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Motivation from both sides. PDF Print E-mail
Written by Jason Parker   
Friday, 28 November 2008
RTW Motivation and Costs

Understanding the non-medical issues that affect a worker’s motivation to return to work is the key to solving complex disability cases. This article, the third in a series that looks at some straightforward rules for handling these cases, looks at the importance of what the person stands to gain or — just as importantly — lose by returning or not returning to work.

Imagine you are told that, to get $100, you need to do A, B and C. You accept the challenge, but eventually find your motivation runs out. You don’t get the $100. That’s okay, you rationalize, because you never had the $100 in your pocket in the first place.  Now imagine you are given $100 and, in order to keep it, you need to do A, B and C. This time, you find yourself working harder to complete A, B and C.  Why would you work harder to prevent losing something than to gain something? Surely, in the age of positive thinking, positive outcomes and the “spinning” of messages that talk all about what people can gain, you would think you would be more motivated by gain than loss. As it turns out, humans are predictably irrational.

A typical Scenario


Mary is a 47-year-old nurse who is currently off work because of low back pain. Her case manager, Frank, has been working with Mary to get her back to work. To do this, Frank has been trying to motivate Mary by telling her why she should return and all of the good things that will happen if she does. Yet, with each phone call to Mary, Frank finds himself becoming increasingly frustrated. Mary just doesn’t seem to be buying in. During each call, Frank is met with a flurry of excuses, hearing “Yes, but …” over and over. Instead of moving toward the idea of returning to work, Mary seems to be going in the opposite direction.

Mary is a 47-year-old nurse who is currently off work because of low back pain. Her case manager, Frank, has been working with Mary to get her back to work. To do this, Frank has been trying to motivate Mary by telling her why she should return and all of the good things that will happen if she does. Yet, with each phone call to Mary, Frank finds himself becoming increasingly frustrated. Mary just doesn’t seem to be buying in. During each call, Frank is met with a flurry of excuses, hearing “Yes, but …” over and over. Instead of moving toward the idea of returning to work, Mary seems to be going in the opposite direction.

Frank’s frustration leads him to do something entirely different.  Frank realizes he has been so busy telling Mary why she should return to work that he has never asked her why it is important to her to return to work. Without Mary verbalizing this, Frank never had her commitment to the idea and never understood her reasons for returning.

So Frank asks her to find out why it is important for her to return to work. Mary tells him that it is important for her to return to work because she is a nurse, has trained as a nurse, and that is who she is. She loves her patients and enjoys the care and compassion she can provide during their times of trauma and stress. Frank notices Mary’s eyes widen as she talks about her job.

Delighted by this development, Frank recalls that research indicates that a worker’s expectation about return to work is influential in the choices people make about returning to work.  Frank talks to Mary about her expectations. Mary reveals that she expects to have problems because she has had back pain in the past. Although she hopes she can return successfully, she notes that it didn’t go so well last time she was off. Her first attempt to return failed.

Frank also gets in touch with Mary’s doctor. In his reply, the doctor notes that he has discussed with Mary the need to strengthen her back. Although he feels she can return, he believes she will need some job coaching on lifting mechanics and will likely need a graduated re-entry.

Concerns and Fear of Loss

You will recall from the previous articles that Mitchell suggested return to work is a function of three factors. The first, giving rise to the first rule, is the value the worker places on work or the utility of work. The second, giving rise to the second rule, is the worker’s perceived chances of success. This brings us to the third factor: the cost of returning to work (Mitchell, K. (1979). Vocational rehabilitation of the myocardial infarction patient. In D. Gentry & R. Wiliams (Eds.), Psychological aspects of myocardial infarction and coronary care, 2nd Ed. St. Louis, MO: Mosby].

Each person will judge the cost of going back to work. The cost may be economic, in that the person will weigh what he or she stands to gain or lose financially. The perceived cost may be physical, in that the person may fear increased pain or discomfort. The worker may silently be saying, “If I go back to work, the pain will kill me!” or “I can’t return to that toxic environment!” Not only is there the cost of returning to work, but I would add to Mitchell’s equation the inherent cost of not returning to work. This, too, can be decidedly motivating to a worker.

Ask the worker “What concerns you most about returning to work?” and “What concerns you most about not returning to work?”

Notice what the first of these questions is asking. It asks the worker to identify concerns — and not just any concerns, but what concerns the person the most. By answering this question, you will learn the top two or three concerns of the worker, giving you some very important information and putting you in a much better position to help the worker return to work. More often than not, when these two or three issues of most concern are dealt with, it removes any resistance to returning to work. At the same time, it increases worker confidence that he or she will be successful (thus also addressing the second factor about the perceived chances of success).  It also presupposes that the worker has concerns and, more importantly, that you know the worker has concerns, which is why you are asking the question in the first place. This is a very good way of demonstrating empathy and concern.

The second question tackles concerns from a different angle. It asks the worker to identify what concerns the person most about not returning to work. In other words, it asks what the worker is going to lose by not returning to work.

Here’s the rub. Return to work has been consistently framed as being positive, which it is. But disability management professionals are the ones doing all this framing, pointing out all the benefits of returning to work! Oftentimes, disability management professionals find themselves in the “hard sell” position, talking about all of the things workers will get or all of the ways they will benefit by returning to work. In other words, they are constantly explaining why returning to work is good for the worker because of this reason and that reason.

Loses are Motivating

Remember my point in the opening paragraphs, that a person will work harder to prevent losing $100 dollars than to gain it. Nobel laureates Daniel Kahneman and co-researcher Amos Tversky sought to explain this very curious behaviour. In their landmark research, they demonstrated something called “prospect theory” [Kahneman, D. & Tversky, A. (1984). Choices, values, and frames. American Psychologist, 39(4), 341-350].

Essentially, this theory says that, when people contemplate gains, they become risk-adverse, and when they contemplate losses, they become risk-seeking. In other words, all in all, people will be more motivated to avoid losses than to secure gains. Avoiding losses tends to be more motivational than securing gains. In fact, a person is likely to take two to three times more risk to prevent losing something than they are to gain something.

Curiously, we see evidence of this in appeals to women to do breast self-examinations. Campaigns that focus on the benefits of early detection of breast cancer, or the gains that women would get by early detection, are less effective than campaigns that emphasize the costs of late detection or the losses women would incur by late detection. The goal of the campaign is to increase self-exams. Understanding what motivates people increases the likelihood that the desired behaviour, in this case to increase self-exams, will occur.

Different Outcome

Let’s go back to Frank. Frank decides ask Mary what concerns her the most about returning to work. Mary stops and thinks about it. She then replies that she is concerned about reinjury, because if she reinjures herself, she believes she will end up with a permanent disability. She also expresses concern about her long-term ability to stay in the job.

Frank then asks Mary what concerns her the most about not returning to work. Again, Mary stops and thinks before replying and then says, “If I don’t return to work, I am going to lose my seniority.” It turns out that Mary’s collective agreement does not allow members to accumulate seniority while absent from work. Mary expands on this, explaining that she is near the top of the seniority list, with many others close to her. If she doesn’t return to work, she is going to lose her seniority and, with that, her choice of shifts, postings, vacation time, etc. 

Frank responds by saying, “That is concerning. Then we need to get you back to work as quickly as possible, in a safe and sustainable way, so that you don’t lose those things.”  What happens next surprises him. Mary doesn’t put up a barrier. Instead, she begins to identify ways to return to work because she knows what she will lose by not returning to work. This mean Frank can now align himself to work towards the same goal of returning Mary back to work and, at the same time, help her avoid losing those things that are important to her.

Motivation from both sides.

At the end of the day, as a disability management professional, we just don’t know what will motivate someone to return to work. What we can’t assume, according to Kahneman and Tversky, is that the things the person will gain by returning will be the motivating factor. That would be an error on our part. However, assuming it will be all the things the person will lose would be equally myopic.

Instead, by asking the worker to identify both what he or she will gain by returning to work and lose by not returning to work, we increase our chances of connecting with the person and finding out what is most important. By extension, we increase our chances of finding out what is most likely to motivate him or her to — ultimately — reach our goal of helping them return to work in a safe and sustainable manner.

Last Updated ( Tuesday, 08 March 2016 )