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

This column will begin a three-part series on motivation from the client’s perspective. I chose this topic because motivation to change often fluctuates during the early phases of recovery, and how a client deals with motivation is a significant factor in sustaining recovery, making positive life changes, or relapsing.

In this first column, I discuss what motivation is and levels of motivation to change. Although a major issue in early recovery, motivational struggles can occur years into recovery. Consider the recent overdose death of the actor Phillip Seymour Hoffman, who relapsed after twenty years. A change in his motivation to stay sober changed, leading to relapse. Sadly, he lost his life and hurt many others, including his young children.

In the second column I will discuss client motivational struggles and factors impacting motivation. Brief comments or experiences of clients will illustrate key points. In the third column, I will discuss motivational approaches to treatment and ways counselors can help clients address motivational issues. Each column will end with a few observations and/or questions to consider.

Meet Matt and Anita

Matt, a thirty-four-year-old married father of two children, recently said during a group discussion, “I was working hard at recovery, doing well, felt highly motivated to stay sober, and put my life together. I quit drinking for ten months, and my depression and family life improved. Things were clicking for me. Gradually, I got tired of recovery and lost my motivation, blowing off counseling and AA meetings. Since I didn’t talk about this and stopped following my plan, my recovery went in the shitter. I knew things could get bad if I stopped working my recovery, yet I still did this.” Matt moved from working a good, solid recovery program to relapse as a result of a gradual decrease in his motivation to change, which impacted on his participation in treatment and AA. Not sharing his motivational change got the best of him, interfering with his recovery and leading to relapse.

After years of addiction controlling her life, Anita completed a rehab program and followed it with outpatient counseling and active involvement in NA. She was going to meetings, working with a sponsor, and working the Steps. To reach her goal of a career in the medical field, she worked part-time and attended school full-time. To get to her morning classes, she had to get up early and take two busses. Anita said “My desire to make something of myself was so strong I wouldn’t let anything get in my way. Even though I had little time to myself, it was worth it. I worked hard every day to reach my goals.” She now works full-time in a job she enjoys and is active in NA.

We have all had clients like Matt who expressed verbally, or in their behavior, that they lost or were losing interest in treatment and/or recovery. They had mixed feelings about managing their disorder(s), working towards their goals, and changing their lives. Or, they were interested in relief from psychiatric or addictive symptoms provided by medications, with little or no interest in psychosocial treatments or mutual support programs. Some had been in treatment so many times they were “tired” of attending sessions and just wanted medications. The key issue with clients evidenced by Matt’s experience is not whether motivation will decline in recovery as it often does, but whether the client is aware of this shift, takes action to stay on track, and works through low motivation.

Hopefully we have also had clients like Anita, whose motivation was so strong that she balanced the demands of work, school, and recovery. Her desire to succeed was so strong that she excelled in her classes, graduating with a high average. Anita’s case shows that having specific goals can be a strong motivating factor to succeed. However, life goals cannot supplant recovery goals or push them aside as failure to sustain recovery can adversely impact on other goals.

As these two different situations show, motivation is a significant issue for many clients with behavioral health disorders. It impacts their recovery and ability to reach their goals in life. In addition, it ultimately affects their well-being. Therefore, it is important to assess behavioral health clients’ levels of motivation or readiness to change.

Motivation as a State

In behavioral health care, motivation refers to the client’s desire to get involved in treatment to change and manage a substance use, psychiatric, or co-occurring disorders. Motivation affects treatment entry, engagement, adherence and retention, and ultimately determines whether the client engages in and sustains long-term recovery (Daley & Thase, 2004). Early on, even clients who enter treatment are often ambivalent about changing their substance use habits (DiClemente, Garay, & Gemmell, 2008). Initial motivation is often external as the client may enter treatment to save a job, a marriage or intimate relationship; maintain or get custody of children; or resolve legal problems related to driving under the influence, or criminal charges involving alcohol, drugs or other behaviors. In cases of more severe psychiatric disorders, the client may initially engage in treatment as a result of an involuntary commitment initiated by others concerned about the client’s suicidality, homicidality, or ability to take care of basic needs.

Levels of motivation can be viewed as a “state” on a continuum. Clients can vary from being unmotivated to get help or change, to being highly motivated to change and willing to get help. Even within a client, motivation can increase or decrease over time, sometimes to drastic degrees. Clinicians are better equipped to help if they understand how clients think about and experience motivation in relation to changing or managing their disorder. Changes in client motivation, as well as external and internal factors impacting motivation, should be monitored and explored in treatment.

Levels of Motivation to Change

Motivation can waiver at any time during treatment or recovery, particularly in the early phases. For example, I recently asked eighteen residents in long-term therapeutic community and over twenty clients in early recovery intensive outpatient programs—almost all of who had substance use and psychiatric disorders, and a history of multiple relapses—to rate their current levels of motivation to recover and change their lives and/or to work a recovery program (one=low, five=moderate, ten=high). Most rated their motivation as moderate (four or five) while some rated it low (two or three) and others rated it high (eight to ten). Just about every client acknowledged significant fluctuations in motivation in current or past attempts at recovery, and many stated this was a factor in relapse to their substance use or psychiatric disorder. They often decreased their attendance or dropped out of treatment and mutual support programs when struggling with low motivation. Interestingly, clients stated they knew of coping strategies to help them deal with low motivation, but they often failed to use these. Their negative thinking snowballed and led to reduced interest in doing the work of recovery or working towards their goals. Furthermore, they kept motivational struggles to themselves rather than getting support from a counselor, sponsor or peer in recovery, or other trusted confidante.

Clients also stated that motivation can affect any area of life including health, relationships, work or school, spirituality or religious practices, finances or other lifestyle issues. It is not unusual for a client’s motivation to vary across areas of life. For example, one client reported “Recovery is my number one priority and I work hard to stay sober. However, I still struggle with my weight and following a plan to control it. This is harder for me than my sobriety.”

Some stated they were more likely to make an impulsive decision not in their best interest when feeling less motivated in recovery. For example, one woman said “When I got laid off, I pouted and put myself into a depression. Rather than look for another job, I gave up and sat at home.” Others acknowledged that they used past experiences to motivate them to get their lives together. One man with substantial recovery time—whose addiction once led to losing everything important in his life, including his freedom—said “I learned you don’t get what you want or think you deserve from society. You only get what you work for.” While keeping his recovery a high priority, he worked his way through school and reached his goal of a career working with troubled youth, which brings him much fulfillment.

Clients also shared examples of how motivation can be negative. One woman said “I wanted to make money so bad that I got involved in illegal activities, not thinking how this could affect my recovery or sense of self-worth, not to mention how this could lead to jail time.” Another man with a history of violence said “I’m working hard to get rid of the ‘mental demon’ that motivated me to get revenge if I was mistreated or disrespected by someone else. It isn’t easy, but I’m keeping a lid on any desire for revenge.”

In the second part of “The Client’s Perspective” I will discuss factors affecting motivation and motivational struggles faced in recovery. The more we understand the thinking of clients vis-à-vis their motivation, the more effective we may be in raising their awareness, educating them, and helping them learn and use strategies to sustain motivation over the long-run or deal with dips in motivation.

Observations

Motivation is a significant issue for many clients with behavioral health disorders and needs to be addressed during treatment.
I reviewed the indexes of three major textbooks on addiction and all address motivational issues, mainly related to motivational interviewing, motivational enhancement therapy, or motivational incentives. There are many resources for clinicians on these approaches (Daley & Zuckoff, 1999; Miller & Rollnick, 2012; NIDA, 2010 & 2012).
The American Society on Addiction Medicine (ASAM) addresses “readiness to change” as one of the major domains of functioning to assess, which is an important factor in determining level of care needed.
I reviewed the indexes of the DSM-5, and seven major textbooks on psychiatry and specific disorders. Less than 1/3 of 1 percent of pages address motivational issues. When they do, it is mainly related to substance use disorders. The mental health field clearly needs to focus more on motivational issues.

Questions to Consider

Do you think of client motivation as an important domain to consider in clinical work?
Do you regularly assess your clients’ motivational levels to help them identify and address these issues?

References

Daley, D. C., & Thase, M. E. (2004). Dual disorders recovery counseling: Integrated treatment for substance use and mental health disorders (3rd ed.). Independence, MO: Independence Press.

Daley, D. C., & Zuckoff, A. (1999). Improving treatment compliance: Counseling and systems strategies for substance abuse and dual disorders. Center City, MN: Hazelden.

DiClemente, C. C., Garay, M., & Gemmell, L. (2008). Motivational enhancement. In M. Galanter & H. D. Kleber (Eds.), The American psychiatric textbook of substance abuse treatment (4th ed.). Washington, DC: American Psychiatric Publishing, Inc.

Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change (3rd ed.). NY: Guilford Press.

National Institute on Drug Abuse (NIDA). (2008). The science of treatment: Dissemination of research-based drug addiction treatment findings. Rockville, MD: National Institute on Drug Abuse, Substance Abuse and Mental Health Services Administration, Addiction Technology Transfer Center.

National Institute on Drug Abuse (NIDA). (2012). Principles of drug addiction treatment (3rd ed.). Rockville, MD: National Institute on Drug Abuse, National Institutes of Health, US Department of Health and Human Services.