“Why should I write this paper?” “What is motivating me?” Questions like these are a natural occurrence in our lives, adapted to different sectors. There can be several reasons for one to act, but what drives the action is motivation. Further, motivation to change is even more difficult, overriding what has been engrained and routine. For others, such as people living with mental illness, motivation to change is a complex and difficult process. Mental illness is a challenge within itself. Coupled with other medical comorbidities and oftentimes substance abuse issues, the motivation to change negative health habits seem out of reach. This report will examine what motivates people with mental illness to change. Internal factors elicited by motivational interviewing, external motivators such as vouchers and financial rewards, and natural motivators in the community, are motivators for persons with mental illness and substance abuse problems to change their behaviors.
Motivation can be defined as a reference to a “central mechanism or constellation of mechanisms that lie at the heart of why and how people change addictive and health behaviors,” as defined by Bandura (as cited by DiClemente, Nidecker, & Bellack, 2008). This is independent from the outcome, whether or not a behavior is changed. Different things motivate different individuals, based on their values, culture, and lived experiences. In the mentally ill population, DiClemente, Nidecker, & Bellack state, “individuals with two or more diagnosable psychiatric conditions are often differentially motivated,” highlighting that this population may have unique motivation mechanisms (2008). The challenge in this population is that the mentally ill often have co-existing psychiatric issues, co-existing medical issues, and oftentimes substance use disorders. In fact, it has been cited that half of all individuals with chronic and serious mental illnesses have met the criteria for a substance use disorder, indicating a need for change to achieve better health outcomes (DiClemente, Nidecker, & Bellack, 2008).
Theories about motivation have similar, broad concepts about an individual’s interest and need for change, their goals and intentions, the need to take ownership and commit to change, and the sustenance of changed behavior with “adequate incentives for change” (DiClemente, Nidecker, & Bellack, 2008). Specifically, the trans-theoretical model involves several stages of change. The stages are categorized as pre-action and action-oriented stages. Pre-action includes precontemplation, contemplation, and preparation. Action-oriented stages involve implementing the actual changed behavior and the maintenance of sustaining the change. Successful resolution of the preceding stage lays the groundwork for advancing to the next stage, with cycles of the stages reoccurring (DiClemente, Nidecker, & Bellack, 2008).
As all lived experiences are unique, motivators are unique to the individual. One way to extract what motivates someone is to employ motivational interviewing. Motivational interviewing accepts the patient as a unique individual, making this technique patient-centered. It begins with patient engagement, with the focus being on their concerns. Motivational interviewing is an evidence-based technique that has been successful for providers in eliciting information from clients. Motivational techniques using motivational interviewing has been cited as promising in interventions for improving medication adherence and treatment regimen by studies from Zygmunt, Olfson, Boyer, and Mechani, and Swanson, Pantalon, and Cohen (as cited by DiClemente et al, 2008). Motivational interviewing utilizes “collaborative goal setting that recognizes harm reduction and small steps in reaching larger goals” (DiClemente, Nidecker, & Bellack, 2008). The interaction between the patient and the provider entails discussion about individual values and concerns without confrontation nor pressure and identifying reinforcers that can support the goal to change a behavior or behaviors (DiClemente, Nidecker, & Bellack, 2008). With the skills of the provider and maintaining a judgment-free space and the client’s ability to communicate, motivational interviewing will allow for the identification of motivators. With the identification of motivators, the provider can better tailor a plan to motivate a client to change (that is, if the client wants to change). Motivational interviewing operates under the premise that nothing is forced or pressured onto the client. Resolutions and thoughts are drawn up from the client, with the provider acting as a buffer and guide to better navigate the thought process for a client. It’s as simple as that- find what motivates someone, use it as an incentive for change, and the change will be enacted.
On the contrary, simplicity is not to be taken for easiness. It takes a certain level of cognition and consciousness for someone to identify what motivates them, to communicate it, and to sustain the motivation for change. In the population with mental illness, it is argued that some of these clients do not have the ability and cognition to identify motivators. DiClemente et al pose questions that include if the mentally ill population can “access the intentional process of change and make use of decision making, intentionality, commitment, planning, and experiential and behavioral processes of change when they make changes in their substance-abusing or adherence behaviors” (2008). Further, DiClemente et al question if mental illness with cognitive impairments will interfere with decision-making and if it will hamper self-evaluations (2008). Additionally, the Center for Substance Abuse and Treatment state the “more severe the mental illness and the substance abuse problems are, the more dysfunctional thought processes, impaired decision-making skills, and the lack of insight diminish the ability to recognize the need for treatment as well as the individuals’ ability to seek and participate in it,” supporting that motivational interviewing will be most effective in the cognitively-capable (as cited by DiClemente, Nidecker, & Bellack, 2008). Other professionals suggest that people with severe mental illness and coexisting disorders “may be more driven by external considerations or reinforcers, seems less intentional, and appears more chaotic than the process among individuals without these problems” (DiClemente, Nidecker, & Bellack, 2008). DiClemente et al state:
“Substance-abusing individuals with mental illness … have attitudes, opinions, beliefs, and intentions that are integral, but often detrimental, to making and adhering to behavior changes. They can have problems with commitment and planning as well as with implementation and revision of those plans. In addition, they can have significant problems sustaining behavior changes over long time periods… They may benefit from external reinforcers to enhance internal processing, the use of less cognitively complex assessment and treatment approaches, and/or stabilizing medications and skills development to help them access the process of change” (2008).
This suggests that there are other motivators that need to be considered with the mentally ill population.
By the same token, there has been much success in external incentive programs for motivation in substance abusing individuals with mental illness. Voucher incentive programs are used as external contingent reinforcers, with specific awards that clients value. Budney and Higgins have tested voucher incentive programs, with much success (as cited by Substance Abuse and Mental Health Services Administration, 1999). Voucher incentives operate under the rationale that an enticing external motivator can be an immediate and powerful reinforcer to compete with drug reinforce. Vouchers will satisfy the need for immediate gratification. As per the Substance Abuse and Mental Health Services Administration, it has been demonstrated that “money or an equivalent alternative is nearly always appealing” (1999). Vouchers are earned for abstinence, with point values, sometimes indicating a cash value. Points are awarded each time the client submits drug- free urine, for example. When vouchers are accumulated, clients trade in their points for goods and services. Options include paying bills with their voucher or spend their money on shoes, clothing, groceries, etc. (Substance Abuse and Mental Health Services Administration, 1999). By allowing individuals to use points and rewards as they want in exchange for changed behavior, they are motivated to move toward a positive direction.
In addition, a motivator to change can be effected by using a Community Reinforcement Approach (CRA). Community Reinforcement Approach involves fusing natural reinforcers to abstinence. The difference from external reinforcers such as vouchers is hat natural reinforcers can be praise, occurring in a normal, every-day environment that the client is in. The ideal situation that the Substance Abuse and Mental Health Services Administration discusses is in employment. There would be an agreement between employer and client in which the client would be allowed to work and earn money when they are drug and alcohol free. The rationale is that the benefits of work and money to be earned become associated with abstinence. Another component is Job Club, which offers skills training and strategies for getting a job (interviewing, dress, applications). The Substance Abuse and Mental Health Services Administration state “employment serves as an immediate reinforcer by meeting the practical need for money, but other aspects of employment take time to become reinforcing” (1999).
In conclusion, motivators to change in people with mental illness are not cut and dry. Motivational interviewing is an excellent tool in eliciting the client’s values and personal motivators, or internal factors, if cognition is intact. External motivators and incentives such as vouchers and financial rewards are also effective in motivating change. Additionally, Community Reinforcement Approaches (highlighting employment) also serve as motivators for change by merging natural and external motivators. The need for behavior change in persons with mental illness and substance abuse is a health problem that needs to be addressed. Traditional treatments may not work in this population due to the existence of other conditions. By using a patient-centered approach, outcomes are likely to be favorable in starting and maintaining a positive change.
References
DiClemente, C., Nidecker, M., & Bellack, A. (2008). Motivation and the stages of change among individuals with severe mental illness and substance abuse disorders. Journal of Substance Abuse Treatment, 34 (1). Retrieved from http://www.sciencedirect.com.citytech.ezproxy.cuny.edu:2048/science/article/pii/S0740547207000980
Substance Abuse and Mental Health Services Administration. (1999). Enhancing Motivation For Change in Substance Abuse Treatment. Center for Substance Abuse Treatment. Retrieved from https://store.samhsa.gov/shin/content/SMA13-4212/SMA13-4212.pdf
