# Personality Characteristics Determine Health-Related Quality of Life as an Outcome Indicator of Geriatric Inpatient Rehabilitation

Authors: Jörg Richter; Martina Schwarz; Barbara Bauer
Journal: Current Gerontology and Geriatrics Research
 (2008)

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## Abstract

Background. The aim of the present study was to investigate the relationships between personality and quality of life during the course of geriatric rehabilitation, against the background of Cloninger's biosocial theory of personality. Methods. All consecutive patients of a geriatric rehabilitation clinic during one year were evaluated at admission and discharge (N=687) by means of the ‘‘Vienna List’’ (a newly developed questionnaire for the assessment of quality of life in patients with severe dementia), and two variants of the Temperament and Character Inventory.
Results. Self-directedness showed the most general and highest impact on quality of life and successful rehabilitation. Conclusions. It is probable in old and very old individuals who are on their highest level of maturity that the character represents the most important regulatory system in the encounter with challenges of daily life, which necessitates rehabilitation.


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## Body

## 1. Introduction

The aim of
geriatric rehabilitation is to improve the health conditions of the elderly and
to maximise functions, mobility, and independence of elderly individuals
following the impact of disease and/or injury, in order to improve their quality
of life.Quality of life
(QoL) is an important outcome variable when the value of geriatric
rehabilitation is evaluated [1, 2]. QoL is commonly defined as the perception
by individuals of their position in life, in the context of the culture and
value systems in which they live and in relation to their goals, expectation
standards, and concerns. However, the definition of QoL remains vague and
varies widely between research groups. Additionally, there is still a lack of
well-adjusted assessment methods. There are various approaches to
the conceptual structure of QoL in elderly persons. Marcoen et al. [3] presented a six-dimensional
relational model of subjective well-being comprising psychological, physical,
social, material, cultural, and existential aspects. Silberfeld et al. [4]
described six groups of attributes of QoL of dementia patients: global
impression of QoL, physical well-being, social/family well-being,
emotional well-being, functional well-being, and cognition,
whereas Rabins et al. [5] used five different assessment categories: social
interaction, awareness of self, enjoyment of activities, feelings and
mood, and response to surroundings. In very old and severely demented patients,
Porzsolt et al. [6] empirically derived five important factors in the
evaluation of QoL as communication abilities, aggression, and expression of
negative feelings, mobility, and possibilities of physical contact.QoL should be used as an outcome
parameter of geriatric rehabilitation since it reflects major areas of
rehabilitation goals in terms of the improvement in self-service, mobility,
interpersonal behaviour, and communication.To be able to address the global goal of
rehabilitation of old and very old persons, that is, to improve their quality
of life effectively, consistently, and adequately, knowledge is needed about
determinants of quality of life. Quality of life is, of course, predominantly
determined by the individuals’ health conditions,
including the sensory system and cognitive functions [7, 8], their functional
level in daily life, coping recourses and available social support, their
financial situation, environmental and community conditions, and last but not
least, by the individual’s personality.Several
investigations were performed with different approaches. State anxiety and behavioural
coping, played no predictive role at admission into geriatric rehabilitation
and became the strongest predictors of autonomy at discharge [9]. Extrovert
personality measured by Eysenck’s Personality Inventory and active coping
strategy predicted improved ADL functions among former stroke patients at the three
years follow-up stage [10]. Vigour alone was a predictor of current
quality of life, while emotional stability was related to
psychological well-being and satisfaction with significant relationships
being reported by a Swedish study in 100 elderly persons by Hagberg et al. [11] using the Gordon Personality Inventory [12]. Ascendancy and ability
to maintain personal relations were related to an optimistic outlook on
life and an absence of psychosomatic symptoms. Summarising their results,
the authors concluded that various personality characteristics are related
to various quality of life dimensions. However, comparison of the
investigations is complicated by the differing theoretical approaches and
measures.Recently, Cloninger proposed a psychobiological
theory of personality including the behavioural systems of temperament and
character, which are assumed to be related to two major neural systems for the
adaptation to experiences at various levels [13–15]. The
temperament dimensions: novelty seeking (tendency towards exhilaration in
response to novel stimuli or cues), harm avoidance (bias in the inhibition or
cessation of behaviour), reward dependence (tendency to maintain or pursue
ongoing behaviour), and persistence (perseverance in behaviour despite
frustration and fatigue) are defined as genetically homogenous and
independently inherited and reflecting individual differences in conditioned emotional responses,
such as anger, fear, love, and tenacity. The character
dimensions self-directedness, cooperativeness, and self-transcendence are
defined as reflecting individual differences in self-concepts according to the
extent of identification with themselves as autonomous individual, with the
humanity and with the whole universe. Based on this theory, Hansson et al. found
lower levels of harm avoidance and higher levels of self-directedness to
be significantly related to a better subjective quality of life in schizophrenic
patients [16]. Self-directedness was significantly associated with a better subjective quality in all aspects measured, and explained a substantial amount of variance (range of 4–12%).Therefore, the aim of our present study
was the application of the biosocial theory of personality by Cloninger [14, 15] with respect to its major personality domains such as
temperament and character when investigating the relationships between
personality characteristics and quality of life during the course of geriatric
rehabilitation. This project met several challenges. An extensive literature
search yielded neither a measurement for personality nor for quality of life
which could be easily used in the population of severely disturbed old and very
old patients and which would be likely to be of high specificity and
sensitivity to changes during the course of rehabilitation.Accordingly, our research questions were
the following: are personality characteristics in terms of temperament and
character determinants of the outcome in geriatric rehabilitation? Is it
possible to demonstrate distinct relationships between particular domains of
quality of life, which are important in the context of geriatric rehabilitation
including, for example, communication abilities, mobility, and daily
functioning, with a particular pattern of personality variables in the
population of interest?More specifically, we hypothesised that(i)
self-directedness is related to all
measured aspects of quality of life [16];(ii)
cooperativeness and reward dependence
predominantly influence aspects relating to social interaction like the
expression of aggressive or other negative emotions and physical contact;(iii)
novelty seeking and persistence
are involved in communication and mobility capabilities; and(iv)
harm avoidance combined with self-directedness
is assumed to be related to emotional aspects as suggested by the ample evidence
in the literature concerning their relationships with depression [17–19].


## 2. Methods

Within the framework of a comprehensive
research project, all consecutive patients of the Geriatric Rehabilitation
Clinic in Neubrandenburg (Neubrandenburg, Germany) being admitted from November 2001 to October 2002 were evaluated at
admission and discharge [20, 21]. Six hundred
and eighty seven patients were contacted at their admission (see Table 1). Four
of them died in the clinic. Due to their poor health status at admission, all
patients provided a written informed consent to participating in the project at
discharge when their health condition had improved. The research protocol was
approved by the Ethical Review Committee of Mecklenburg-Vorpommern.Table 1
Characteristic of the patients.
MaleFemaleTotalNumber N/%188/27.4499/72.6687Age in years (x±SD)74.5±8.678.9±7.677.7±8.1Time of acute inpatient care before rehabilitation
in days (x±SD)27.4±22.922.4±14.323.7±17.1Time of inpatient rehabilitation in
days (x±SD)21.3±6.521.5±6.621.5±6.6Number of comorbid diagnosis5.4±2.54.9±2.15.0±2.2Range0–140–140–14Heart and lung diseases29/15.455/11.084/12.2Stroke and other brain diseases68/36.2127/25.5195/28.4Fractures31/17.0199/39.9231/33.6Extrapyramidal and walking diseases17/9.037/7.454/7.9Abdominal and kidney diseases20/10.639/7.859/8.6Peripheral circulatory diseases15/8.022/4.437/5.4Others7/3.720/4.027/3.9The physician conducted a comprehensive
evaluation of all patients on the day of their admission. This evaluation focussed
upon the assessment of the functional deficits and the patient’s social
situation. Individual treatment goals and treatments were derived from the
results of the evaluation. Treatment programmes were tailored to meet the needs
of the patient. The nurses set out goals specific to the individual and care
plans based on the care concepts of Roper [22–24] and Bobath [25–28]. Dependent on
the condition of the patient, physiotherapeutic, occupational-therapeutic,
speech therapeutic, and psychotherapeutic treatments were instigated in
addition to the use of pharmaceuticals. The professionals predominantly
performed the treatment in individual sessions. Unfortunately, the time of
inpatient rehabilitation in Germany
is generally limited to three weeks due to the restrictions set by the health
insurances companies.The rehabilitation diagnoses were
performed following the criteria of ICD-10. Age, gender, and the duration of
the acute inpatient treatment before rehabilitation were used in the present
analyses.Personality in terms of temperament and
character was measured based on Cloninger’s biosocial theory of personality by
means of two methods that were completed by different proxy raters. An
abbreviated version of the Temperament and Character Interview [29] was
performed by one of the authors with the patients at discharge. Four hundred
and ninety nine patients could be interviewed. The patients who could be
interviewed received higher scores in the Mini Mental State Examination at
admission (t=4.52;
P  <  .001; 24.2±4.2
versus 21.9±5.2) and more comorbid diagnosis (t=3.9; P  <  .001) than
those who could not be interviewed. The instrument consists of 25 questions,
one each for every original subscale of the personality dimensions of the
Temperament and Character Inventory. The interview is highly structured with
clearly defined answers and needs about 30 minutes to be completed. It was included in the
closing talk at discharge. The selection of the questions was oriented towards
the life of elderly individuals. A score for each dimension (novelty seeking, harm
avoidance, reward dependence, persistence, self-directedness, cooperativeness,
and self-transcendence) was calculated by summing up the scores within each
dimension divided by the number of items in the dimension, which enables a more
direct comparison of the dimensions.Sample items
Are
you usually more worried than most people that something might go wrong in the
future?(i)
Undecided.(ii)
If “yes”—how typical is it for you that you are worried
that something might go wrong in the future?—“Highly typical” or “typical.”(iii)
If “no”—are you usually less worried that something
might go wrong in the future?—“Yes” or “no.”Are
you more likely to cry at a sad movie than most people?(i)
Undecided.(ii)
If “yes”—do you cry at every sad movie? “Yes” or “no.”(iii)
If “no”—did you ever cry at a sad movie? “Yes” or “no.”Additionally, the physiotherapist was
trained to complete a visual analogue scale (VAS)
relating to each personality dimension with descriptions of the anchor points for
high and low expressions on the dimension
scale (see Figure1).Figure 1The physiotherapist was used as proxy
rater because of her frequent and intensive contact with the patients,
evaluating 612 of the patients during the investigation period. Both subsamples
investigated (TCI interview and VAS) were representative of the total patient
population during one year without systematic dropouts in any of the diagnostic
groups. The modification of the methods was necessary in order to limit the
strain placed on the old and very old patients during the interview.A questionnaire for the assessment of
quality of life in dementia patients, the “Vienna List” by Porzsolt et al. [6, 20, 21], was completed for each patient by specially
trained nurses as proxy ratings at admission and discharge. This list consists
of 41 items subdivided between five factors: communication (15 items), negative
affect (10 items), physical contact (5 items), aggression (4 items), and
mobility (6 items) which have to be rated on a 5-point scale from 1  =  never to
5  =  always. Cronbach’s alpha coefficients as a measure of internal consistency
between 0.93 for factor “communication” and 0.81 for “mobility” were calculated
for nurses' ratings. This instrument was chosen for two reasons: (a) many of the
patients in geriatric rehabilitation suffer at admission from functional rather
than cognitive deficits, which are highly comparable with those suffered by severely
demented patients, and (b) to demonstrate its specificity concerning
rehabilitation diagnosis and the related functional disturbances, as well as
its sensitivity to changes in functional status [20, 21].Statistics
Mean scores, standard deviations, and
frequencies were calculated. Pearson correlation coefficients of quality of
life scores from discharge and of the relative changes of the quality of life
scores from admission to discharge with personality variables were calculated and controlled for the
influence of age and gender. Multivariate analyses of variance were calculated
with the personality scores and with quality of life variables as dependent, gender
as fixed factor, and age and duration of acute inpatient care before
rehabilitation as covariates. Multiple regression analyses (method: enter) were
performed with the personality scores as independent and the quality of life
scores as dependent variables. The SPSS software was used.


## 3. Results

Most of the patients belonged to the group
suffering from various fractures, followed by a group of patients suffering from
stroke or other brain injuries (see Table1). A significant relationship
between gender and patients group occurred (χ2=33.9; df  =  6; P  <  .001). On
average, females suffered more often from hip or limb fractures, whereas males
suffered more often from stroke and other brain injuries, abdominal and kidney
disease, and from peripheral circulatory diseases.The results of the MANOVA concerning QoL
factors from admission showed significant main effects for gender (Pillai’s trace  =  0.04;F(5/650)  =  4.32; P  =  .001;  η2=0.04)  based on
differences in the factors aggression and physical contact and for the duration
of acute care (Pillai’s trace  =  0.03;  F(5/650)  =  3.14; P  =  .008; η2=0.03) based on differences in factors communication abilities and negative
affect (see Table 2 for descriptors). There was neither a significant main
effect for age nor any significant interaction between one of the independent
variables. With regard to discharge quality of life scores, significant main
effects occurred for gender (Pillai’s trace  =  0.09; F(5/650)  =  10.70; P  <  .001; η2=0.08)  based on differences in factors
communication abilities, aggression and negative affect, for the duration of
acute care (Pillai’s trace  =  0.03; F(5/650)  =  2.87; P  =  .014; η2=0.03) based on differences in factors communication abilities,
aggression and mobility, and for age (Pillai’s trace  =  0.03; F(5/650)  =  2.98; P  =  .011; η2=0.03). Again, interaction terms were not significant.Table 2
Means scores of QoL scores from
both assessments by gender.
MaleFemaleTotalCommunication—admission3.7±0.63.8±0.63.7±0.6Communication—discharge3.7±0.63.9±0.63.9±0.6Aggression—admission1.3±0.51.2±0.41.2±0.4Aggression—discharge1.4±0.61.2±0.51.3±0.5Negative affect—admission1.7±0.51.8±0.61.8±0.6Negative affect—discharge1.7±0.51.9±0.61.8±0.6Physical contact—admission4.2±0.94.4±0.84.3±0.8Physical contact—discharge4.3±0.94.4±0.84.4±0.8Mobility—admission2.1±0.52.1±0.52.1±0.5Mobility—discharge2.3±0.42.3±0.42.3±0.4When searching for differences in personality,
significant main effects were found for gender (Pillai’s trace  =  0.03;F(7/678)  =  2.16; P  =  .037;
η2=0.03)  based on
differences in harm avoidance, cooperativeness, and self-transcendence, and for
age (Pillai’s trace  =  0.06; F(7/678)  =  4.40; P  <  .001; η2=0.06) based on
differences in novelty seeking and reward dependence when using the results of
the TCI interview (see Table 3 for
descriptives). Concerning the visual analogue scales, only a significant main
effect for gender (Pillai’s trace  =  0.03; F(7/678)  =  2.54; P  =  .014; η2=0.03) based on differences in harm avoidance and novelty seeking could be found.Table 3
Mean scores of both personality measures.
TCI interviewTCI analogue scalesMaleFemaleMaleFemaleNovelty seeking2.4±0.72.3±0.62.9±1.42.6±1.3Harm avoidance2.5±0.82.9±0.92.9±1.63.2±1.5Reward dependence2.6±0.82.8±0.83.7±1.13.7±1.1Persistence3.8±1.13.6±1.13.7±1.43.5±1.3Self-directedness4.4±0.64.3±0.63.5±1.33.3±1.3Cooperativeness3.4±0.63.6±0.63.6±1.23.7±1.2Self-transcendence2.4±1.02.1±1.03.7±1.13.9±1.0When the relationships between quality of
life and personality scores were controlled for the influence of age and
gender, significant correlation coefficients were most pronounced for the
assessment at discharge, for communication abilities, aggression, and negative
affect, for self-directedness, and with higher coefficients for the
relationships with scores of the visual analogue scales compared to the
interview data (see Table4). Communication abilities were related to self-directedness
and negatively to harm avoidance (interview) and to all personality scores of
the Visual Analogue Scales. The higher reward dependence and persistence were
rated by the physiotherapist, the greater the evaluated differences in
communication abilities between admission and discharge.Table 4
Partial correlation coefficients
between personality (TCI interview—first row; TCI visual
analogue scales—second row) and quality-of-life
variables
(controlled for age and gender).
GroupNSHARDPSSDCOSTCommunicationDischarge0.11*−0.14**−0.020.13**0.26***0.080.13**0.27***−0.25***0.32***0.45***0.42***0.38***0.23***Difference−0.020.003−0.01−0.0003−0.030.010.02−.010.03−0.16***−0.15***−0.09*−0.11**−0.13***AggressionDischarge0.070.005−0.03−0.06−0.30***−0.17***−0.030.10*0.12**−0.27***−0.25***−0.23***−0.32***−0.35***Difference−0.040.0070.040.040.15***0.11*0.05−0.060.060.16***0.10**0.12**0.19***0.20***Physical contact admissionDischarge0.050.030.030.040.060.020.070.02−0.0040.17***0.10*0.050.12**0.15***Difference−0.09−0.007−0.04−0.010.0050.01−0.06−0.03−0.04−0.14***−0.08−0.05−0.08−0.09*MobilityDischarge0.09*−0.09*−0.060.13**0.20***0.040.10*0.16***−0.21***0.09*0.20***0.21***0.19***0.09*Difference−0.02−0.0020.04−0.01−0.10*0.07−0.05−0.05−0.0020.07−0.05−0.09*0.09*−0.02Negative affectDischarge−0.040.16***−0.02−0.09*−0.19***−0.09*−0.04−0.10*0.32***−0.21***−0.31***−0.32***−0.31***0.22***Difference0.003−0.050.060.00070.070.11*−0.030.01−0.080.040.060.050.040.0003The more self-directed and cooperative
(interview) the patients were, the less aggressive they were perceived to be at
discharge, and the more cooperative and self-transcendent they were rated (VAS). The more cooperative, the more self-transcendent,
and the more dependent on rewards the patients were (VAS),
the less they behaved aggressively.The higher the scores on self-directedness
(interview), cooperativeness and persistence; and the lower that for harm avoidance
(VAS) were, the more mobile the
patients were evaluated to be at admission.The more self-directed; less harm
avoidant (interview); more reward dependent, persistent, and cooperative the
patients were (VAS), the less
negative affect was observed at discharge. The personality measures' scores were
able to explain substantial amounts of variance in all five quality-of-life
scores at discharge as well as of the relative changes during rehabilitation in
communication, aggression, and negative affect, with varying contributions from
the several temperament and character dimensions (see Table5). Whereas reward dependence
is exclusively responsible for the significant results (interview and VAS) concerning physical contact, harm avoidance,
and self-directedness were the significant factors in the regression equations
for negative affect. Self-directedness (interview) and harm avoidance were
responsible for the significant results related to mobility. Whereas self-directedness
and novelty seeking (interview) and, additionally, cooperativeness and persistence
(VAS) contributed substantially to
the prediction of the communication abilities at discharge, reward dependence (interview
and VAS) remained as significant
in the equation for the prediction of the changes in communication abilities combined
with self-directedness for the interview data only. Aggression at admission
could be predicted by cooperativeness scores combined with the scores of self-directedness
and harm avoidance (interview) and novelty seeking, persistence, and self-transcendence
(VAS), respectively, and the
changes in the expression of aggression were substantially explained by self-directedness
(interview) and by novelty seeking and self-transcendence (VAS).Table 5
Multivariate
regression analysis with QoL variables and their changes as dependent and
personality (interview-data—1st row; visual
analogue scale—2nd row) as
independent.
GroupAdjustedr2FPCommunicationDischarge0.2426.92<.0010.2528.12<.001Difference0.032.53.0140.043.20.002AggressionDischarge0.1818,11<.0010,1919,37<.001Difference0,076,30<.0010,076,69<.001Physical
contact admissionDischarge0,043,75.0010,043,87<.001Difference0.0080.65.7150.021.87.072MobilityDischarge0.076.48<.0010.086.91<.001Difference0.021.55.1490.021.50.166Negative
affectDischarge0.1818.41<.0010.1819.03<.001Difference0.032.18.0340.021.99.054


## 4. Discussion

The aim of the present investigations was
to evaluate the relationships between personality characteristics and quality
of life in the course of geriatric rehabilitation, independent of the patients' particular illnesses. It was theoretically based on the biosocial theory of
personality [13–15] with its subdivision
of personality in temperament and character and on a model of quality of life
by Porzsolt et al. [6, 20, 21] relating to very old and severely
demented patients. There are only a few studies in the literature concerning
the topic, each using different theoretical approaches and measurements.A large representative sample of patients
who were treated during one year at the rehabilitation clinic was included in
the study. Limitations of the interpretations of the results are predominantly
due to the “soft” measurements relating to personality characteristics, which
were used for the first time with the presented design, even though they are
based on a well-established theoretical background.However, we found substantial results in
terms of significant correlation and regression coefficients, which are in line
with the theoretical background and supported our hypotheses even though most
of the coefficients were of small to medium effect size. That was expected as personality
characteristics are only one of the determinants of quality of life. Of course,
health conditions and the patient’s functional status represent the major
influential factors relating to quality of life in the course of geriatric
rehabilitation.The gender differences identified relating
to quality of life scores and to personality partly represent gender-related
social stereotypes in terms of men being more likely to speak loudly
(aggression) and being women rather more focused on physical contact and being more
frequently described as becoming sad or depressed (negative affect).
Furthermore, lower levels of novelty seeking and higher harm avoidance and cooperativeness
were found in women compared to men in several studies, as was the age
dependency of novelty seeking and reward dependence [30, 31].There were various differences in
correlations and regression results found depending upon the measurement of
personality—interview versus VAS—in terms of
higher scores derived for VAS the data
mostly related to
the communication, aggression, and negative affect factors. These differences
are probably not exclusively due to the different source of information—structured
self-description versus proxy rating. The physiotherapist was heavily involved
in the treatment process of the patients, with physiotherapy often being
perceived as hard work involving several conflicts between the demands of the
therapist and the actual abilities and/or willingness to follow them on the
part of the patient. This close relationship might have caused a bias in the
evaluation of personality characteristics, which is reflected by the dominance
concerning relationships with the factors communication, aggression, and
negative affect. The higher importance of cooperativeness in these
relationships based on VAS compared
to interview data would support the presented explanation.Self-directedness proved to be of
substantial impact referred to all measured domains of quality of life in the course
of geriatric rehabilitation. Mature, responsible, reliable, and well-integrated
individuals are more engaged in their own rehabilitation, which causes better
communication and mobility abilities, less aggression and negative affect
compared to individuals low in self-directedness. This corresponds to the
results in the literature reported by Hansson et al. [16] who found self-directedness
to be significantly associated with all measured aspects of
well-being explaining 4 to 12% of variance. In our study, we found
most of the determination coefficients to be on a comparable level concerning
the prediction of changes and higher levels for the prediction of outcome
referred to communication, aggression, and negative affect.Communication and mobility factors reflecting
a wide range of abilities and personality characteristics were accordingly
found to be related to several personality dimensions—cooperativeness (VAS data), novelty seeking and harm avoidance were
affected. The combination of these two temperament dimensions might have caused
approach (high novelty seeking)—avoidance (high harm
avoidance) conflicts in some patients in the course of rehabilitation including,
for example, relearning mobility abilities despite pain and lack of physical strength.
However, a mature, developed character in terms of high self-directedness and
high cooperativeness might enable individuals to cope with these contradictions
which are partly caused by temperament make-up. However, the fact that change
in communication is
predominantly predictable by reward dependence points to the dependency of changes
during rehabilitation upon intensive and effective emotional rewards for even
small steps of progress being provided by all involved staff.Interestingly, physical contact was
exclusively related to the temperament dimension reward dependence implying
that the more dependent on emotional rewards the patient is, the more easily she/he
is able to handle physical contact.Negative affect was related to self-directedness
and harm avoidance based on both measures, reflecting the well-established importance
of these two personality dimensions for depressive mood and their sensibility
to changes of depressive mood [17, 19].


## 5. Conclusions

In conclusion, we were able to confirm
our hypotheses and the application of the biosocial theory of personality to the
determination of quality of life in the course of geriatric rehabilitation was
successful, leading to some differentiating results in line with the
theoretical background and clinical practice. Self-directedness was established
as the personality dimension with the most general and highest impact on
quality of life and successful rehabilitation. It appears that character
dimensions in terms of self-directedness and cooperativeness are of higher
importance than temperament dimensions reflected by higher correlation
coefficients. It is likely that in old and very old individuals, who are at their
highest level of maturity, the character represents the most important
regulatory system when individuals are confronted with the challenges of daily
life including severe disturbances in health and functional conditions, which
caused the necessity of rehabilitation in old and very old individuals.Furthermore, it can be concluded that consideration
of the personality characteristics of geriatric rehabilitation patients can
improve the effectiveness of the rehabilitation process which, in turn, can
improve the quality of life of the patients. For example, highly reward
dependent individuals should be continuously positively reinforced [32];
whilst the treatment of patients who are high novelty seekers should be process-oriented,
without the setting of clearly defined targets, in order to encourage their own
activity.  On the other hand, low novelty
seekers require clearly defined targets from the rehabilitation team; and highly
self-directed individuals can be guided to a more autonomous rehabilitation in
contrast to low self-directed patients who are in need of more frequent contact
with the therapists who need to motivate the patients to achieve their targets
and complete their rehabilitation.



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