In cases where a doctor would like to achieve a change in the behaviour of his patient, this then takes place by motivating the patient rather than by motivation on the part of the doctor.

The history of motivational research goes back to the drive theory of Sigmund Freud, who reformulated it in various stages of his professional career, initially mainly about sexual and egocentric drives, although in the final form of the drive theory destruction and life drives were presented together.

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A prominent example of insufficient motivation and guidance of the patient is seen in the illness of Jean-Paul Sartre. Simone de Beauvoir, who lived with him for many years, wrote about the 10 years period in which Sartre, whose illness was marked by severe and labile hypertension and recurrent strokes. There is no doubt that the fact that he was so well-known made it particularly difficult for doctors to treat him appropriately. However it appears that there was never any real attempt to reduce the enormous consumption of alcohol, cigarettes, coffee, tea and stimulants. Sartre was described in May, 1971 during his stroke: "... with a cigarette repeatedly falling from his paralyzed lips". Simone de Beauvoir tells in her book how doctors could only be obtained for urgent calls, and would often want to refer this prominent patient to a "more appropriate colleague". Again and again one reads that he had been forbidden to smoke.

M. J. Halhuber asks questions which concern the basic rules of motivation and guiding patients. "Sartre had his first hypertensive crisis in 1954. Why was it that ever since that time, there was never any long-term dependable working relationship between himself, Simone de Beauvoir and a single experienced doctor that he trusted? His diary reveals a succession of different specialists, who undertook mainly diagnostic procedures. Where however was the enthusiasm with which therapeutic methods were seriously and consequently applied to changing his way of behaviour?" According to the pictures in Simone de Beauvoir's diary: "Again and again prohibitions and the usual suggestions were heard in the surgery or at the bed-side, of whose uselessness we could convince ourselves day after day."

At the start of any attempt to motivate a patient, there are four basic considerations

1.	Can the patient be motivated at all?
2.	How important is the objective of the motivation?
3.	Where is the major resistance likely to be?
4.	Am I, as the doctor, motivated enough myself?

In the first instance, motivation is a dialectic task. As dialectic is the art of leading a discussion away from the initially opposed opinions, the objective has to be the art of persuasion going onto conviction. Motivation should not be confused with manipulation. In the case of manipulation, prohibited techniques, doubtful tricks or suggestions are consciously used to influence a person. A successful dialectic procedure needs logic, psychology and a grounding in rhetoric.

A fine example of (unfair) dialectic is found in the story of the monk who smoked. A monk, who loved to smoke, if possible day and night and even during prayer times, wondered how he could get permission from his abbot to smoke at all times. He realized that this request would hardly meet with success if he asked: "May I smoke during intercession?". He turned this round according to dialectic principles and was successful when he asked his abbot "May I pray while I smoke?"

A person does not act without reason, and he agrees to treatment not without reason. This does not mean that his reasons have to be conscious, and usually they are unconscious. However first knowing what the reasons are allows people to be moved to act or moved not act: that is to motivate.

The following reasons can be decisive in the way a person acts.

•	Needs
•	Emotional reasons  Anxiety Shame Guilt Feelings of inferiority
•	Rational reasons  Interest Calculations/plans Experience
•	Value-based reasons  Ideals Attitudes Worthy motives
•	Expectations  Hopes Desires
•	Habits
•	Prejudices

Particular grounds for motivation aggregate from this range of reasons for action (such as hopes, ideals or needs) whilst other reasons (habits, prejudices or anxiety) work in the opposite direction and lead to demotivation.

One of the basic rules of motivation technique is as follows: "Creating anxiety, awaking feelings of guilt or shame is just as unlikely to lead to motivation as is attacking prejudices, deeply-established habits and so-called 'articles of faith'".

For example, the following statements are of hardly any use to motivate:
"Every packet of cigarettes shortens your life by 10 minutes." 
"Most patients are able to keep to their diet better than you." 
"You are bound to have a heart attack if your blood pressure does not come down."

Certain attitudes to life, pseudo-arguments and cliches are commonly used by patients, obstructing motivation:
"Its better to live well for 10 years than grow old."
"Who knows, what tomorrow will bring?"
"My father smoked 30 cigarettes a day and died when he was 87."

These conditions have to be fulfilled for successful motivation:

1.	It must be possible to motivate the patient. Cognitive, intellectual and situation factors should not come in the way of motivation from the very onset. It will hardly be possible to put in enough energy to motivate certain behaviour (long-term medication, diet) in the depressive patient with no drive, the patient with advanced impairment of brain function, or the patient with completely different cultural values.
2.	There must be a clear objective. Spelt out this means, the objective must be recognizable, attainable, realistic and desired by the patient. If the patient does not understand what it is all about, if it seems to him that the initial objective is unattainable, or if he is not interested in the objective of the motivation, it is very unlikely that motivation will be possible.
3.	The doctor himself has to be motivated. The success of a doctor's involvement is closely related to his own conviction about the advice and recommendations for therapy. Studies from many different areas have shown that the success of treatment markedly depends on the degree of motivation of the therapist himself. The example of the doctor is itself a motivating (and demotivating) factor of major importance.

 

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