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University of Connecticut
DigitalCommons@UConn
Master's Theses University of Connecticut Graduate School
4-29-2011
Effect of Distress, Referral Source, and Pressure to
Attend Therapy on Motivation to Change
Lyn E. Moore
University of Connecticut, lynmoore@gmail.com
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Recommended Citation
Moore, Lyn E., "Effect of Distress, Referral Source, and Pressure to Attend Therapy on Motivation to Change" (2011). Master's
Theses. Paper 30.
http://digitalcommons.uconn.edu/gs_theses/30
Running head: MOTIVATION TO CHANGE
i
Effect of Distress, Referral Source, and Pressure to Attend Therapy
on Motivation to Change
Lyn Erin Moore
B.A., Franklin & Marshall College, 2009
A Thesis
Submitted in Partial Fulfillment of the
Requirements for the Degree of
Master of Arts
at the
University of Connecticut
2011
Running head: MOTIVATION TO CHANGE
ii
APPROVAL PAGE
Master of Arts Thesis
Effect of Distress, Referral Source, and Pressure to Attend Therapy on Motivation to Change
Presented by
Lyn E. Moore, B.A.
Major Advisor ___________________________________________________________
Rachel B. Tambling, PhD
Associate Advisor ________________________________________________________
Stephen Anderson, PhD
Associate Advisor ________________________________________________________
Shayne Anderson, PhD
University of Connecticut
2011
Running head: MOTIVATION TO CHANGE
iii
Acknowledgements
First and foremost I want to thank my advisor, Dr. Rachel Tambling, for her guidance,
support, and attention to detail. Without her this project and past year would have been
insurmountable. Her ability to edit my countless drafts with expediency and precision
demonstrated her care and concern for my work and personal wellbeing. Thank you, Dr.
Tambling, for always keeping me motivated. I also want to sincerely thank and appreciate the
other members of my committee, Dr. Stephen Anderson and Dr. Shayne Anderson for their
assistance and mentorship throughout my research and time in the program. I am indebted to the
clinic for the data collection and resources, as well as the opportunity to perform this study. I am
thankful for the support of my colleagues, friends, and family during the past two years as they
motivated my clinical, personal, and academic development. Thank you to everyone that
supported, guided, asked about my work, or helped with last minute edits! Your care and concern
did not go unrecognized and made a difference to my stress and anxiety. Last but not least, I
owe my education and supervision to the Marriage & Family Therapy faculty, the Human
Development and Family Studies Department, and the Graduate School of the University of
Connecticut. Thank you!
Running head: MOTIVATION TO CHANGE
iv
Abstract
Psychotherapy is an effective form of treatment, yet difficulties with engagement and dropout
continue to plague the field. Poor outcomes are more likely to be achieved by poorly motivated
clients and those who are mandated to attend therapy (Prochaska, DiClemente, & Norcross,
1992). This study examined links between motivation to change, initial levels of distress, referral
source, and pressure to attend therapy in a sample of 587 individuals who attended therapy at a
university-based counseling center in the Northeast. Results indicated a relationship between
distress and motivation to change as well as a link between the perceived pressure felt by a client
and motivation to change.
Keywords: motivation to change, stages of change, pressure, therapy, treatment factors
Running head: MOTIVATION TO CHANGE 1
CHAPTER 1: INTRODUCTION
Effect of Distress, Referral Source, and Pressure to Attend Therapy on Motivation to Change
Psychotherapy researchers have devoted significant attention to determining the efficacy
of therapy. Individual reports and meta-analyses indicate that psychotherapy can be a highly
effective form of treatment that creates the desired change for clients (Piper, Ogrodniczuk, Joyce,
& Weideman, 2011; Matusiewicz, Hopwood, Banducci, Lejuez, 2010). Despite the efficacy of
psychotherapy, researchers and clinicians report difficulties in client engagement (Repel &
Destefano, 2009), high incidences of early termination from therapy (Pekarik, 1992), and
frequent relapses after brief improvement (Shadish & Baldwin, 2003; Sprenkle, 2002). Of
additional concern are findings that suggest that poor outcomes are more likely to be achieved by
those clients who are poorly motivated to change (O’Hare, 1996; Sue, Zane, & Young, 1994)
and those clients who are mandated to attend treatment (Prochaska, DiClemente, & Norcross,
1992). One possible explanation for poor outcomes in psychotherapy populations is the lack of
understanding of factors associated with motivation to change among such clients.
It is apparent that motivation to change shapes a client’s engagement in treatment and the
process of therapy. Initial research on motivation studied mandated clients in addiction treatment
(Prochaska & DiClementi, 1982; Prochaska & DiClementi, 1983). Studies expanded to include
perpetrators of serious crimes such as pedophiles and those convicted of incest or child abuse
(Taft et al., 2001; Azar, 1984). Much of the research suggests that mandated clients appear
resistant, are poorly motivated or difficult to motivate, and difficult to engage in therapy (Begun
et al., 2003; O’Hare, 1996). With respect to motivation, mandated and voluntary clients appear
to experience different factors that affect their experience and tenure in therapy. Research is
Running head: MOTIVATION TO CHANGE 2
necessary to determine the role of the therapist or referring agency in aiding in the engagement
of clients in therapy.
Factors such as distress levels, perceived pressure to attend, and the effect of the referring
agency may influence a client’s motivation in therapy, yet these connections need further
examination. This research will contribute to a greater understanding of potential factors that
contribute to a client’s motivation to change. To understand the role of distress, pressure, and
referral source on a client’s motivation to change, it is necessary to examine client’s initial
distress levels, perceived pressure to attend therapy, and the referring agency in relation to
motivation to change.
Distressed clients are more difficult to engage in therapy and often experience higher
rates of premature termination from therapy (Knerr et al, 2009). Mandated clients appear to
experience high levels of distress when entering therapy (Knerr et al, 2009) and this distress
appears to impact their tenure in therapy (Knerr et al, 2009). Additional research is necessary to
examine the relationship between referral source, the pressure exerted by that referral source, and
client distress.
Minimal research is known to this author on the effect of pressure and the effect of the
referral source on clients in therapy. No research is known to this author on a potential
relationship between these two factors. Agencies making a referral expect changes in client
behavior. For example, they may expect greater use of coping skills for anxiety or a reduction in
anger or abusive behavior. Referring agencies exert varying amounts of pressure on clients
depending on their perception of the client’s need to change. Mandated clients experience high
levels of pressure and they also experience lower levels of engagement and higher rates of drop
out (Begun et al, 2003; Chamberlain et al, 1984). It is possible that the pressure experienced by
Running head: MOTIVATION TO CHANGE 3
clients influences engagement in therapy. High levels of pressure to attend therapy can result in
a client feeling as though they have lost their free will (Anker, Duncan, & Sparks, 2009). Clients
who have reported a loss of their autonomy report feeling judged by their therapist, which leads
to poor engagement (Ackerman, Colapinto, Scharf, Weinshel, & Winwaer, 1991). Factors such
as distress, the referring agency, and the pressure they experience from that agency appear to
interact with motivation and engagement in treatment. Distress, referral source, and pressure to
attend therapy may affect clinical motivation to change but these relationships have yet to be
examined.
The second chapter of this manuscript will describe the current theories and research on
mandated and non-mandated clients. This chapter will also identify clinical profiles that are
defined and examined. The second chapter will also highlight research related to the effects of
initial levels of distress, the referring agencies, and the pressure to attend therapy while
emphasizing the importance of motivation within different populations. In the third chapter the
methodology used in the study will be identified. The fourth chapter will discuss the results. A
discussion of the results and a summary of the present study and suggestions for future research
will be presented in the fifth chapter.
Running head: MOTIVATION TO CHANGE 4
CHAPTER 2: LITERATURE REVIEW
Although therapy is effective for a variety of clients (Piper, Ogrodniczuk, Joyce, &
Weideman, 2011; Matusiewicz, Hopwood, Banducci, Lejuez, 2010), it is necessary to develop
the dialogue related to factors that influence motivation and engagement in psychotherapy. To
provide the most effective treatment to clients, additional research is needed to better understand
potential links between distress, referral source, pressure to attend, and motivation to change
among psychotherapy clients.
This study will explore three key areas related to motivation to change. First, clients who
are highly distressed when entering treatment experience higher levels of dropout and lower
levels of engagement in the therapeutic process (Knerr, Bartle-Haring, McDowell, Adkins,
Delaney, Gargamma, Glebova, Grafsky, Meyer, 2009) than voluntary clients. This study will
examine the relationship between a client’s initial level of distress, as measured by depression
and anxiety scales, and his or her motivation to change. Second, the potential relationship
between the client’s referral source and his or her motivation will also be assessed to determine
the role that various referring agencies play in the development of client motivation to change
and perceived pressure to attend therapy. Third, it is clear that mandated clients often struggle
to engage in therapy and have high rates of dropout (Begun et al., 2003; O’Hare, 1996). It is
necessary to determine if pressure applied by the referral source to attend therapy influences
motivation to change. This study will explore potential links between the pressure perceived by a
client and motivation to change. Taken together, a better understanding of the relationships
among distress, referral source, perceived pressure to attend therapy, and motivation to change
will provide a more insightful depiction of the development of motivation to change in
psychotherapy.
Running head: MOTIVATION TO CHANGE 5
Motivation to Change
Developing a framework for motivation. Many individuals, couples, and families
choose to enter psychotherapy and other forms of mental health treatment voluntarily. However,
some individuals are referred or mandated to attend therapy for a variety of reasons, such as
alcohol or drug dependency (Haley, 1992; Harris & Watkins, 1987; Rooney, 1992). Clinicians
and researchers working with alcohol and drug dependent clients have identified varying levels
of motivation among these clients. Based on the idea that individuals appear to be experiencing
varying levels of motivation, research explored models to assess and understand motivation to
change. This research is grounded in a belief that some form of intrinsic motivation is necessary
to change one’s behavior, particularly one’s maladaptive behavior. Among the most popular
models, the Transtheoretical Model of Change (Prochaska & DiClemente, 1982) stands out. The
Transtheoretical Model is perhaps the most widely accepted and well-researched model of
motivation to change. This model is a stage-based model developed by Prochaska, DiClemente,
and colleagues within the framework of alcohol and other drug treatment. In its present
conceptualization, the model has five stages (Prochaska & DiClemente, 1982, 1992),
precontemplation, contemplation, preparation, action, and maintenance. Within each stage,
information is provided which addresses addiction severity (McLellan, Luborsky, Woody, &
O’Brien, 1980), patterns of addiction and family characteristics (Wanberg & Horn, 1983), or
common factors among substance users.
Transtheoretical Model of motivation to change. Developed in the field of addictions
treatment, the Transtheoretical Model of Change (Prochaska & DiClemente, 1982) describes
motivation to change as occurring in a series of mutually exclusive stages. The model originally
Running head: MOTIVATION TO CHANGE 6
included six stages, but was later modified (Prochaska & DiClemente, 1986, 1992) to include
five stages of change: precontemplation, contemplation, preparation, action, and maintenance.
Individuals in the first stage of motivation to change, precontemplation, do not foresee
making changes in near future, which is defined at the next six months (Prochaska, Johnson, &
Lee, 2009). Unaware of the impact of their behavior or demoralized by prior attempts to change,
these clients present to therapy as resistant or poorly motivated (Prochaska, Johnson, & Lee,
2009). Many agencies and clinicians may not be prepared to handle the needs of mandated
clients in the precontemplation stage, which could lead to frustration on the part of the therapist
resulting in poor alliances and unproductive treatment (O’Hare, 1996).
Individuals considering making a change within the next six months but who have not yet
begun to undertake any changes are in the contemplation, the second stage of motivation to
change. Individuals in this stage are not yet committed to the idea of changing problematic
behavior. They are weighing the pros and cons of changing, which can result in extended
ambivalence. Therapists may refer to this behavior as “behavioral procrastination” or “chronic
contemplation” (Prochaska, Johnson, & Lee, 2009, p. 61). The contemplation stage of change
may be an extended stage for some clients in which they are beginning to ponder the possibility
of change but do not know how to make change, do not know what change would look like, and
may never move towards the next stage of change. Clients in this stage may appear similar to
those in the precontemplation stage, but they anticipate that there might be something worth
changing.
Individuals in the preparation stage are planning to undertake action in the near future,
commonly defined as within the next month. They have likely tried to make changes in the past,
which have not been successful, but they are now ready to make changes with support.
Running head: MOTIVATION TO CHANGE 7
Individuals in the preparation stage are seeking information and tools for change. In regard to
treatment, these individuals are ready for action-focused interventions (Procahska, Johnson, &
Lee, 2009). People in the preparation stage may continue gathering information for a period of
time before making active changes.
Individuals in the action stage have begun actively making changes to their lives. They
have made observable changes that are concrete in nature and related to the identified problem
(Prochaska, Johnson, & Lee, 2009). Within the context of therapy, they may be seeking ideas,
techniques, guidance, or support in regard to making permanent their new temporary changes.
Clients in the action stage appear motivated to make and maintain changes, open themselves to
the assistance of others, and actively engage with their therapist.
In the maintenance stage, individuals are working to prevent relapse and maintain the
changes that they have made in regard to their behavior. The further into the maintenance stage
the individual is, the less likely and the less tempted he or she will be to relapse. Over time
confidence builds within these clients. This stage can become permanent (Prochaska, Johnson,
& Lee, 2009).
Movement through the stages is not always linear. Many clients may progress and
regress through the stages as doubts increase, initial attempts at change fail, or their commitment
and motivation strengthens. Individuals may simultaneously be in different stages for different
problems. Further, individuals may pass through various stages of change relative to a problem
throughout a day or a week, as motivation fluctuates. These issues make it difficult to clearly
identify one stage of motivation for each individual.
Stage-matched interventions. Interventions are most appropriate when matched with a
client’s stage of motivation, according to the Transtheoretical Model of Change (Prochaska &
Running head: MOTIVATION TO CHANGE 8
DiClemente, 2005; 2009; DiClemente et al., 1991; Edens & Willioghby, 2000). For this reason
it is important that clinicians assess client motivation. Certain stages of change have been linked
with lower alliance scores and premature termination (DiClemente et al., 1991; Edens &
Willoghby, 2000). For example, those in the precontemplation and contemplation stage are often
less motivated to change and less engaged in treatment (DiClemente et al., 1991). It is suspected
that mandated clients enter treatment in these pre-action stages of change and have yet to accept
that they need assistance or would benefit from making the change suggested by a referring
agent.
Therapeutic interventions are most appropriate and applicable when matched to a client’s
level of motivation (McConnaughy Prochaska, & Velicer, 1983). In order to match interventions
to a client’s stage of change, therapists need to assess a client’s level of motivation. The
application of behavior interventions with pre-action or poorly motivated clients will strain the
therapeutic relationship, as the client is not read for this advancement (DiClemente & Hughes,
1990). Therapists who do not assess for motivation are more likely to mismatch interventions.
The stages of change may provide guidance for the therapeutic process and aid the therapist’s
understanding of the experience of his or her client. Assessing for motivation is an essential
component of therapy (McConnaughy Prochaska, & Velicer, 1983; DiClemente & Hughes,
1990).
Assessment of Motivation. One of the most popular formal assessments of motivation
to change is the University of Rhode Island Change Assessment, a 32-item self-report measure
(URICA; McConnaughy Prochaska, & Velicer, 1983; DiClemente & Hughes, 1990). It includes
four subscales that measure the five stages of change: precontemplation, contemplation,
preparation, action, and maintenance (McConnaughy et al., 1983; DiClemente & Hughes, 1990).
Running head: MOTIVATION TO CHANGE 9
The majority of research on the URICA has been done with smoking cessation and addiction
populations; the generalizability is assumed, but unknown. Until 2006 all of the research on the
TTM had been done with homogeneous addiction treatment populations, but noting the gap in
the research Hoffman and colleagues (2006) conducted a study on smoking cessation in an ethnic
minority population. In Hoffman et al., 2006, individuals seeking treatment were from a variety
of backgrounds. Additional research, which examines the utility of the URICA with ethnic
minority clients, is necessary to determine its applicability. Other formal (Readiness to Change
Questionnaire, Rollnick et al, 1992; SOCRATES, Miller and Tonigan, 1996) and informal (body
language, verbal response, tone, acceptance of the therapist, attitude, and willingness to engage)
assessments exist to assess motivation and should be incorporated into the therapeutic process
and assessment. Clinicians who assess for motivation have greater awareness of their client’s
needs, can appropriately address resistance, and apply interventions fittingly.
Assessing resistance versus poor motivation. Without proper assessment, poorly
motivated clients are often misinterpreted as resistant and are treated as hostile and
uncooperative within the context of therapy. With a greater understanding of resistance and
assessment of motivation to change in psychotherapy, clinicians could better evaluate whether
clients are resistant or simply in need of motivational enhancement (McConnaughy Prochaska, &
Velicer, 1983; DiClemente & Hughes, 1990). This transition from resistant to poorly motivated
would promote the use of stage-matched interventions with these poorly motivated clients,
enhancing the outcome of therapy (McConnaughy Prochaska, & Velicer, 1983; DiClemente &
Hughes, 1990). Current research does not examine whether different applications of theories,
models, and techniques with voluntary, mandated, and soft mandated clients is necessary (Begun
et al., 2003; Orlinsky & Howard, 1986).
Running head: MOTIVATION TO CHANGE 10
Factors Influencing Treatment in Outpatient Psychotherapy
A variety of factors appear to affect a client’s level of motivation. This review examines
the effect of distress on motivation to change, the effect of the referral source on motivation to
change, and the effect of pressure on motivation to change. High levels of distress are associated
with low levels of engagement, poor alliance, and higher rates of dropout (Knerr et al., 2009;
Tambling & Johnson, 2008). Initial research on mandated substance abusing populations
indicates a relationship between distress and motivation (Velasquez, Crouch, von Sternberg, &
Grosdanis, 2000). The referral source is the link between the client and the clinician and
therefore appears to hold considerable power. An examination of the effect of the referral source
is important to improve the referral process and prepare clients to enter into therapy. Clients
who have a difficult, hostile, or antagonistic relationship with the referral source may bring those
feelings into therapy and experience high levels of distress and resistance. Both the client’s level
of distress and referral source may be affected by and affect client’s experience of pressure.
Pressure has been linked with a client’s display of resistance towards the therapist (Satterfield,
Buelow, Lyddon, & Johnson, 1995).
Distress
Client’s experience of distress prior to and throughout therapy likely influences
engagement in psychotherapy. Distress levels have been linked to low levels of engagement and
trouble forming a strong therapeutic alliance (Knerr et al., 2009) both of which likely influence
the high rates of dropout in distressed populations (Tambling & Johnson, 2008). Foundational to
the field of motivation, research on substance abusing populations also indicates that client’s
distress affects client motivation (Velasquez, Crouch, von Sternberg, & Grosdanis, 2000). This
research goes on to posit that motivational enhancement is a key role of the therapist due to the
Running head: MOTIVATION TO CHANGE 11
many factors affecting a client’s motivation when they enter treatment (Velasquez, Crouch, von
Sternberg, & Grosdanis, 2000). Research examining the link between distress and substance
abusers’ motivation to change indicates that severe alcohol problems cause high levels of
distress, which may be enough to motivate these clients to attend treatment (DiClemente,
Bellino, & Neavins, 1999). The origins of the clients’ distress are unknown, but one potential
cause is the pressure placed on traditionally mandated clients from their referral source. A link
between clients’ distress levels and pressure to attend therapy has yet to be identified and future
research should explore this relationship.
The pressure applied by the referral source, the agency or person who requests that the
client obtain therapy, has the power to influence the client’s approach to and engagement in
therapy. Referring agencies may be seen as oppressive and authoritarian towards clients, which
limits the client’s autonomy and role in the process (Ackerman, Colapinto, Scharf, Weinshel, &
Winwaer, 1991), leading clients to feel coerced. Due to links between distress and motivation
the manner in which a referral is made has the ability to impact the course of therapy (Knerr,
Bartle-Haring, McDowell, Adkins, Delaney, Gargamma, Glebova, Grafsky, Meyer, 2009).
Mandated clients likely experience significant amounts of pressure from their referring
agency, particularly if that agency has the potential to effect negative outcomes for failure to
cooperate. Such is the case for powerful referees, such as the court system or a state social
service agency like the Department of Children and Families. Clients referred by such powerful
sources may present to therapy with high levels of distress exhibited through anxiety.
Throughout the legal process or state proceedings mandated clients are labeled as problematic,
resistant, or highly reactive (Anker, Duncan, & Sparks, 2009). Resistance appears normative
when placed in the context of a coercive referral process and potentially invasive therapeutic
Running head: MOTIVATION TO CHANGE 12
treatment. The lack of free will experienced by traditionally mandated clients may escalate their
levels of distress (Anker, Duncan, & Sparks, 2009).
Highly distress client demonstrate high levels of engagement and high rates of drop out
from therapy (Knerr et al., 2009; Tambling & Johnson, 2008). Client experiencing high levels of
distress may feel violated by the invasive therapeutic process. It is important that the origins of
their distress be explored as well as the relationship between clients’ distress and motivation.
Other factors such as the referral source and the pressure experienced may also be affecting a
client’s distress levels. Relationships between these factors are important to examine, as
therapists and referring agencies may be able to address them.
Effect of distress on client engagement. Initial levels of a client’s motivation may play
a key role in his or her willingness to engage in treatment. It is clear that a client’s engagement
in the therapeutic process is essential to the change process and effectiveness of therapy
(Connors et al., 1998). Current research highlights a link between a client’s therapeutic alliance
and his or her level of motivation to change (Conners et al., 1998). Understanding a client’s
level of motivation may allow a clinician to understand strains in the client’s level of
engagement and then to assist the client in making the adjustment to therapy.
Research on engagement is most commonly explored in terms of the therapeutic alliance.
An integrative model of alliance defines the alliance as having three parts: the collaborative
relationship, the bond between patient and therapist, and their ability to collaborate on goals and
tasks (Bordin, 1987). The therapeutic alliance is essential no matter the unit of therapy,
individual, couple, or family, and has been linked with success rates (Martin, Garske, & Davis,
2008). A client’s alliance may be a direct consequence of his or her motivation. Clients
experiencing high levels of distress generally have low levels of engagement (Knerr et al., 2009)
Running head: MOTIVATION TO CHANGE 13
Clinicians must be cognizant of the effect of motivation on the client’s engagement in the
therapy and the client’s alliance with the therapist (Orlinsky & Howard, 1986; Schottenfeld,
1989; O’Hare, 1996; Prochaska, Johnson, & Lee, 2009). For a client to be receptive to a
therapist’s interventions, an alliance must be present, especially in behavioral interventions or in
stretching of the client for those in the later stages of motivation (Bordin, 1979, as cited in
Connors et al., 1998; Greenson, 1967, as cited in Martin, Garske, & Davis, 2008). Clients who
believe that their therapist is attuned to their therapeutic needs, and who engaged with the client,
are more likely to disclose personal information and follow through with therapeutic
interventions, both of which demonstrate alliance and motivation.
Pressure to Attend Therapy
The pressure applied by the referral source, the agency or person who requests that the
client obtain therapy, has the power to influence the client’s approach to and motivation in
therapy. Clients may see referring agencies as oppressive and authoritarian, which limits their
autonomy and role in the process (Ackerman, Colapinto, Scharf, Weinshel, & Winwaer, 1991).
Pressure from the referral source has the potential to increase clients’ perceptions of stigma
related to therapy attendance or the view that therapy is a form of punishment. Clinical
resistance may be increased by the client’s negative opinion of the referring agency, which is
then transferred to the clinician (Larke, 1985).
Pressure to attend therapy may be especially significant among mandated clients.
Mandated individuals may experience pressure, and therefore distress, from the court system or
other agencies such as the Department of Children and Families. Throughout the legal process or
state proceedings mandated clients are labeled as problematic, resistant, or highly reactive.
Anker, Duncan, and Sparks (2009) found that the lack of free will experienced by traditionally
Running head: MOTIVATION TO CHANGE 14
mandated clients escalated their levels of distress. Mandated clients typically enter therapy with a
presenting problem that has been identified by someone else and which they are likely to
disagree with because of its origin an external system (O’Hare, 1996). The distress experienced
by traditionally mandated clients is likely high, as they are facing a variety of threats from the
court system or state agencies, such as incarceration, loss of children, financial burdens, or social
isolation from the community.
Different client profiles experience different effects and levels of pressure. A population
experience the most apparent level of pressure are mandated clients. Mandated clients
experience low levels of motivation and have low alliances (Begun et al., 2003). Poorly
motivated clients are likely to display resistance in therapy (Chamberlain, Patterson, Reid,
Kavanaugh, & Forgatch, 1984; Haley, 1992; Lhmer, 1986; Miller & Rollnick, 1991; Rooney,
1992). Resistance, which influences the overall therapeutic process (O’Hare, 1996) and
decreases the chance of a successful outcome (Smith, Subich, & Kalodner, 1995), has been
linked to higher rates of dropout (Satterfield, Buelow, Lyddon, & Johnson, 1995). Motivation is
likely instrumental in clients’ initial engagement or termination of treatment, but individuals,
couples, and families may have different experiences of both motivation and termination.
Without intrinsic motivation clients may likely be resistant to treatment, be more susceptible to
the effect of pressure, have minimal desire to engage with the clinician, and have higher rates of
dropout (Phillips, 1985; Howard et al., 1989; Garfield, 1994).
The pressure to attend, along with messages of stigmatization, oppression, therapy as
punishment, and the distress associated with a lack of free will has the potential to affect client’s
motivation to change in therapy. Pressure to attend therapy has the potential to affect clients’
Running head: MOTIVATION TO CHANGE 15
motivation to change and the entire course of therapy (Knerr, Bartle-Haring, McDowell, Adkins,
Delaney, Gargamma, Glebova, Grafsky, Meyer, 2009).
Pressure and resistance. Research on resistance indicates that resistant clients have
experienced a loss of free will, likely due to feelings of pressure. Resistance and pressure have
also been linked with early termination (Satterfield, Buelow, Lyddon, & Johnson, 1995). It is
this loss of free will and other factors, which affect their display of resistant in treatment.
Clinical resistance limits the effectiveness of therapy and increases the rate of dropout from
therapy (Begun et al, 2003; Miller & Rollnick, 1991). Resistant clients may have experienced
high levels of pressure from their referring agency. Their experience of pressure may have
reduced their engagement in therapy and their lack of patience with the therapeutic process.
Two large national studies have found that individual dropout rates in outpatient therapy
are quite high and that dropout is very common (Garfield, 1994). In a study by NIMH (1981),
69 percent of over 350,000 children and adolescents attended no more than five sessions. In
another survey “44% of adults seen by psychologists and psychiatrists came to fewer than four
sessions” (Howard et al., 1989). On average between 40 percent and 55 percent of clients
discontinue treatment after the first session (Phillips, 1985). Research indicates that many clients
drop out of treatment early on in the process (Phillips, 1985; Howard et al., 1989; Garfield,
1994). Not all clients in treatment are engaging in the process or entering into an alliance with
their therapist. These clients may not receive any benefits from therapy, frustrate both the
therapist and themselves, become more entrenched in their current behaviors, and become
resistant to future assistance. Poor motivation not only impedes the client experience in therapy
but also affects the therapists who are working with resistant clients, as the therapist may become
discouraged (O’Hare, 1996). Clients who prematurely terminate therapy are unnecessarily
Running head: MOTIVATION TO CHANGE 16
wasting clinicians’ and referring agencies’ time and mental health resources. Therefore, it is
imperative to study the possible reasons for premature termination in order to provide the most
effective treatment and the best use of clinical resources (Garfield, 1994; Weisz, Weiss, &
Langmeyer, 1987, as cited in Masi, Miller, & Olson, 2003).
Studies focusing on traditionally mandated clients include research on the motivation,
resistance, and attendance of those accused of or convicted of crimes for child abuse or incest.
These populations likely experience the highest levels of pressure to attend treatment, as they are
given little to no option to attend. These individuals are commonly in denial about their actions
and resistant to help (Azar, 1984). Although these individual are resistant, research indicated
they have an increased attendance rating of five times the voluntary clients (Wolfe, Aragona,
Kaufman, & Sandler, 1980; Irueste-Montes & Montes, 1988). This is likely due to the high level
of pressure place on the client and a greater understanding of the ramifications they will face
should they fail to attend therapy. In these cases, the severe consequences and high levels of
pressure faced by the parents appear to motivate them to complete treatment. The client’s
motivation appears to be one of the most important determinants of the therapeutic outcome
(Horton, Johnson, Roundy, & Williams, 1990). Those convicted of accused of crimes against
children are facing very different consequences then voluntary or soft mandated client. This
again supports the identification of a third category of soft mandated clients who face less severe
consequences should they fail to attend therapy.
Referral Source
The referral source has the potential to increase the stigma of therapy attendance.
Therapy may feel or be associated with punishment due to the referring agency. The client’s
relationship with their referral source may impinge on their view of therapy and may be a factor
Running head: MOTIVATION TO CHANGE 17
affecting the client’s engagement with the therapist. Clinical resistance may be increased by the
client’s negative opinion of the referring agency, which is then transferred to the clinician
(Larke, 1985).
Experience of voluntary clients in outpatient psychotherapy. Voluntary clients are often
highly motivated (Orlinsky & Howard, 1986; Schottenfeld, 1989; O’Hare, 1996; Prochaska,
Johnson, & Lee, 2009) due to their intrinsic desire or need for treatment. Research indicates that
psychotherapy is effective with these populations (Matusiewicz, Hopwood, Banducci, Lejuez,
2010). Highly motivated clients will likely engage in treatment and collaborate with the
therapist on creating change. Motivated clients are more likely to engage with their therapist
promoting the formation of the therapeutic alliance, which is necessary for treatment persistence
(Connors, DiClemente, Dermen, Kadden, Carroll, & Frone, 1998). Voluntary clients are
considered the therapeutic norm for treatment. It is unknown whether mandated clients have a
similar experience in therapy and whether or not theories apply to mandated clients and
voluntary clients in similar ways.
Voluntary clients collaborate with their therapist to identify a presenting problem and
path for therapy. These clients may feel more motivation to work on something they had an
active role in identifying and engage more fully in the overall process because it is collaborative
(Orlinsky & Howard, 1986; Schottenfeld, 1989; O’Hare, 1996).
Experience of mandated clients in outpatient psychotherapy. Twenty-five percent of clients
in therapy are mandated to attend treatment (Phillips, 1985; Howard et al., 1989; Garfield, 1994).
A limitation of the current understanding of mandated clients is that much of the research has
focused on those referred due to substance use. Yet many other individuals, couples, and even
families are mandated to attend treatment. Traditionally mandated clients are referred to therapy
Running head: MOTIVATION TO CHANGE 18
by legal systems or state agencies to work towards goals developed by the court or other
referring agency (Storch & Lane, 1989). The court uses mandated therapy as a form of treatment
to change negative behaviors and avoid incarceration. Court systems and state agencies utilize
varying degrees of pressure when making a referral to therapy, as some clients are required to
attend whereas others are provided an option. Only 20 percent of those referred under duress to
psychotherapy end up attending treatment (Mohr, Hart, Howard, Julian, Vella, Catledge, &
Feldman, 2006). It is unknown whether these 20 percent believe that therapy could help them or
they see no other option then to attend. Therapists need to assess client’s resistance and
motivation in order to provide the best care.
Research suggests that mandated clients are resistant and less motivated than those who
enter therapy voluntarily (Begun et al, 2003; Chamberlain et al, 1984; Lehmer, 1986; Miller &
Rollnick, 1991; Rooney, 1992; Taft, Murphy, Elliot, & Morrel, 200l, as cited in Snyder &
Anderson 2009). Most therapists presume that if a client enters therapy voluntarily, the client is
motivated to change (Cingolani, 1984; Haley, 1992; Harris & Watkins, 1987; Rooney, 1992), but
this says little for those who enter under duress.
For mandated clients, their experience of the referral and the relationship with the referral
source appears to not only influence their attendance in therapy but more importantly their
perception of the therapist and attitude towards engagement. The client’s involvement with the
legal system may have tainted their perception of the therapist prior to the start of treatment. The
therapist is likely viewed as an outsider who, in association with the legal system and oppressive
society, will judge their family (Ackerman, Colapinto, Scharf, Weinshel, & Winwaer, 1991).
Even greater barriers exist in the treatment of minority and oppressed groups, who are
disproportionately represented in mandated client populations (Pinderhughes, 1989). These
Running head: MOTIVATION TO CHANGE 19
clients may be resistant towards the therapist who they perceive as part of the oppressive society
and legal system that has disadvantaged them.
Court ordered clients are mandated to treatment to address a specific problem and prevent
incarceration. These individuals many enter therapy with a lack of acceptance of the problem or
motivation to change, which manifests itself through resistance (Chamberlain et al., 1984).
Research by Miller and Sovereign (1989), indicates the more resistant the client, the less likely
the client is to experience change through therapeutic intervention and even less likely that
traditionally mandated clients will remain in therapy (Chamberlain et al., 1984).
Research indicates that mandated clients experience low levels of motivation and are
poorly engaged in therapy (Begun et al., 2003). Traditionally mandated clients may attend
therapy, agitated, frustrated, and resistant towards the therapist and process. Other factors leading
to resistance include the embarrassment of disclosing information to a therapist, an outsider,
especially if they are in treatment for something uncomfortable or socially unacceptable
(O’Hare, 1996). Resistance on the part of a traditionally mandated client appears valid when
explored by the therapist.
Resistant clients, deemed untreatable in the past, may be individuals who are either
unsure about their ability to make a change or have been forced to confront a prescribed problem
they do not yet understand. Resistant clients may appear quiet, sullen, rude and argumentative,
or have frequent attendance failures (Chamberlain et al, 1984; Miller & Sovereign, 1989).
Unfortunately, these clients have high dropout rates (Miller & Sovereign, 1989).
Mandated clients are commonly sent to therapy with an identified problem, whether the
problem has been identified by the court system, the state agency, or the client (Lhmer, 1986;
Miller & Rollnick, 1991; Rooney, 1992). Mandated clients have lost their freedom to identify a
Running head: MOTIVATION TO CHANGE 20
collaborative problem. Therapists can assist a client in feeling engaged in the therapeutic
process if they collaborate with the client and explore the presenting problem with the client,
whether the client is voluntary or mandated (Connors, DiClemente, Dermen, Kadden, Carroll, &
Frone, 1998). It is important for clinicians to assess the client’s motivation, take it into
consideration when working on alliance, and to work with the client on collaborative goals and
tasks for therapy.
The current research on mandated clients is limited and focuses predominately on
individuals and couples who have committed crimes, engaged in antisocial behavior, or are
presently abusing alcohol or other drugs. Much of the research examined clients who were given
no alternative but to complete treatment, or face incarceration. Current research with
traditionally mandated client’s highlights the confusion in regard to the client’s motivation.
Some studies find both similarities and differences between the experience of motivation for
traditionally mandated and soft mandated client (Begun et al., 2003; De Leon, Melnick, & Tims,
2001; Irueste-Montes & Montes, 1988; Azar, 1984). Soft mandated clients are not mandated to
attend therapy and face mild consequences such as family or social pressure rather then
incarceration. The experience of soft mandated clients in therapy is expanded later in this
manuscript. In some cases, research indicates that mandated referrals appear to negatively
impinge on the client’s motivation, while other research suggests that it may increase a client’s
extrinsic motivation (Larke, 1985). This contradiction in the research may be due, in part,
because clients who might be more accurately categorized as soft mandated are considered
mandated in some studies and voluntary in other studies. The variation within the literature is an
indication that more research on the topic is necessary.
Running head: MOTIVATION TO CHANGE 21
Some studies have explored possible benefits of mandating psychotherapy. One
hypothesis posits that hard mandated clients will experience high levels of motivation due to the
severe consequences they are facing (De Leon, Melnick, & Tims, 2001). Some studies indicate
that clients who are actively involved with the Department of Children and Families in a custody
case when entering treatment are much more likely to be actively involved and complete
treatment (De Leon, Melnick, & Tims, 2001). These clients are likely motivated by the potential
loss of custody, which also signifies the potential importance of motivation for mandated clients
(De Leon, Melnick, & Tims, 2001).
Experience of soft mandated clients in outpatient psychotherapy. Currently, the
research makes a distinction between voluntary and mandated clients (Synder & Anderson,
2009; O’Hare, 1996; Storch & Lane, 1989). While the two distinct groups have been studied
broadly, not all clients fit well into one of these two categories. Clients who enter into therapy
under pressure to do so have diverse experiences and further differentiation is necessary.
This author proposes the use of a third category, “soft mandated,” to better capture
unique differences among clients of varying motivational categories. Voluntary clients
experience internal motivation that drives them to seek treatment. Mandated clients are typically
referred by the court system or a state social service agency and face severe consequences, such
as the removal of children from the home, incarceration, or high fines if they do not attend
treatment. Not all clients who are referred to therapy will encounter such severe consequences,
thereby creating another distinct population in treatment: soft mandated clients. Soft mandated
clients will face milder consequences such as family or social pressure, negative effects in court,
or extra court-regulated educational classes from their referral source if they fail to attend
therapy. For example, clients who are encouraged to attend therapy by the court to aid in their
Running head: MOTIVATION TO CHANGE 22
case, parents who bring their children to therapy for the sake of the family, and couples who are
encouraged by social services to seek counseling all fit into this category. Soft mandated clients
are neither required to attend therapy nor severely punished for not attending therapy. In the
case of soft mandated clients, the power, influence, and pressure applied by the referral source
often generates the motivation to attend therapy.
Engagement levels for soft mandated clients are unknown, as this has yet to be
researched. Potential differences between the engagement levels of soft mandated, hard
mandated, and voluntary clients are unknown. The pressure that the client feels from the
referring agency may impact their engagement in the process of therapy; however, little is known
about the pressure experienced by soft mandated clients.
Soft mandated clients experience very different consequences than mandated clients, yet
they, unlike voluntary clients, lack the internal motivation to seek therapy on their own. Soft
mandated clients may or may not experience the same barriers to treatment and it is possible that
they have their own unique barriers. Soft mandated clients may be ambivalent towards change
but may welcome the referral to assistance. Despite valuable research that suggests stage
matching as a useful strategy in psychotherapy (Prochaska & DiClemente, 1986, 1992), little is
known about the interventions suitable for soft mandated clients. While it is possible that soft
mandated clients may benefit from strategies that are part of many stage-matched interventions
to increase motivation, it is unknown if this is true. Presently it is unclear how motivation will
impact this population, but future research should try to discern the barriers affecting this
population to gain a better understanding of which types of stage-matched interventions may
work with this population.
Running head: MOTIVATION TO CHANGE 23
Summary of factors affecting clients’ motivation. Research on factors affecting
motivation indicates that a client’s level of motivation may have a clinically significant impact
on the possible outcomes of psychotherapy. Clients with low levels of motivation appear to have
lower rates of engagement (Begun et al., 2003), lower therapeutic alliances (Connors et al.,
1998), and higher rates of premature dropout (Phillips, 1985; Howard et al., 1989; Garfield,
1994). Without addressing these barriers to treatment with mandated clients, a therapist may
unknowingly contribute to the problem or label the client as unworkable. It is necessary that
research expand the clinical understanding of differences between varying client profiles with
concentration on other potential client profiles such as soft mandated clients. This research has
the potential to provide a means of preventing or reducing dropouts and resistance, which appear
to occur more with poorly motivated and highly pressured clients. Currently poorly motivated
clients contribute to the misuse of mental health resources. It is important to have further
research and development on the effect of referral source on drop out rates potentially through
the medium of motivation.
Conclusion
Current research on motivation to change has been focused in the context of the client
profiles created by referral sources. Clients experience varying levels of distress, which appears
to affect their engagement and tenure in therapy. The referral course creates different client
profiles depending on the level of pressure placed on the client. Both the referral source and
pressure may be linked with the client’s level of motivation to change through the context of
therapy. Two client profiles previously examined include voluntary and mandated clients.
Voluntary clients enter treatment willing to engage with the therapist, form an alliance, and are
motivated to make and maintain changes. Mandated clients, who are pressured to attend therapy,
Running head: MOTIVATION TO CHANGE 24
experience higher rates of dropout (Miller & Sovereign, 1989), lower levels of engagement
(Conners et al, 1998; Rempel & Destefano, 2001), are resistant toward forming an alliance, and
experience high levels of distress. Clients interact with a spectrum of factors and barriers to
treatment.
This research will expand knowledge about the relationship between pressure and
distress on client motivation to change. Further, distress among soft mandated and voluntary
clients will be explored as distress has been linked to differences in motivation. The research
also hopes to draw attention to a third client profile, soft mandated clients. The formation of this
new category will facilitate the examination of different levels of motivation for a variety of
mandated clients.
Current research has left many gaps in the information available that links initial distress
levels, effects of referral source, and the perceived pressure the client feels to attend therapy or
motivation to change. This research addresses the impact of initial distress, referral source, and
pressure to attend therapy on motivation to change by answering the following research
questions:
1. Does a client’s level of distress, as measured by depression and anxiety scales, predict
membership in the stages of motivation to change?
2. Does the degree of pressure to attend therapy predict membership in a particular
motivation to change stage?
3. Among high versus low motivated clients, is there a difference in regard to their referral
source?
Running head: MOTIVATION TO CHANGE 25
CHAPTER 3: METHODOLOGY
Sample
Data was obtained from individuals, couples, and families who participated in at least one
therapy session at the Humphrey Clinic for Individual, Couple, and Family Therapy (hereafter
referred to as “Humphrey Clinic”). No new participants were recruited or enrolled in the study
as the study utilized archival data from the Humphrey Clinic database. No specific population
was targeted as the data was obtained exclusively from the existing archival data set. The
existing archival data represent a period from 2008 - December 2010. Participants for this study
were from a university-based counseling center in the Northeast United States. Participants were
587 individuals seen at the clinic between 2008 and December 2010. Two hundred and thirty-
eight individuals identified as male and 348 identified as female. Participants were
predominantly Caucasian (n=437; 74%). The other ethnicities represented included Hispanic
(n=29; .5%), Black/African American (n=26; .4%), and Asian (n=15; .3%). Two hundred and
twenty three participants made less than $49,000 annually (40%) and 156 participants made
more than $50,000 (28%) annually, the 32% did not state their income level. Three hundred and
seventy one participants had previously attended some type of therapy and 178 had not been in
therapy before. Clients were between 12 and 76 years of age (M = 31.7; SD = 12.5).
Procedure
This study was a retrospective analysis of existing clinic data from clients who sought
treatment at a COAMFTE – accredited marriage and family therapy training program in the
Northeastern United States. The Humphrey Clinic is the on-site training clinic for graduate
students enrolled in the Department of Human Development and Family Studies programs in
marriage and family therapy. Individuals, couples, and families seek treatment for a variety of
Running head: MOTIVATION TO CHANGE 26
presenting problems, including anxiety, depression, relational conflicts, behavior problems,
domestic violence issues, general life skills, parenting skills, and coping skills. The therapists are
masters or doctoral students in marriage and family therapy. To ensure proper care and increase
training opportunities, professors in the marriage and family therapy program, supervise all
therapists.
Clients contacted the clinic seeking treatment via phone or walk-in. Clients went through
a phone triage and were then matched with a therapist. Clients were normally seen on weekly or
biweekly basis and paid a sliding fee based on their income or student status. As part of routine
treatment at that clinic, various clinical data were collected from clients via clinical
questionnaires. Those data were then stored in an archive. Clients who consented to treatment
filled out a demographic and assessment questionnaire at the start of therapy, weekly feedback
forms, and assessment packets periodically throughout the course of treatment. Data for this
study were obtained from the archive of data entered from clinical questionnaires.
Measures
Clients who consented to treatment were asked to fill out an intake questionnaire that
included general demographic questions and a variety of measures of personal, relational, and
familial functioning. This questionnaire included a set of questions regarding the client’s
motivation to change, questions identifying their referral source, the pressure they felt to attend
therapy, the locus of the problem, past experience in therapy, and other services they were
receiving. These data were the focus of this study.
Motivation to change questions. The client’s perceived readiness to change was
measured with a set of several questions based on the theoretical constructs underlying the
Transtheoretical Model of motivation to change. Clients were asked to rate their willingness to
Running head: MOTIVATION TO CHANGE 27
change in regard to the problem or problems for which they were seeking treatment. There were
five response categories. Participants responded to the following question: “Starting with
the most important, please list the issues that brought you to therapy. Following each
issue indicate which sentence below best describes how you feel about it. 1. I don’t intend to
make any changes related to the issue. 2. It might be worthwhile to work on this issue, but I
haven’t made any decisions yet. 3. I know this is a difficulty and I’m getting ready to make
some specific changes. 4. I’ve already started working on this issue, 5. I’m here to maintain the
changes I’ve made and to prevent the difficulty from returning.” Participants then wrote a list of
the problems on which they intended to focus in therapy and checked the number of the
corresponding motivational statement that best captured their thinking about that problem.
Category 1 is representative of the precontemplation stage of change. Category 2 is
representative of the contemplation stage of change. Category 3 is representative of the
preparation stage of change. Category 4 is representative of the action stage of change.
Category 5 is representative of the maintenance stage of change. This study only examined their
answer for their first presenting problem as many client’s only stated one problem and they were
asked to rank their problems in order of importance.
Referral source. Participants reported their referral source by responding to the
question: “Who referred you to the clinic?” Responses were provided by indicating that one was
referred by one of the following: self, partner, friend, former or current client, physician,
minister/clergy, school, DCF/Court, Other (please specify).
Pressure to attend. The pressure that the client felt to attend therapy was assessed by
asking “How much did someone else pressure you to come for therapy?” Participants responded
Running head: MOTIVATION TO CHANGE 28
by checking one of the following: not at all pressured, a little pressured, somewhat pressured,
very pressured.
Depression & anxiety scales. Depression was assessed with the Major Depression
Inventory (MDI; Bech, Rasmussen, Olsen, Noerholm, & Abildgaard, 2001); anxiety was
assessed with the Generalized Anxiety Disorder 7-item scale (GAD-7; Spitzer, Kroenke,
Williams, Lowe, 2006).
Major depression inventory. The Major Depression Inventory (Bech, Rasmussen, Olsen,
Noerholm, & Abildgaard, 2001) is a 10-item scale that assesses clients’ level of clinical
depression. There are three different cut off scores provided: mild depression (20-24), moderate
depression (25-29), and severe depression (30 or more). The highest possibly score on the MDI
is 50. The MDI was developed to cover all of the symptoms from the DSM-III/DSM-IV and the
ICD-10 (Olsen, Jensen, Noerholm, Martiny, & Bech, 2003). The MDI has been assessed for
internal and external validity (Olsen et al., 2003). The MDI has adequate internal validity for a
unidimensional scale (Olsen et al., 2003) and the external validity of the MDI and the MDI total
score is significantly correlated with the HAM-D. (Hamilton, 1960, Beck, Steer, & Garbin,
1988). Multiple tests indicated that the MDI has concurrent validity with the Hamilton
Depression Scale (Hamilton, 1960; Beck, Steer, & Garbin, 1988).
Generalized anxiety disorder. The GAD-7 (Spitzer, Kroenke, Williams, Lowe, 2006) is
a 7-item scale that has been tested for reliability. Increased scores on the scale are associated
with increased levels of anxiety. Spitzer et al, (2006) found that the scale has good “criterion,
construct, factorial, and procedural validity” (p. 1092), and they found that there is “good
agreement between self-report and interviewer- administered versions of the scale (p.1092).”
The internal consistency is excellent according to Spitzer et al, (2006), and the test-retest
Running head: MOTIVATION TO CHANGE 29
reliability was also good in the sample. The scale was also related to the Health-Related Quality
of Life Scale (Spitzer et al., 2006).
Running head: MOTIVATION TO CHANGE 30
CHAPTER 4: RESULTS
The purpose of this study was to examine the association between a variety of factors
known to influence motivation to change in outpatient psychotherapy. Using data obtained from
counseling intake questionnaires, the effects of distress, referral source, and pressure to attend
therapy were examined to explore a potential relationship with motivation to change and a
reciprocal association.
Descriptive statistics
Frequency statistics for each variable are presented in Table 1. The most frequently
reported referral source was Department of Children and Families/court referrals (n=163;
27.9%). The second most frequently reported referral source was referrals reported as “other” by
respondents (n=114; 19.5%). Self-referrals were the third most frequently reported source (n=89;
15.2%). Most (n=321; 54.7%) clients felt no pressure to attend therapy. The second most
reported answer were clients who felt a little pressure to attend (n=114; 19.5%). The mean score
on the MDI (MDI; Bech, Rasmussen, Olsen, Noerholm, & Abildgaard, 2001) was 57.29 (SD =
12.13). The mean score on the GAD-7 (GAD-7; Spitzer, Kroenke, Williams, Lowe, 2006) was
13.91 (SD = 5.88). The MDI has a range of 0 to 63, with higher scores indicating high levels of
depression. The GAD has a range of 0 to 21, with higher scores being indicative of high levels
of anxiety. Depression and anxiety are significantly negatively correlated (r = -.690, p < .01).
Table 1
Frequency Statistics
Questions n %
Referral Source 538 92
Self (1) 89 15.2
Partner (2) 34 5.8
Friend (3) 38 6.5
Former or Current Client (4) 11 1.9
Physician (5) 38 6.5
Minister/clergy Person (6) 4 .7
Running head: MOTIVATION TO CHANGE 31
School (7) 47 8
DCF/Court (8) 163 27.9
Other (9) 114 19.5
Pressure to Attend 561 1
Not at all Pressured (1) 321 54.7
A Little Pressured (2) 114 19.4
Somewhat Pressured (3) 70 11.9
Very Pressured (4) 56 9.5
Table 2
Descriptive Statistics: Means and Standard Deviations
N Minimum
Maximum
M SD
Depression 504 18 72 56.07 12.47
Anxiety 533 7 28 14.58 5.98
Table 3
Correlations: Depression and Anxiety
Pearson Correlation
Depression Anxiety
Depression - -.692**
Anxiety -.692** -
Note: ** p < .01 (2-tailed)
Association between distress, as measured by depression, and referral source. In
order to determine the relationship between scores on the Major Depressive Inventory and
referral source, a one-way analysis of variance was conducted. The independent variable, the
referral source, included nine variables: self referral, partner referral, friend referral, former or
current client referral, physician referral, minster/clergy person referral, school referral,
Department of Children and Families/court referral, or other referral. The between groups
ANOVA was significant, F(8) = 11.17, p = .00. To determine the source of the variation in
depression scores, Tukey post hoc testing was conducted. A Bonferroni adjustment was used to
modify the expected level of significance. As eight tests were conducted, the p value required to
assume significance is .00625 (p=.05/8). Each referral source was analyzed to determine
Running head: MOTIVATION TO CHANGE 32
differences in depression scores across referral sources. Those not reported were not significant.
The results indicated that self-referral is significantly different from a Department of Children
and Families or court referral (p=.000). A referral by a friend is significantly different than a
Department of Children and Families or court referral (p=.000). A physician referral is
significantly different than a Department of Children and Families or court referral (p=.000). A
school referral is significantly different than a Department of Children and Families or court
referral (p=.000). Last, any referring agencies not provided as options are also significantly
different than a court referral (p=.000). Two other noteworthy comparisons, although they were
not statistically significant, were the comparison between self and a partner referral (p=.041) and
a former or current client referral from a Department of Children and Families or court referral
(p=.037).
Results of this test suggest that depression scores differ by referral source. Clients who
are referred by the Department of Children and Families/ court system or by their partner have
lower scores on the MDI, indicative of lower levels of depression than those who are self
referred and seeking therapy of their own accord. Those referred by the courts or by the
Department of Children and Families have higher scores on the MDI than those referred by their
friends, other clients, physicians, their school, or any other referral source.
Association between distress, as measured by anxiety, and referral source. To
determine if a relationship exits between scores on the Generalized Anxiety Disorder – 7 items
(GAD-7; Spitzer, Kroenke, Williams, Lowe, 2006) and referral source, a one-way analysis of
variance was conducted. The independent variable, referral source, included nine conditions:
self referral, partner referral, friend referral, former or current client referral, physician referral,
minster/clergy person referral, school referral, Department of Children and Families /court
Running head: MOTIVATION TO CHANGE 33
referral, or other referral. The between groups ANOVA was significant, F(8)=5.73, p=.00. To
determine the source of the variation in anxiety scores, Tukey post hoc testing was conducted. A
Bonferroni adjustment was used to modify the expected level of significance. As eight
comparisons were made, the p value required to assume significance is .00625 (p=.05/8). Self-
referral is significantly different from a Department of Children and Families or court referral
(p=.000). A physician referral is significantly different than a Department of Children and
Families or court referral (p=.005). A DCF or court referral is significantly different than a
friend referral (p=.000). Last, any referring agencies not provided as options, are also
significantly different than a court referral (p=.000). Two other noteworthy comparisons,
although they were not statistically significant, were the comparison between a friend referral
and a Department of Children and Families or court referral (p=.027) and a DCF or court referral
and other referral (p=.000). Results indicate that scores on the GAD-7 differ by referral source.
Clients referred by the Department of Children and Families or by the court system have higher
scores on the GAD-7, indicative of higher levels of anxiety, compared to clients referred from
friends, other clients, physicians, their school, or any other referral source.
Effect of referral source on client’s motivation. To determine whether there were
differences in level of motivation between clients who received a soft mandated referral, one that
comes from the court or Department of Children and Families, and a voluntary referral, one that
comes from other more casual sources, a one-sample Chi-squared test was conducted. For this
analysis, the categorical variable of referral source was collapsed into a dichotomous variable to
highlight the contrast of interest. Clients who stated that their primary source of referral was an
agent of the court or the Department of Children and Families were distinguished from those
who were referred by all other options, such as school, friends, religious leaders, and others. This
Running head: MOTIVATION TO CHANGE 34
study examined the referral source with the most power, which was determined to be the legal
system or Department of Children and Families, as compared to the less powerful referring
agencies. The results of the test were not significant, χ2(1, N=155) = 2.39, p> .05. These results
indicated that there was no significant difference in level of motivation between clients referred
by the court or Department of Children and Families and those referred by all other options.
Distress and motivation. To determine whether scores on the Major Depression
Inventory (MDI; Bech, Rasmussen, Olsen, Noerholm, & Abildgaard, 2001) varied based on
client’s self reported level of motivation, an independent-samples t-test was conducted. The test
was not significant, t(180) =.856, p=.999. The results indicated that there are no differences in
MDI scores across all groups. To determine whether a client’s motivation differed by their level
of anxiety on the GAD-7, an independent-samples t-test was conducted. The test was not
significant, t(180) = .999, p=.856. There is no significant difference between scores on the GAD-
7 and the client’s reported level of motivation. These results indicate that motivation does not
vary in relation to depression and anxiety scores.
Effect of pressure to attend on client’s motivation. To determine the association
between pressure to attend therapy and level of motivation to change, a one-sample Chi-squared
test was conducted. Clients stated their perception of the level of pressure they had to attend
therapy on by selecting one of the following options: “not at all pressured,” “a little pressured,”
“somewhat pressured,” and “very pressured.” To highlight the differences between those clients
who felt very pressured and clients who felt less pressured, the scale was condensed. Data from
those clients who felt very pressured was compared with data from all other clients. The data
were collapsed due to the researcher’s belief that there is a distinct difference between very
pressured and all other clients and that the differences between not at all and a little pressure are
Running head: MOTIVATION TO CHANGE 35
not of significance. Overall the researcher is most interested in learning about clients reporting
the highest level of pressure. The results of the test were significant, χ2(3, N=197) = 11.19, p <
.011. Twenty four percent of people who felt very pressured were in the pre-contemplation stage
of change. In contrast, seventy six percent of those who reported feeling not al all, a little or
somewhat pressured were in the action stage of change (p = .011). These results suggest that
pressure to attend therapy is associated with motivation to change in the expected fashion. Those
clients who feel more motivation to change are more likely to attend therapy under less pressure.
Those clients who felt most pressured were also those most likely to be in pre-action stages of
change.
Running head: MOTIVATION TO CHANGE 36
CHAPTER 5: DISCUSSION
This study provides some initial evidence that distress levels are associated with a client’s
motivation to change and that there experience of pressure affects their motivation to change.
Results of the quantitative analysis include several interesting findings. First, depression scores
significantly differ by referral source. Those clients referred to therapy by the court system or the
Department of Children and Families experienced higher levels of depression than those who
were self-referred or referred by friends, other clients, physicians, their school, or any other
referring agency. Also participants referred by their partner had higher levels of depression than
those who were self-referred. In addition, participants’ anxiety scores and their referral source
were significantly associated. Results indicated that anxiety differs by referral source. Clients
who were referred by the courts or the Department of Children and Families were more likely to
have high scores on the anxiety measure when compared to clients referred by friends, other
clients, physicians, their school, or any other referral source.
Results indicated that there is an effect of perceived pressure on a client’s motivation.
These results suggest that pressure to attend therapy is associated with motivation to change in
the expected fashion. Those clients who attend therapy under less pressure are more likely to feel
more motivation to change. Clients who are more pressured to attend therapy are less motivated
to change in therapy. Clients who felt the most pressure were most likely to be in the pre-action
stages of change, meaning that they have the lowest motivation or interest in changing. These
clients also commonly believe that they do not have a problem and there is nothing that they
could use therapy to work on.
Results examining the effect of the referral source were not significant indicating that the
referral source is not as impactful as the perceived pressure from that referral source. The
Running head: MOTIVATION TO CHANGE 37
pressure place on a client is very important and yet the specific referral source appears to have
less of an impact according to this research. This indicates that referral sources could have great
influence in regard to the experience of the client by engaging with the client and monitoring the
perceived pressure.
Factor’s Effecting Mandated and Voluntary Clients
Psychotherapy has been shown to be efficacious with a variety of voluntary and
motivated clients and assisted them in creating desired change. Yet many clients are mandated
to attend therapy by legal systems, state agencies, and other referral sources. Mandated clients
have a different experience in therapy because they may be resistant to attending therapy.
Mandated clients who are coerced into attending therapy may feel resistant or may feel that their
sense of autonomy has been challenged. Soft mandated clients experience less pressure then
traditionally mandated clients and face less severe consequences. Soft mandated clients may
have similar feelings with respect to loosing their autonomy but they are not facing the severe
and potentially life-changing consequences that mandated clients may encounter.
This study found that the perceived pressure a client experiences is more important than
the source of the referral. High levels of pressure may be hindering the client’s therapeutic
engagement and follow through with the course of therapy. The experience of the client both
prior to and in therapy is important as it is affecting the outcome of the therapeutic process. This
research identified that soft mandated clients, clients referred by the court or DCF, may also
experience high levels of pressure and low levels of motivation, similar to the experience of a
mandated client. Soft mandated clients differ from traditionally mandated clients because they
may not feel as compelled to follow through with therapy as they are not facing as severe
consequences as hard mandated clients. There appear to be both similarities and differences
Running head: MOTIVATION TO CHANGE 38
between voluntary, soft mandated, and hard mandated clients in therapy, which require further
examination. Factors that distinguish among traditionally mandated, soft mandated, and
voluntary clients appear to include the client’s level of distress and the pressure felt by their
referral source.
The present study contributes to the already collected research on voluntary and hard
mandated clients while also contributing to the knowledge of important factors that the therapist
should address in the therapeutic process, distress and pressure. This research highlighted the
different between pressure and referral source, which is an important distinction and factor to
assess with hard and soft mandated clients.
Implications
The results of this study are valuable for agencies, clinicians, and researchers in family
therapy due to a variety of reasons. First, the pressure to attend therapy perceived by the client
predicts membership in a particular motivation to change stage. Clients who reported feeling
high levels of pressure to attend were most likely to also report being in the pre-action stages of
change, indicating that they have the lowest levels of motivation. This signifies that the more
pressure a client is feeling from their referral source, the less engaged they might be and the
more resistant they may be to the typical tasks of therapy. Clinicians should question their
clients, not only about their motivation, but also about the pressure that they feel to attend
therapy. Agencies need also be aware of the pressure they are placing on clients to attend
therapy and the ways in which the referral is being portrayed to the client.
Second, the results of this study indicate that distress is related to motivation. Clients who
are experiencing high levels of depression are more likely to refer themselves to therapy, perhaps
because others have noticed their depression and commented or because they find it to be getting
Running head: MOTIVATION TO CHANGE 39
in the way of living a normal life. Clients who are experiencing high levels of anxiety are more
like to be referred by the Department of Children and Families or the court system, indicating
that those referred by these powerful agencies are experiencing high levels of anxiety, which
may be interfering with their treatment. The clinician should monitor high levels of anxiety.
Finally, motivation does not seem to be directly connected to referral source. Instead, the
pressure put on the client appears to have the greatest effect on the client rather then the specific
referring agency. The same referral source can cause different levels of pressure for a client and
this is something of which the agency needs to be aware. An individual could be told by the
courts that they must attend counseling but the delivery, time frame, and expectations could all
be used as ways to indicate the importance and severity while maintaining the client’s autonomy
as much as possible. Clients who feel forced and pressured into attending are likely to have
lower levels of motivation to change. This may explain why prior studies on mandated clients
had varying results in regards to client motivation. If pressure is the most important factor then
the presence of a third profile of clients, soft mandated, many affect the results.
Strengths and Limitations
As with any research, this study had strengths and limitations. Some limitations of the
study included the data set, population, and the assessment measure used. The archival data set
did not provide as diverse a sample as would have been preferred. Using archival data meant
that no one sample was selected for and limited the possibility of researcher’s selection bias. The
sample size was adequate but many of the clients were voluntary due to the type of clinic and its
location, therefore the sample of more pressured and lower motivated clients weakened the
power of the tests. Other limitations included the accuracy of the assessment use of motivation
to determine concrete differences between the stages of motivation for a client.
Running head: MOTIVATION TO CHANGE 40
The measure used to assess motivation was a variation of the University of Rhode Island
Change Assessment, which assesses for the five stages of change indicated by the
Transtheroretical Model of Change (Prochaska & DiClemente, 1986, 1992). The measurement
of motivation used in this research, as well as the URICA, both have room for improvement.
The method used in this study was a variation of the URICA in which clients ranked their
presenting problems and then answered a scaling question that identified the 5 stages of change.
This study only examined their answer for their first presenting problem, which many have
limited the variability of answers. Another limitation was the possibility that clients
disproportionally wrote something that they were very motivated to change for their first option.
The scale did not assess for overall motivation to change through the process of therapy rather it
was in regard to their presenting problem. With respect to the URICA assessment, the
precontemplation and action stages of change appear to have validity, but the distinctions
between the other stages appear to be less clearly differentiated. It appears hard to differentiate
between each of the pre-action stages, which is why this study analyzed pre-action versus action.
The strengths of the current research includes the sample size, the assessments used to
measure clients distress, pressure, and referral source, and the identification of a third category
for examination. The research questions were appropriately addressed by the assessments used
and the previously collected data. Another strength includes the use of deidentified data to
assess an accurate clinical population.
Future Research
This study is only a starting point for future research into the factors influencing
mandated and voluntary clients. Future research is necessary to examine diverse samples of
voluntary, soft mandated, and hard mandated clients and the factors that shape their treatment.
Running head: MOTIVATION TO CHANGE 41
Continued research is necessary for the development of techniques and models that may be vital
to assist in the treatment of differently motivated clients.
Additionally, future research should not only expand to include differently motivated
clients but to also include different formulations of clients such as couples and families as the
field of family therapy research needs to expand measures to assess motivation for couples and
families. It is unknown whether the properties of the URICA make it appropriate for use with
couples and families.
Overall the validity of the URICA as a measurement for distinctive stages of motivation
needs to be assessed and reexamined. It may provide the path to greater understanding and
assessment of motivation especially if it can be generalized across treatment modalities and
populations. The current research using the URICA with substance abusing individuals and
perpetrators of serious crimes may not be generalizable to other populations. Indeed, some
studies (Blanchard, Morganstern, Morgan, Labouvie, & Bux, 2003; Dozios et al., 2000;
Greenstein, Franklin, & McGuffin, 1999) suggest that the URICA may not have adequate
predictive and discriminant validity to suggest that it is an adequate measure of stage of change.
The use of the URICA should be examined by future research and new measurements or
modifications could be developed to expand motivational assessment measures.
Conclusion
Despite some weaknesses, the present study contributes to the literature in the area of
motivation to change and factors affecting clients in treatment. It is the first study to identify and
then examine soft mandated clients as a population. The assessment of the data in this study
provided information about distress levels, perceived pressure, and referral source in regard to
Running head: MOTIVATION TO CHANGE 42
motivation in voluntary and soft mandated clients. This study has advanced the dialogue on
motivation and provided suggestions for necessary research in the future.
Running head: MOTIVATION TO CHANGE 43
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