Motivation from the Inside Out: The Client’s Perspective, Part II

This is the second column in a three-part series on client motivation to change. The first part discussed motivation as a state, examined levels of motivation to change, and provided examples of clients with different degrees of motivation. This column reviews common motivational struggles and factors affecting clients’ motivation to change such as severity of symptoms, moods and emotions, beliefs and thoughts, coping strategies, impulsive decisions, support from others, and past experiences in treatment and/or recovery. I end with a few observations and questions for therapists or counselors to consider.

Clients reported struggles with accepting and managing their substance use disorders (e.g., “my strong desire for drugs” interfered with my desire to stay sober and attend my therapy sessions or NA), psychiatric illness (e.g., feeling increasingly depressed or anxious, which as one woman stated, “pulls me down, and puts me in a rut I cannot get out of,”) or other areas of life (e.g., not working out or exercising regularly, not going to church or practicing spiritual principles in daily life, not going to work or school regularly, or not managing money wisely). This is not surprising and shows that clinicians often work with clients who struggle with developing or sustaining their motivation to change, and remain engaged in a recovery program over the long-term. Some embrace recovery and work hard while others struggle and are not sure it they are capable or even want recovery. However, even the ones who work hard in recovery may lose focus, make impulsive decisions based on perceived immediate rewards, experience ambivalence about change or a significant decrease in their motivation to continue recovery or change their lives. Ambivalence about change and impulsive decisions can lead to early treatment drop out, which is associated with poor outcome, such as increased risk of relapse to substance use or a recurrence of psychiatric illness.  

For many clients, interpersonal and environmental factors can impact on motivation (Corrigan, Mueser, Bond, Drake, & Solomon, 2009; Madden & Bickel, 2009; Marlatt & Donovan, 2007; Ralph & Corrigan, 2005). Recently, I asked several groups of clients what affected their motivation to change, or interfered with taking action when their motivation is low. They identified many internal and external positive and negative factors. 

Some clients are more adversely affected by their disorder or disorders and are more likely than others to feel a decrease in motivation to change. Others are more resilient and able to sustain the desire to change over the long-term, often working through periods of low motivation. The following are a few comments from clients showing different ways they reacted to their disorders: 

• “When I got real depressed, I quit caring about sobriety and was more likely to drink or use drugs.” 
• “When my voices—hallucinations—got too loud and strong, I isolated myself, and missed my doctor and counselor appointments, sometimes stopping my meds.” 
• “When I stuck with treatment, no matter how anxious or depressed I felt at times, I got better.”
• “My cravings for drugs or alcohol always decreased if I rode them out, didn’t act on them, and used coping skills I learned in treatment.”  

Managing emotions or moods is a major issue in the recovery from many psychiatric or substance use disorders. Any emotional state or mood—positive as well as negative—can affect motivation to recover, depending on whether the client has and uses skills to manage these. Lowered motivation can lead to failure to cope with a negative emotion or mood, contributing to a relapse (Daley & Thase, 2004; Marlatt & Donovan, 2007). Here are examples from several clients:  

• “I felt hopeless, so why should I bother doing anything about my mental condition?” 
• “I got bored with sobriety and needed some fun, so I cut down, then stopped my recovery activities.” 
• “When I reminded myself of the blessings in my life and felt grateful, I got more motivated to fight through my struggles and stick with my recovery.”

Many of the slogans or self-talk strategies used in Twelve Step programs and cognitive behavioral therapies aim to help clients identify and change cognitive distortions or faulty thinking, which impact motivation to change. Examples from clients include: 

• “I worried that I was a burden to others if I shared my mental health problem.” 
• “I believed I should have been able to get myself out of a funk on my own when I didn’t care about my recovery or my life.” 
• “I resisted my doctor’s suggestion to take an antidepressant to help improve my depression because I thought I should be drug-free.” 
• “When I told myself I deserved recovery and would get well, I committed to it.” 
• “Just because I obsessed about getting high didn’t mean I would get high, so I talked myself out of making a bad decision.”  

Using active coping strategies may reduce relapse risk as the client copes positively with a high-risk situation or change in motivation. Clients may face any number of high-risk factors related to their illness, support network, living environment, and their internal thoughts and feelings. Using active coping strategies increases the client’s ability to deal with high-risk factors and maintain motivation to change. Examples shared by clients include: 

• “I let criticism from my family drag me down.” 
• “Praying didn’t work, so I said ‘the hell with it’ and quit trying, which only made things worse.”
• “When I felt stressed out and thought about dropping out of school, I talked with my counselor and decided not to.” 
• “I repeated the NA slogan—‘this too shall pass’—to remind myself that low motivation does change, and it did as being patient paid off for me.”   

The desire for immediate pleasure or relief can win out over the desire for delayed or long-term benefits of controlling impulses and the desires to use substances or engage in unhealthy behavior (Madden & Bickel, 2009). Some addicted clients report doing well until feeling overwhelmed with an impulse to drink or use drugs. Scientists suggest that there may be competing brain regions responsible for choosing immediate pleasure (limbic system) or choosing to work for long-term improvement based on delaying the decision to use substances at the present time (frontal regions). Clients sometimes verbalize two sides that create conflicts in their recovery: the healthy, recovering side, and the sick, addicted side. Several clients have expressed variations of this by saying they felt, “the devil on one shoulder and an angel on the other.” They also reported giving in to the unhealthy side, which led to relapse to substance use.

Impulsive decisions are common with some psychiatric disorders, such as bipolar illness, or antisocial and borderline disorders. With the latter personality disorders, impulsive decisions can be made to hurt oneself (e.g., cut or burn oneself, threaten or attempt suicide, or threaten others) or engage in high-risk behaviors (e.g., sex with strangers, gambling, violence towards others, other addictive behaviors). With antisocial disorder, it is common for clients to live in the moment without thinking about the consequences of their behaviors on self or others, such as breaking the law, quitting a job without another to go to, ending a relationship due to boredom, or acting on desires to do something harmful to others or society.

Social support is important for everyone, and positive, supportive social networks are helpful for recovery from a medical, psychiatric or substance use disorder. This is one of the reasons that the founders of AA started the First Step with the word “we” rather than “I.” They knew recovery requires connection with and support from others. The models of recovery from psychiatric or mental illness also promote the importance of social support, belonging, and connection with others (Corrigan, Mueser, Bond, Drake, & Solomon, 2009; Ralph & Corrigan, 2005). Negative social networks can interfere with recovery while positive ones can aid recovery, especially during times when motivation wavers: 

• “When others criticized me, I took it to heart and let it get me down, losing some of my desire to change my life.” 
• “When I hung out with others getting high, it was only a matter of time before I joined them.” 
• “It was hard to trust and let others into my life, but when I did, life was much better.” 
• “I learned the hard way, but I learned that I just can’t be around old friends and even family members getting high because I let them mess with my motivation.”  

Clients with histories of multiple relapses or recurrences often need help overcoming feelings of guilt, shame or demoralization. They need to know recovery is possible and that there is hope for them regardless of their past history. The best they can do about past relapses is learn from them and figure out ways to sustain their motivation to change during periods in which they struggle with recovery. Examples from clients include: 

• “I been in the psych hospital so many times I wonder if I’ll ever get better.” 
• “This is my sixth time in rehab—Will I stay sober this time?” 
• “I had two years of sobriety before, so I know I can stay off alcohol.” 
• “I had many years between episodes of depression, so I know recovery is possible because there are lots of people who care about and support me.” 
• “When I stay on meds and keep my sessions, even when I don’t feel like it, good things happen to me.” 

• Changes in motivation are common, especially in the early phases of recovery. However, even clients with stable recovery can experience dips in motivation related to their recovery or other areas of life.
• Poor or low motivation is best seen as a clinical issue to address rather than a reason to not work with a client or discharge a client from treatment.
• Many factors impact on motivation, both in positive or negative ways. It is our role as counselors to help clients understand what affects their motivation and learn strategies to manage periods of low motivation.

• What factors do you see most often with clients that impact on lowering their motivation to change?
• What factors do you see most often with clients that impact on increasing their motivation to change?

Corrigan, P. W., Mueser, K. T., Bond, G. R., Drake, R. E., & Solomon, P. (Eds.) (2009). Principles and practice of psychiatric rehabilitation: An empirical approach. New York, NY: Guilford Press. 

Madden, G. J., & Bickel, W. K. (Eds.) (2009). Impulsivity: The behavioral and neurological science of discounting. Washington, DC: American Psychological Association. 

Marlatt, G. A., & Donovan, D. M. (2007). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors (2nd ed.). New York, NY: Guilford Press. 

Ralph, R. O., & Corrigan, P. W. (Eds.) (2005). Recovery in mental illness: Broadening our understanding of wellness. Washington, DC: American Psychological Association.