Our study published in Psychotherapy in December 2014 focused on psychotherapy motivation among patients with substance use disorders (SUD) based on Self Determination Theory (SDT; Ryan & Deci, 2000). The study showed that SUD patients’ amotivation predicted increased dropout rate in the step from assessment to starting therapy (Philips & Wennberg, 2014).

These results add to previous research findings based on SDT with other patient populations, which show that autonomous motivation predicts better session outcomes (Michalak, Klappheck and Kosfelder, 2004; Pelletier, Tuson and Haddad, 1997) as well as better treatment outcomes (Zuroff, Koestner, Moskowitz, McBride, Marshall and Bagby, 2007).

Another finding from our research group within the same naturalistic study of SUD patients mentioned above showed that dropout is also predicted by psychotherapy expectations characterized by defensiveness (Frankl, Philips & Wennberg, 2014).

Pre-Therapy Preparation Sessions

These findings and others point to the need of many patients for pre-therapy preparation aimed at facilitating therapy motivation and realistic therapy expectations. This need is probably greater for those patients who are known to be difficult to engage in treatment, such as patients with SUD. These pre-therapy preparation interventions could share many features with Motivational Interviewing (MI), as MI is highly concordant with SDT (Markland, Ryan, Tobin & Rollnick, 2005; Sheldon, Joiner, Pettit & Williams, 2003; Vansteenkiste & Sheldon, 2006) and several studies show promising results for MI as a preparation before cognitive behavioral therapy or pharmacological treatment for various psychiatric disorders (Westra, Aviram & Doell, 2011). However, this knowledge needs to become an integral part of other psychotherapy orientations as well, such as psychodynamic or experiential psychotherapy.

Psychotherapy’s Three Ingredients

Based on SDT, we suggest that psychotherapy should include three important ingredients, found to satisfy fundamental human needs and to contribute to growth and well-being in numerous areas in life (Ryan & Deci, 2000):

• Autonomy support: To help people experience a sense of choice and volition in deciding how to act and think, without unnecessary external pressure.
• Competence support: To help people feel efficacious in their efforts to try new ways to act and think.
• Relatedness support: To provide people with an important other person to whom they feel attached or related; another person who can prompt, model or value the new ways of acting and thinking.

Improving the Beginning Phase of Psychotherapy

Based on this knowledge, we make the following suggestions for psychotherapeutic technique during the assessment interviews and the initial phase of therapy, in order to improve retention in treatment and to facilitate good outcomes.

These therapeutic principles could also be employed later in therapy, if the patient’s treatment motivation declines. Such interventions might repair alliance ruptures and prevent dropout from treatment.

1. Give the patient a clear description of the rationale for the therapy, so that the patient can make a conscious evaluation of this and perhaps start internalizing the treatment goals and the activity expected from him or her in therapy. Furthermore, the patient is given the chance to consciously start integrating these goals and tasks with his or her own set of important personal values and beliefs.
2. Engage the patient in a thorough discussion of the pros and cons of committing to the therapeutic tasks and goals, following the model of MI (Miller & Rollnick, 1991), to further facilitate the patient’s internalization and integration of the aims and methods of therapy. These first two points concern autonomy support – emphasizing the patient’s own responsibility for choosing to engage in the therapeutic endeavor and encouraging the patient to make this choice in respectful dialogue, strengthening the patient’s sense of agency.
3. Provide the patient with warmth, empathy and safety, hence satisfying the patient’s fundamental need for relatedness, which will increase the patient’s feeling of well-being and strengthen his or her motivation for therapy.
4. Highlight and explore all the joyful and satisfying moments that the patient experiences in therapy, such as a genuine interest in exploring new sides of one’s psyche or genuine joy in reaching a new insight. These moments constitute the intrinsic motivation for psychotherapy, which should be cherished and used for enhancing the therapeutic process.
5. Validate the patient for all the good work that he or she is doing in therapy (competence support). However, be careful not to exaggerate this. Praise from the therapist should not become an external reward pushing the patient towards controlled motivation for therapy, which could decrease the patient’s autonomous therapy motivation.
6. In psychodynamic therapy: The initial sessions should focus on motivational work until you know that the patient is fully engaged in the task of exploring his or her unconscious desires and conflicts. During this phase, abstain from making interpretations of the patient’s resistance and their possible unconscious sources. Interpretations of resistance and transference towards a patient who is not yet motivated and engaged in the therapeutic work are violations. Such interventions in this early phase should only be used in critical situations, in which the patient’s mental state constitutes a danger for him or herself, others, or therapy.

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Björn Philips