in the rehabilitation plan. In doing this, the client has autonomy in the process and perceives the process as a positive influence on achieving a successful outcome, the impact of internal pressures is released and, as a result, counteracts unmotivated behaviour. In addition, Grahn et al. (2000) suggest that it is as important for the rehabilitation professional to understand the nature of individual interventions, as much as it is important to understand the nature of organisational, community, and policy change.
The return to work plan needs to be considered practically, by rehabilitation professionals. It is easy to suggest that rehabilitation interventions that may be linked with long-term time frames are more likely to have a successful outcome, when in reality it is impossible to have a large amount of time for a treatment due to funding restrictions. Comcare (2008) is working with Commonwealth agencies to improve their rehabilitation performance and reduce the duration of claims, and has pursued a number of activities aimed at improving rehabilitation outcomes. In parallel, Heads of Workers Compensation Authorities (HWCA, 2005) aim to monitor the delivery of costeffective rehabilitation that avoids unnecessary repetition and is integrated with treatment services and provided in a timely manner in order to maintain motivation levels. In suggesting this, Grahn et al. (2000) state that delays are inevitable in the workers' compensation system, and they have been proven to reduce client motivation.
Rehabilitation professionals can assist by developing realistic but efficient timeframes, responding quickly, and coordinating other stakeholders to do likewise (The Foundation for Research into Injury and Illness in the Workplace Inc., 2007).
Macro activities go beyond individual interventions but are often based on needs, problems, issues, and concerns identified in the course of working one on one with service recipients (Netting, Kettner, McMurtry, & Thomas, 2012). Macro practice involves professionally-guided interventions designed to bring about change in a larger sense, such as organisational, community, and policy arenas (Grahn et al., 2000).
Macro practice is based on a number of practice approaches, and operates within the boundaries of professional values and ethics. It includes the contribution of associated professions, and involves the skills from these disciplines to interact in order to encourage client motivation to return to work (Netting et al., 2012).
In considering that the macro context could be de-motivating due to regulations and limitations, macro practice should also encourage advocacy to make systems more motivating and supportive of the return to work outcome. In response to this concept, the Australian Society of Rehabilitation Counsellors (ASORC) and the Rehabilitation Counselling Association of Australasia (RCAA) are involved in assisting the profession of rehabilitation counselling to increase their impact on systems that influence practice.
The main objectives of these associations are to assist in implementing new and innovative approaches to the rehabilitation of persons, and to encourage government bodies to maintain or introduce policies or procedures which ensure the proper and reasonable delivery of services to meet rehabilitation needs of persons with a disability.
The practice implications regarding motivation and the differing levels of cost are presented by Grahn et al. (2000), suggesting that increased motivation could substantially influence the total cost to society. They underline the importance of taking account of the interactions between the client and the healthcare service. Research has demonstrated that the indirect costs between the highly motivated and the less motivated clients was calculated at 4:1 in favour of the highly motivated clients (Grahn et al., 2000), benefiting all stakeholders.
Rehabilitation counselling professionals are required to maintain ongoing knowledge and skills to evolve in response to changing service delivery systems, policy and legislation mandates (Leahy et al., 2003). Private sector rehabilitation services experience significant growth because of regulatory changes that have encouraged improved injury management practices. Although traditional functions continue to be important, it is apparent that identifying processes central to effective rehabilitation practice, such as client motivation, and developing correlating skills sets is required to work effectively in these changing environments (Matthews et al., 2010).

Implications for research
The research described in this review confirms the complexity of the concept of 'motivation' and indicates a number of avenues for enhancement of motivation, which fit in well with a growing openness and partnership in the delivery of health care (Guthrie & Harvey, 1994). This paper provides relevant information about the relationship between motivation and rehabilitation outcomes. However, it also indicates some areas for further research, such as the relevance of working identity and how contextual factors influence client motivation.
An individual's working identity plays a key role in the return to work process and the motivation level of the client. In assessing literature surrounding these concepts, it has been identified that there is limited evidence about the importance of a person's working identity. Based on the literature and making connections with the return to work process, it seems that a person's working identity would be one of the key factors in motivating a person. Being able to identify with the client about what they do and do not connect with in a workplace, would be an essential aspect to being able to deliver the most effective interventions possible. Further research should therefore explore the relevance of a person's working identity to the level of motivation in a workplace rehabilitation plan.
In examining changes in employment for people with disability or injury, it is important for policy makers and service providers to be responsive to an increasingly complex array of economic and labour force trends. The current expectation for healthcare and rehabilitation professionals to use empirically supported interventions in their practices will continue to strongly shape the future of rehabilitation counselling research and services (Chan et al., 2010). Additional research could explore the effectiveness of different rehabilitation counselling strategies by collecting data from Rehabilitation Counsellors about what they observe about motivation, its influence on outcomes, and how practice can improve the understanding of individual contexts and strategies in order to affect client motivation levels. Furthermore, collecting data from past clients about their motivation levels during the rehabilitation process, how their behaviour changed and what helped in the return to work process would be useful.

Conclusion
This article has explored the role of motivation for a client in workplace rehabilitation.
Throughout this analysis, the information provided has clarified reasons for its presence and absence, and why motivation is essential in the rehabilitation process. The significant influencing factors for motivation levels within a client's workplace rehabilitation program have been identified and explored and include internal motivation, external regulation, stakeholders, social supports, hope, perceived cost and benefit, and a client's working identity. Implications for rehabilitation counselling with regard to both practice and research have also been suggested. The focus for practice is on third party pressures and systems and the impact that this has on the way that a Rehabilitation Counsellor can work with client motivation. Meanwhile, the research implications include exploring the role of working identity in motivation and return to work, collecting further data from Rehabilitation Counsellors regarding observed client motivation, and interviewing past clients with regard to their personal motivation experiences.

Biographical notes Amanda Mabin completed a Bachelor of Human Services/Master of Rehabilitation
Counselling combined degree at Griffith University in 2012. Her research interests focus on issues of client motivation. She is currently working for Konekt, a workplace rehabilitation provider. Within this role the majority of her experience has been with providing rehabilitation services to the Australian Defence Force. During this role she has conducted initial assessments, vocational assessments and counselling as well as ongoing case management and return to work programs. She looks forward to gaining further experience in the workplace rehabilitation field and furthering her knowledge of the injury management sector.

Christine Randall is a Lecturer in Rehabilitation Counselling in the School of Human
Services and Social Work, where she teaches injury management and case management courses, convenes rehabilitation counselling and industry programs, as well as convening field placement for postgraduate students. As a founding director of the Rehabilitation Counselling Association of Australasia (RCAA), her work includes advancing the interests of the RC profession nationally and internationally. Her research interests include occupational rehabilitation systems and workplace stress, rehabilitation counselling competencies, disability management, and case management.