CBTp Techniques for Relationship Building From a MOTR Perspective

Currently, the primary CBTp techniques for building and maintaining the therapy relationship are normalizing and (emotional) validating (e.g., Lincoln, 2006). From a MOTR perspective, both techniques are motive-oriented in many but not all therapy situations. Normalizing conveys to the patient that many other people have similar experiences. First, this is likely to satisfy the need for affiliation, as one is part of a group of many similar human beings. Second, normalizing implies that one is not “crazy” or “abnormal,” preventing further threats to self-esteem and also preventing a threat for autonomy (“I’m crazy and will be in a ward for the rest of my life”). Last not least, normalizing may help to satisfy the need for orientation and control, because the information that even psychotic symptoms are rather normal in fact provides orientation. With regard to validation, similar motive-oriented consequences for patients are likely. Particularly, validation means that patient and therapist do not argue about the truth of a delusional belief or the authenticity of voices. In contrast, the therapist understands the emotional and behavioral reactions of the patient and communicates this understanding and empathy. This is a corrective experience for many patients as they are no longer forced to defend their view of the world or conceal it in order to protect their self-esteem and need for orientation. In line with this, the effect of normalizing and validation compared to educating supported psychological treatment motivation in an analog study (Lüllmann and Lincoln, 2013). However, if the maintenance of a delusional belief of a patient has a strong instrumentality for self-esteem (e.g., grandiose or erotomanic delusions, voice of God, etc.), a standard normalizing approach would be adverse according to MOTR because it endangers an important instrumentality of the behavior (e.g., a therapist saying “Many people think that they have a special connection to God, this is normal” is likely to threaten the need for self-esteem enhancement and/or attachment of a patient).

Medication Compliance

The behavior “refuses medication” might primarily serve to satisfy the need for autonomy, as in the example in the previous section. However, another patient might refuse medication in order to evoke additional sessions with a therapist or a closer contact with caregivers, to satisfy his need for attachment. Yet, another patient who beliefs he is persecuted outside the ward might refuse medication to prolong his hospitalization, in order to satisfy his need for security. Furthermore, another patient might “forget” taking medication in order to avoid being reminded of being ill, which in turn protects self-esteem. And yet another patient may simply want to avoid negative side effects. Thus, one problematic behavior can serve very different motivational purposes. In addition, a problematic behavior can be multiply determined (e.g., serving autonomy and affiliation).

MOTR suggests different therapeutic stances and interventions, depending on the instrumentality of the problematic behavior. With regard to autonomy and control, satisfying the Plan “exercise control” by broadening the opportunity for decision-making in other domains can be expected to weaken the motivational basis for not taking medication. In contrast, a dispute of the pros and cons of medication each time the patient rejects medication would be a positive reinforcement of the patient behavior (C+), because he or she experiences herself as in control which would be in line with the basic need (given that the medication is not forced). When the problem behavior is instrumental for attachment (evoking more caregiver contact by refusing medication), regular and non-contingent short contacts would be derived from the MOTR approach in order to saturate the motivational basis for rejecting mediation.

Maintenance of a Delusional Belief

In line with the cognitive model of psychosis (Garety et al., 2001), the maintenance of a delusional belief is likely to satisfy the need for orientation and control in many patients. In addition, the direct cognitive disputation of such a belief can be seen as threat for the self-esteem. In that sense, “typical” therapeutic strategies such as psychoeducation or persuading patient into being insightful are problematic therapist behaviors for many patients, as they pose a direct threat to the self-esteem and to the need for orientation and control. However, if a patient has a first episode, no elaborated delusional beliefs and a deprived need for orientation and control, then psychoeducation and the facilitation of a biopsychosocial problem model is expected to be very helpful, according to MOTR. Thus, MOTR enables the therapist to make informed decisions when to use which intervention.

If the maintenance of a delusional belief is multiply determined (i.e., is instrumental for two or more superordinate motives) and has an instrumentality for self-esteem (e.g., grandiose delusion), MOTR would suggest that the therapist supports the self-esteem in each session. In such a way, MOTR would satisfy the self-esteem motive independent of grandiosity delusion thus paving the way for direct interventions regarding the delusional belief or other helpful interventions. When the need for orientation and control is satisfied by the maintenance of a delusional belief, MOTR would suggest that the therapist helps the patient to develop an intrinsic motivation to challenge his beliefs (e.g., with a four-field-schema).

Negative Symptoms

The effects of pharmacological and psychotherapeutic interventions on negative symptoms are small (Elis et al., 2013; Chue and Lalonde, 2014). Is MOTR for schizophrenia able to address these treatment difficulties? First, using MOTR could support therapists to maintain a good therapy relationship even in face of severe negative symptoms such as blunted affect or alogia. When there is only minimal non-verbal or verbal feedback from the patient, therapists have an even higher demand for framework that guides therapeutic action in order to meet the needs of a patient, with MOTR being such a framework. Second, if future research should reveal that negative symptoms also have an instrumental aspect, MOTR might help to satisfy the motivational basis of negative symptoms.

Emotions and Plan Analysis

From a Plan Analysis perspective, negative emotions signal that important Plans and basic needs are threatened or blocked, positive emotions that they are favored (Caspar, 2011) and are valuable diagnostic information. In general, five types of sources of emotions are assumed in Plan Analysis, which are described and illustrated in Table ​Table11.

Schizophrenia is often accompanied by a loss of individual abilities and changes in the environment (i.e., hospitalization, job loss, etc.). Under such circumstances, the flexibility and resilience of the patient’s Plan structure is particularly important. The more the structure is rigid or includes conflicting Plans, the more patients have problems satisfying their basic needs and experience negative emotions (see Table ​Table1).1). Then, Plans might be in effect even though they have severe short- or long-term side effects, such as endangering the therapy relationship or even threating life (when a patient kills himself as a last demonstration of autonomy). For example, a loss of individual abilities might block most of the Plans related to self-esteem. Under such circumstances, the remaining Plans such as “maintain paranoid delusion” are particularly important for the patient, even though they can severely disturb the therapy relationship, highlighting the utility of MOTR for many patients with schizophrenia.

Although an individual Plan Analysis for each patient is necessary, findings from basic schizophrenia research should be taken into account to inform individual Plan Analyses were appropriate. In the next section, the instrumental perspective of Plan Analysis is used to review the literature of psychological mechanisms of the development and maintenance of schizophrenia.

Need for Orientation and Control

Epstein (1990) assumed that there is a basic human need for orientation and control that helps individuals to make sense of their experiences and informs them about the degree of control they have in an environment. A deprived need for orientation and control is often signaled by anxiety. Orientation and control are psychological processes that are central to various models and findings from basic schizophrenia research and will be discussed in the next paragraph.

Need for Enhancing and Protecting Self-Esteem

Findings from basic clinical and psychotherapy research highlight the relevance of self-esteem for positive symptoms and therapeutic alliance in schizophrenia. Decreases in self-esteem can precede paranoid ideation in daily life according to studies with intensive longitudinal assessments (Thewissen et al., 2011). In experimental studies with sub-clinical samples, the effect of social exclusion on paranoid ideation was mediated by decreases in self-esteem (Kesting et al., 2013) and paranoid interpretations of social exclusion protected the self-esteem on a short-term scale (Lincoln et al., 2014). Lack of insight is accompanied by less self-stigmatization and demoralization across one year in patients with schizophrenia (Cavelti et al., 2014), with stigmatization being associated with lower self-esteem (Link et al., 2001). There is also evidence for a positive association of patient’s rating of the therapy relationship and their level of self-esteem in group interventions (Lecomte et al., 2012). Finally, prototypical Plans such as “Repair the self-esteem” were present in six of seven patients with schizophrenia in a qualitative study (Hellener, 1997).

Blocked or threatened Plans that serve to satisfy the need for self-esteem enhancement might be relevant for many individual Plan structures. In particular, rigid Plan structures (only limited means for enhancing self-esteem), conflicting Plans (the means of one motive such as affiliation block the means of another motive such as self-esteem) and a predominance of avoidance Plans (protection of self-esteem limits the opportunities for increasing self-esteem) are likely to be part of individual Plan structures of many patients with psychotic disorders. For example, the satisfaction of the need for self-esteem enhancement can depend on a rigid Plan structure of a patient, which includes solely the Plans “keep job” and “maintain belief of being loved by Jodie Foster.” When this patient is hospitalized, the Plan “keep job” is blocked. Under such circumstances, other sources for self-esteem enhancement should be established (e.g., validation by the therapist, social skills training, etc.; compare to Gassmann and Grawe, 2006) prior to a challenging the maintenance of the delusional belief, which is the very last means for protecting self-esteem.

Implications for Psychotherapy

The main advantage of MOTR in schizophrenia treatments is expected to be that evidence-based interventions from different fields such as pharmacotherapy, CBT or family therapy can be applied more effectively. However, Plan Analysis has more potential than only guiding in-session therapist behavior. Plan Analysis can enrich a case formulation and inform a therapist about patient resources, appropriate skills trainings, and the reasonable sequence of interventions. For example, if the Plan “maintain belief that the voice comes from an angel” serves the need for affiliation and self-esteem, and the patient has only few other means for satisfying these needs, one should include interventions for building up affiliation resources and self-esteem enhancement in the treatment plan. An accordingly staged treatment plan could be: (1) activating and validating patient resources in order to build up a therapy relationship, (2) skills training for enriching the rigid Plan structure for self-esteem and affiliation (e.g., social skills training) and cognitive disputation of automatic thoughts that reflect conflicting Plans, (3) cognitive disputation of the auditory hallucination related delusions (if they are still maintained), and (4) relapse prevention.

Currently, more and more specific interventions for schizophrenia are being developed and evaluated. These interventions target emotion-related processes such as worrying or insomnia, are directly derived from basic research and are a valuable contribution to the treatment of schizophrenia (Foster et al., 2010; Myers et al., 2011). However, not all “negative” emotions stem from psychopathological processes such as worrying or sleep deprivation due to insomnia. In order to understand the generation of emotions that might trigger psychotic symptoms in a more generic manner, one can make use of Plan Analysis, because it captures recurring emotions on a broader scope. For example, if a patient with schizophrenia experiences negative emotions due to Plans related to a comorbid social phobia, the therapist can address this source of distress by offering the patient exposure therapy (without having to wait on the first treatment manual for exposure therapy in patients with schizophrenia with comorbid social phobia).

Implications for Pharmacotherapy

When psychiatrists are able to identify their patient’s needs and to adapt to them, the instrumentality of the problem behavior “refusal of antipsychotic medication” is less likely to be overlooked. Vicious circles of problematic patient and problematic therapist behaviors could be prevented or stopped (e.g., therapist tries to coerce patient to being insightful in order to take medication, patient refuses medication in order to experience himself as autonomous, and so on). If future empirical research corroborates the hypothesis that there are prototypical Plan structures for patients with schizophrenia, short MOTR trainings for psychiatrists would be feasible and beneficial that do not require psychiatrist to conduct a complete Plan Analysis for each patient.

Research Implications

A research agenda for MOTR for schizophrenia encompasses three main domains. First, the hypothesis that motivational constructs such as blocked or threatened Plans are relevant to the therapeutic relationship in addition to other variables such as symptom severity or neuropsychological deficits has to be tested. Second, individual Plan Analyses of patients with schizophrenia are necessary in order to empirically determine the validity and reliability of Plan Analysis in schizophrenia. Possibly, such studies will reveal prototypical Plan structures that help to inform future research and trainings. Third, randomized controlled trials are necessary to test whether treatments as usual (e.g., pharmacotherapy, CBTp, etc.) enriched with MOTR are more effective than treatments as usual without MOTR. In addition, such intervention studies would investigate whether therapists that adopt MOTR with patients with schizophrenia are more comfortable and experience themselves as less helpless when using MOTR, because they are able to see the underlying acceptable human needs of their patients’ problematic behaviors and can thus avoid vicious circles of problematic behaviors (see Schmitt et al., 2003). Thus, MOTR has the potential to contribute to the mental health of therapists and other care providers.

Taken together, MOTR has the potential to improve both pharmacological and non-pharmacological treatment for schizophrenia by enabling therapists to proactively adapt to their patient’s motives and to preventing problematic behavior. The approach makes use of (current and future) findings from basic and psychotherapy research and is generic in this respect, but at the same time guides therapeutic action precisely and flexibly in a patient oriented way.