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Motivational structure
Addictive Behaviors 27 (2002) 925 – 940
Motivational structure Relationships with substance use and processes of change W. Miles Coxa,*, Eric Klingerb a
School of Psychology, University of Wales, Bangor, Bangor, LL57 2DG Gwynedd, South Wales, UK b University of Minnesota, Morris, MN, USA
Abstract The motivational model stresses that substance misuse occurs in the context of the satisfactions and frustrations that people derive from incentives in other areas of their lives. Therefore, it is important to assess substance users’ motivational structure, that is, the patterns by which they strive for these incentives. This article presents a technique for assessing motivational structure, through which people’s motivation to use substances can better be understood. Results of studies using the assessment suggest the following: (a) Unless university students with alcohol-related problems have adaptive motivational structures, they are less able to control their drinking. (b) Alcohol abusers’ motivational structure leads them to experience less life satisfaction than does university students’ motivational structure. (c) In treatment, substance abusers with more adaptive motivation show less problem denial and more motivation for change than those with a more maladaptive pattern. (d) Alcohol abusers with healthier motivational structures show better immediate responses to treatment and have better long-term outcomes than those with less healthy patterns. (e) Systematic Motivational Counseling (SMC) improves motivational structure and reduces substance use. These results support the motivational model. D 2002 Elsevier Science Ltd. All rights reserved. Keywords: Motivational structure; Motivational assessment; Substance abuse; Alcohol abuse
1. Introduction The motivational model (Cox & Klinger, 1988, 1990) emphasizes that drinking alcohol and other substance use must be viewed in the context of the other incentives in people’s * Corresponding author. Tel.: +44-1248-38-3774; fax: +44-1248-38-2599. E-mail address: [email protected] (W.M. Cox). 0306-4603/02/$ – see front matter D 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 4 6 0 3 ( 0 2 ) 0 0 2 9 0 - 3
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lives. Nevertheless, the model takes into account a variety of factors that influence people’s motivations to drink alcohol and use other substances, including biological, psychological, environmental, and cultural variables. All of these factors contribute to people’s expectations about how using substances or not doing so will bring about changes in their affect. Within the model, the balance between people’s expected positive and negative affective consequences of using substances forms the final common pathway—the proximate link in the causal chain—that determines actual substance use. People’s decisions about substance use are not necessarily explicitly rational or even conscious (as others have also emphasized, Tiffany, 1990, 1995). Rather, they involve processes that intertwine rational and emotional components (e.g., Damasio, 1994; Loewenstein, Weber, Hsee, & Welch, 2001; Mellers, 2000). Nor are these decisions made in isolation from other life areas. An important influence on these substance-use decisions is the emotional satisfaction that the person derives from other areas of life. If a person is unable to find satisfaction from other positive incentives, he or she is more likely to turn to alcohol or other substances as a way to gain pleasure or find emotional relief. When the model was originally developed, there already was some evidence to support this view. For instance, it seemed that people would be more likely to recover from a serious drinking problem if their lives were fulfilling in terms of personal relationships, work, finances, and physical and emotional health (Klinger, 1977; Tucker, Vuchinich, & Harris, 1985) and if they could find satisfying activities to pursue as alternatives to drinking alcohol, such as hobbies, physical exercise, or enjoying particular snack foods and nonalcoholic beverages (Perri, 1985; Vaillant,1983, p. 190). Substance use thus depends on the totality and properties of an individual’s current goal pursuits, which we call the individual’s motivational structure and to measure which Klinger, Cox, and Blount (1995) developed the Motivational Structure Questionnaire (MSQ). Respondents taking the MSQ first describe the positive things in their lives that they want to achieve and the negative things that they want to get rid of, prevent, or avoid. They then use rating scales to characterize these goals and their relationships to them. Using the MSQ, we have identified ‘‘adaptive’’ and ‘‘maladaptive’’ motivational structures. In general, respondents with an adaptive motivational structure can identify positive goals to which they are committed, and they expect to derive emotional satisfaction from achieving them and feel optimistic about doing so. Respondents with a maladaptive motivational structure lack one or more of the components necessary for strong motivation. For instance, they might not expect to derive much emotional benefit from achieving their goals even if successful, or they may not perceive much chance of succeeding. As discussed later, we have found that adaptive and maladaptive motivational structures are related to various aspects of substance abuse, including patterns of use, problem recognition, motivation for change, and posttreatment functioning. We have recently adapted the MSQ to make it shorter and more user-friendly. This version is called the Personal Concerns Inventory (PCI; Cox & Klinger, 2000). The PCI is very similar in structure and concept to the MSQ, although the language and some of the scales have been modified and some of the scales are different. The purpose of this article is to introduce the PCI and to summarize some of the previous research on alcohol and other substance use that used this technique for assessing motivational structure.
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2. The Personal Concerns Inventory Respondents are introduced to the PCI by being told simply that we are interested in having them take an inventory of (a) the concerns that they have in different areas of their life and (b) the steps that they would like to take in order to resolve these concerns. The rationale for wanting to know about substance users’ concerns, they are told, is that it might be easier for them to change their use if their important concerns were resolved. Finally, we explain that by ‘‘concerns’’ we do not mean only problems. True, people might have concerns about unpleasant things that they want to ‘‘get rid of,’’ ‘‘prevent,’’ or ‘‘avoid,’’ but they might also have concerns about pleasant things that they want to ‘‘get,’’ ‘‘obtain,’’ or ‘‘accomplish.’’ Respondents are next presented with a list of 11 areas of life in which people often have important concerns. The areas are (1) Home and Household Matters; (2) Employment and Finances; (3) Partner, Family, and Relatives; (4) Friends and Acquaintances; (5) Love, Intimacy, and Sexual Matters, (6) Self-Changes; (7) Education and Training; (8) Health and Medical Matters; (9) Substance Use; (10) Spiritual Matters; and (11) Hobbies, Pastimes, and Recreation. A category called ‘‘Other Areas’’ is also listed, in case a respondent has a concern that is not related to one of the other 11 areas. Respondents are asked to read through the list, thinking carefully about any concerns that they might have in each of the areas. Next, respondents’ attention is called to the PCI Answer Booklet, a page from which is shown in Fig. 1. They are instructed to do three things. First, they are asked to briefly describe their important concerns in each area of life in the spaces provided at the left of the answer sheet. Although each area of life has spaces for as many as six concerns to be listed (front and backside of the answer sheet), a given respondent might have only one concern to describe (or no concern at all) in a particular area. In other areas of life, he or she might have two, three, or more concerns. Second, they are asked to describe what they would like to do in order to resolve each concern—that is, how they would like things to turn out. Third, respondents’ attention is directed to a set of rating scales (see Table 1). Each scale ranges from 0 (none at all) to 10 (the most that I can imagine). They are told to choose the number from each scale that best describes how they feel about each of the goals that they have described in Step 2. The completed questionnaire enables one to calculate motivational indices, from which one can draw each respondent’s motivational profile, which simply consists of an index plotted for each of the corresponding rating scales. The indices are either the ratings averaged for each scale across all of the life areas, or they are averaged for each life area separately, depending on the depth of analysis that is needed. In the latter case, there would be a profile for each of the areas in which the person named any concerns. More elaborate indices can also be calculated. For example, a respondent’s ‘‘Ambivalence’’ index takes into account both the Happiness and Unhappiness ratings for each concern. The index is calculated in such a way that as the difference between these two ratings decreases, the Ambivalence index increases. An example of a goal reflecting ambivalence is that of a respondent who wrote, ‘‘I know that I could benefit a lot from getting to know myself better, but I am afraid of what I would find out.’’ The Commitment/Expected Reward Correspondence index is calculated as the discrepancy between a respondent’s stated
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Fig. 1. A sample page from the answer sheet of the Personal Concerns Inventory (Cox & Klinger, 2000).
commitment to goal pursuits and a function of the product of his or her expected chances of succeeding times anticipated happiness if successful. High scores on this index reflect either strong commitments with low expected chances and/or low expected happiness, or they reflect low commitments with high expected chances and/or high expected happiness. For
Table 1 Rating scale from the Personal Concerns Inventory (Cox & Klinger, 2000) Importance: How important is it to me for things to turn out the way I want? How likely: How likely is it that things will turn out the way I want? Control: How much control do I have in causing things to turn out the way I want? What to do: Do I know what steps to take to make things turn out the way I want? Happiness: How much happiness would I get if things turn out the way I want? Unhappiness: Sometimes we feel unhappy, even if things turn out the way we want. How unhappy would I feel if things turn out the way I want? Commitment: How committed do I feel to make things turn out the way I want? When will it happen? How long will it take for things to turn out the way I want? Will alcohol/drugs help? Will using alcohol or drugs help things to turn out the way I want? Will alcohol/drugs interfere? Will using alcohol or drugs interfere with things turning out the way I want? All ratings are made on a 0 – 10 scale which ranges from 0 (not important at all) to 10 (very important).
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instance, one person said that he would like to get a good job (he expected that he would feel happy if he could and he felt committed to doing so), but he also said, ‘‘It is highly unlikely that I will get a job due to my lack of confidence.’’ The Composite Emotional Intensity index consists of the sum of the respondent’s Happiness and Unhappiness ratings for each concern averaged across all of the concerns. 2.1. Goal facilitation and interference The PCI Rating Scales are used to evaluate goal strivings individually. People’s goals, however, do not occur in isolation. Each goal that a person is striving to achieve can affect that person’s success with other goals. One goal might facilitate success with other goals, whereas another goal might interfere with them. Still another goal might have little or no effect on other goals. It is important to identify how an individual’s goals influence one another, because goal conflicts are associated with both poorer physical health and diminished subjective well-being (Emmons, 1999, p. 73ff; Michalak, Heidenreich, & Hoyer, in preparation). Two goals from one respondent that would facilitate each other were: ‘‘I want to stop using heroin’’ and ‘‘I would like to be able to educate my children about drugs and the harm they can cause, but I can’t do this while I am still using.’’ In order to identify patterns of facilitation and interference among a person’s different goals, we ask him or her to complete a Goal Matrix (designed after Emmons, 1986) in the following manner. After respondents have completed the PCI, they select and rank the five goals that they consider to be most important. In turn, they complete the Goal Matrix for these five goals by rating the degree to which they believe that each goal will help with or hinder the achievement of each of the other goals. A total score is then calculated for each goal to indicate its net pattern of facilitation of or interference with the person’s other important goals. When the Goal Matrix reveals goals that are expected to facilitate other goals (and both sets of goals are judged to be appropriate and realistic), it will likely be to the clients’ benefit to pursue them, and they are encouraged to do so. When, on the other hand, the Goal Matrix identifies goals that are expected to interfere with the attainment of other goals, the goal conflicts will need to be resolved. 2.2. Computer administration We have also developed a computer-administered version of the PCI, which is probably the most user-friendly version of all. Respondents interact with a computer as they describe their concerns and goals, rate their goals along 10 dimensions, and complete the Goal Matrix. The screens in the computer-administered PCI are presented in Appendix A. These show that the assessment process is the same as with the paper-and-pencil format. That is, respondents describe their concerns and corresponding goals in their own words, typing them into the computer. Respondents then describe each goal along the same dimensions as presented above for the paper-and-pencil version. Finally, the computer generates motivational profiles for each. When the PCI is used with substance abusers in treatment, additional details can be produced, such as a treatment-plan form for each person vis-a`-vis the person’s goals, and
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places for progress notes to be added about the achievement of these goals. Examples of these are shown on the screens in Appendix A. 2.3. Using the PCI clinically The PCI has proven to be quite useful in working clinically with clients with alcohol and other drug misuse. Besides providing counselors with an assessment of their clients’ motivation, the PCI provides a way to identify clients’ needs, screen them for admission to a particular treatment program, plan their intervention, set specific treatment goals, initiate case consultations with other professionals, and monitor clients’ progress. It can also be therapeutic for clients to complete the PCI, even if no additional use is made of the results. In fact, in their clinical work in both inpatient units and private practice, Schroer, Fuhrmann, and de Jong-Meyer (Schroer, 2001; Schroer, Fuhrmann, & de Jong-Meyer, in preparation) routinely have clients evaluate their current concerns (in the manner of the PCI) as a therapeutic intervention in and of itself. The version of the assessment that they use more closely resembles the MSQ (Klinger et al., 1995) than the newer PCI. Clients work in groups across several sessions, or in some cases, they finish the work individually in their free time or at home. In the group context, the first session generally involves completing Steps 1 and 2 (describing individual current concerns and the goal strivings that correspond to them). During a subsequent session, clients use the rating scales to evaluate their goal strivings, and they are also asked to complete the Goal Matrix. The purpose of the entire exercise is for clients themselves to assess their current concerns; however, the therapeutic benefits of doing so are apparent. A recent formal evaluation supports these impressions. Schroer (2001) directly compared the impact of the MSQ-based intervention with that of a group socialcompetence intervention that focused on self-assertiveness, as well as a group that used both approaches. All three treatment conditions supplemented standard treatment components and all produced statistically significant reductions in alcohol use as well as improvements in certain quality-of-life indicators. Although the MSQ-based conditions tended toward greater reductions in alcohol use, the differences as assessed in variance analyses fell short of significance. However, the percentages of patients abstinent on the 6-month follow-up were 29% of the two groups that used the MSQ-based procedure versus 12% of the social competency training group ( P < .05). Moreover, the self-assertiveness training required much more therapeutic involvement than did the MSQ-based procedure, which was administered in only three sessions. Systematic Motivational Counseling (SMC; Cox et al., in press; Cox & Klinger, in preparation; Cox, Klinger, & Blount, 1997) is an additional clinical technique based on the MSQ or the PCI technique. It uses treatment components that are selected for each client on the basis of that person’s motivational profile. Consider, for example, the person whose profile is shown as Example 1 in Appendix A. Striking features are the person’s low sense of control over goal achievements, not knowing what to do to achieve them, and being pessimistic about succeeding. At the same time, this person feels that the longed-for goals are highly important, would bring great happiness, and to which he or she feels more than average commitment. The counselor would aim to help a person like this gain a sense of
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excitement and self-efficacy about goal achievements. For example, the counseling could begin by trying to help the person find new incentives to pursue and enjoy, and by using goalladder exercises to help insure success in reaching longer-range goals. By contrast, another person might have unrealistically high expectations about goal achievements, expending fruitless effort trying to make things happen that eventually are unlikely to succeed. The counselor would likely try to help this person identify and resolve conflicts among the current goals and relinquish the ones that are unlikely to succeed or not bring emotional satisfaction. Evaluation of the SMC technique has shown that it brings improvements in clients’ motivational structure (from more maladaptive to more adaptive patterns), with concomitant improvements in their psychological functioning and use of drugs of abuse (Cox et al., in press). An evaluation was performed with traumatically brain-injured patients drawn from predominantly lower socioeconomic strata in Chicago. Between the beginning and the end of treatment (12 sessions over an average of 10 months), 47% of the drinkers in the SMC group became abstinent, as compared to 18% of the comparison group ( P < .05). Although the motivational changes were maintained over a follow-up interval averaging 9 months, enough SMC patients resumed drinking to make the follow-up comparison nonsignificant. By the follow-up, however, the SMC group had significantly reduced the number of substances they used more than was true of the comparison group. The results suggest that SMC should not be terminated abruptly but should be extended to occasional booster sessions, especially, as in the case of these patients, where their prognosis is poor on health and demographic grounds.
3. Research based on the PCI technique We have used the PCI technique in a variety of studies with both nonclinical participants and those who abuse substances. In these studies, we have assessed how motivational structure is related to patterns of use in the nonclinical samples, problem recognition and motivational for change in substance abusers, and long-term outcome in substance abusers following formal treatment. 3.1. University students’ motivational structure and alcohol use University students’ excessive use of alcohol is a problem of great concern in many countries worldwide. Cox et al. (2002), therefore, undertook a study to evaluate the motivational patterns that underlie students’ problematic drinking. We hypothesized that healthy, adaptive motivational patterns would be associated with lower alcohol consumption. If this were found true, it would underscore the importance of interventions for problemdrinking students that focus specifically on altering their motivational structure rather than only on their drinking behavior per se. Altogether, 370 participants were tested in four countries—the Czech Republic, Norway, the Netherlands, and the United States. Their mean age was 20.75 years (S.D. = 3.08; 66.1% females), and they drank a mean of 6.37 (S.D. = 8.62) standard drinks of alcohol per week. Participants in the four countries were administered the Khavari Alcohol Test (KAT, Khavari & Farber, 1978), the Short Michigan
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Alcoholism Screening Test (SMAST, Selzer, Vinokur, & van Rooijen, 1975), the Positive Affect Negative Affect Scale (PANAS, Watson, Clark, & Tellegen, 1988), and the MSQ. Factor analysis of the MSQ indices yielded a two-factor solution, one factor of which reflects an adaptive motivational structure; the other factor reflects a more maladaptive motivational structure. The adaptive factor had loadings on Active Role, Commitment, Joy, Sorrow, and Chances of Success. Participants with high scores on the this factor (a) actively pursued nondrinking goals, (b) had strong commitment to these goals, (c) expected strong joy from attaining the goals and considerable sorrow if they could not attain them, and (d) were optimistic about achieving them. The maladaptive factor loaded positively on Appetitive Action and Active Role, but negatively on Joy and Sorrow. That is, participants with high scores on this factor actively pursued goals, which they regarded as positive, even though they expected to experience little happiness from attaining their goals and little sorrow if they could not attain them. In addition, they pursued their goals whether or not they thought that they would actually succeed in attaining them. In other words, such participants seemed to approach goal strivings in an unrealistic manner and to have an attitude of indifference about achieving them. Further analyses revealed that participants’ country membership did not interact with either their demographic characteristics (age, gender), motivational structure (MSQ Factor 1, Factor 2), affect (PANAS positive affect, negative affect scores), or alcohol-related problems (SMAST) in determining the quantity and frequency of their alcohol consumption. Thus, country membership did not moderate relationships of the other variables with participants’ drinking behavior. However, assessing interactions of the MSQ variables, Factor 1 and Factor 2, with each of the other variables revealed that there was a highly significant interaction between MSQ Factor 1 and SMAST scores. It was clear, therefore, that the hypothesized relationship between adaptive motivation and alcohol consumption depended on the level of alcohol-related problems that participants had experienced. To identify the source of the interaction, participants were classified as those with ‘‘problems’’ or those with ‘‘no problems’’ on the basis of their SMAST scores, and the predictors of alcohol consumption were analyzed separately for the two groups. The regression analysis of participants without alcohol-related problems revealed two significant, unique predictors of alcohol use—gender and negative affect. Males and those with strong negative affect drank more than the other participants. For these participants, there were no relationships between drinking and motivational structure. On the other hand, among the participants with alcohol-related problems, adaptive motivation was a significant predictor of alcohol consumption after country membership and the demographic and affective variables had been controlled. In fact, 98% of the covariation between low adaptive motivation and high alcohol consumption was accounted for by participants’ level of alcohol-related problems, and the negative association between the two variables was highly consistent across the four countries. In summary, the results of this study revealed that as students’ alcohol-related problems increased, the strength of the inverse relationship between adaptive motivation and their alcohol consumption increased markedly. It would appear that having an adaptive motivational structure better enables students who have experienced problems with their drinking to alter it. By contrast, students, who as a result of dysfunctional motivational patterns are
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unable to gain sufficient emotional satisfaction from their goal pursuits in other areas of life, would seem to themselves to have less to lose by continuing their pattern of excessive drinking. In fact, these are probably the students who tend to rely on alcohol as a way to cope with their other life problems, which they are unable to resolve. 3.2. Comparing university students’ and alcohol abusers’ motivational structure Comparisons of alcoholic patients with demographically similar groups are hard to come by. The fall of communism in Czechoslovakia provided a brief window of opportunity to do this (Man, Stuchlı´kova´, & Klinger, 1998), because the leveling effects of communist policies on incomes and social services made it easier than later to find demographically similar groups, and these effects continued briefly after communism fell. Thus, the nonalcoholic group consisted of university students demographically very similar to the alcoholic group. All participants took a Czech version of the MSQ, the patients a few days before beginning treatment. Compared with the students, the patients not only reported 40% fewer goals and reported slightly less average commitment to them, but also reported less average commitment relative to the return they expected from goal-striving (return being expressed as a product of expected joy at goal-attainment times subjective probability of success). It is as if they needed greater expected reward to become committed to goals than was true of the students. This finding is consistent with other findings that alcoholic-preferring animals’ reward mechanisms convey less pleasure for a given size of reward (Crabbe, Belknap, & Buck, 1994; Zhou, Zhang, Lumeng, & Li, 1995) and that alcoholic humans evince less reward dependence (i.e., responsiveness to reward; Wills, Vaccaro, & McNamara, 1994). The parallel finding with the MSQ thus suggests that, whether for genetic reasons or as a result of chronic alcohol consumption (and very likely both), the motivational structure of alcoholic individuals is burdened by less ability to derive emotional satisfaction from attaining nonchemical goals, which would handicap these in competition with substance use. 3.3. Substance abusers’ problem recognition and motivation for change In addiction treatment and research, it has become popular to focus on substance abusers’ stage of change and to choose an intervention on the basis of the stage in which the abuser currently is (Prochaska & DiClemente, 1986, 1992). Accordingly, Cox, Blount, Bair, and Hosier (2000) sought to identify the motivational context in which substance abusers pass through the precontemplation, contemplation, action, and maintenance stages of change. Theoretically, we expected that substance abusers would be more ready for change if they anticipated finding emotional satisfaction through other areas of life as an alternative to using substances of abuse (Cox & Klinger, 1988, 1990). Therefore, readiness to change was predicted to be associated with adaptive motivational structures that would allow access to such alternative incentives. Participants were 77 consecutive admissions to an inpatient detoxification and rehabilitation program, all of whom had a diagnosis of substance abuse or dependence. They completed a short form of the MSQ (Klinger et al., 1995) and a short form of the University
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of Rhode Island Change Assessment (URICA, McConnaughy, Prochaska, & Velicer, 1983). Factor analysis of the URICA yielded two factors, which we called ‘‘Determination to Change’’ and ‘‘Problem Denial.’’ From factor analysis of the MSQ indices, two factors were derived, similar to the ‘‘adaptive’’ and ‘‘maladaptive’’ factors from the Cox et al. (2002) study with university students. Regarding relationships between the URICA and MSQ factors, regression analysis revealed that the adaptive motivational structure factor was a negative predictor of problem denial. In other words, participants who were adaptively motivated were more likely than others to acknowledge that there was a problem with their abuse of substances. The adaptive factor was also a positive predictor of determination to change; the adaptively motivated participants, that is, both recognized the problem and were motivated to change it. In conclusion, these results again support the premise that high motivation to change problematic substance use will arise from the perceived ability to access satisfying incentives in other areas of life (Cox & Klinger, 1988, 1990). 3.4. Motivational structure and treatment outcome Three investigations have probed the relationships between motivational structure and outcomes of treatment for alcoholism. In the first (Klinger & Cox, 1986), 60 alcoholic inpatients took the Interview Questionnaire, the immediate, very similar ancestor of the MSQ, within 8 days after intake. Outcome data (therapists’ judgments) available on 53 of them indicated that 26 could be considered to have achieved a successful treatment outcome and 27 not. The successful patients had more concerns that indicated their embracing of treatment and fewer concerns about avoiding alcohol. They also expected to attain their goals on average sooner than was true for the unsuccessful patients. Motivational structure thus showed a modest degree of predictiveness of immediate response to treatment. Another investigation (Glasner, Cox, Klinger, & Parish, 2001) cluster-analyzed MSQs of 202 alcoholic veterans entering a 30-day treatment program, identifying two clusters, which were significantly related to posttreatment drinking patterns assessed at 12-month follow-up. One cluster, which was characterized by a more active pursuit of attainable, nonchemical goals, reported more feelings of guilt upon relapse and was more likely to relapse in social drinking settings. The other cluster, marked by a more passive pursuit of nonchemical goals that were on average more often inappropriate or unrealistic, was more likely to drink heavily when they relapsed, tended more toward binge drinking, experienced stronger mood changes in response to drinking, and manifested more externalizing behaviors while drinking, such as illegal acts, arguing, and fighting. Here, again, a healthier motivational structure was associated with a different, socially less undesirable drinking outcome. Finally, a demonstration project to assess the utility of SMC (Cox et al., in press) found a significant association between changes in motivational structure as assessed by the MSQ and changes in substance use. The participants here were traumatically brain-injured, chemically dependent patients of rehabilitation programs. Over an average of 19 months from start of treatment, increased commitment to nonchemical goals, joy anticipated at goal attainment,
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sorrow anticipated if goals cannot be attained, and chances of success were associated with significant reductions in the number of substances used. Additionally, patients in SMC were significantly more often abstinent at the end of treatment than was true of a comparison group who received only standard rehabilitation. Although this difference partly dissipated during follow-up, the SMC patients reduced the number of substances used significantly more by the end of follow-up than was true of the comparison group. Their negative affect decreased significantly. They also manifested significant changes in motivational structure from start to follow-up, with significant increases in appetitive (approach) goals, active goal pursuit, anticipated joy upon goal attainment, anticipated sorrow if goals cannot be attained, and time available for beginning goal pursuit, and a significant decrease in unhappiness about attaining goals (i.e., ambivalence). There were no corresponding changes in the comparison group. The direction of the motivational changes by the SMC group consistently indicates improvements in their motivational structure. It thus appears that SMC was a useful method for modifying motivational structure, with associated changes in affect and substance use.
4. General conclusions The results of these investigations are generally consistent with the motivational model. Granted that the determinants of substance use are many and complex, their effects are funneled through a common motivational pathway, individuals’ expectancies regarding the eventual changes in affect produced by any given course of action. The MSQ and the closely related PCI are reliable and valid measures of individuals’ motivational structure, yielding scores that are associated with and predict everyday behaviors, including substance use. SMC, a treatment procedure built around the MSQ and PCI, shows promising signs of effectiveness in changing motivational structure and buttressing response to treatment.
Appendix A. Sample Screens from the Computer-Administered Personal Concerns Inventory (PCI; Cox & Klinger, 2000)
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References Cox, W. M., Blount, J. P., Bair, J., & Hosier, S. G. (2000). Motivational predictors of readiness to change chronic substance abuse. Addiction Research, 8, 121 – 128. Cox, W. M., Heinemann, A. W., Miranti, S. V., Schmidt, M., Klinger, E., & Blount, J. P. (in press). Outcomes of Systematic Motivational Counseling for substance use following traumatic brain injury. Journal of Addictive Diseases. Cox, W. M., & Klinger, E. (1988). A motivational model of alcohol use. Journal of Abnormal Psychology, 97(2), 168 – 180. Cox, W. M., & Klinger, E. (1990). Incentive motivation, affective change, and alcohol use: a model. In W. M. Cox (Ed.), Why people drink: parameters of alcohol as a reinforcer ( pp. 291 – 314). New York: Amereon Press. Cox, W. M., & Klinger, E. (2000). Personal Concerns Inventory. Copyrighted test available from W. Miles Cox.
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Cox, W. M., Klinger, E., & Blount, J. P. (1997). Systematic motivational counseling: a treatment manual. Copyrighted manual available from W. Miles Cox. Cox, W. M., & Klinger, E. (in preparation). Systematic Motivational Counseling. In W. M. Cox, & E. Klinger (Eds.), Handbook of motivational counseling: Motivating people for change. London: Wiley. Cox, W. M., Schippers, G. M., Klinger, E., Skutle, A., Stuchlikova, I., Man, F., King, A. L., & Inderhaug, R. (2002). Motivational structure and alcohol use of university students with consistency across four nations. Journal of Studies on Alcohol, 63(3), 280 – 285. Crabbe, J. C., Belknap, J. K., & Buck, K. J. (1994). Genetic animal models of alcohol and drug abuse. Science, 264, 1715 – 1723. Damasio, A. R. (1994). Descartes’ error. New York: Avon. Emmons, R. A. (1986). Personal strivings: an approach to personality and subjective well-being. Journal of Personality and Social Psychology, 51, 1058 – 1068. Emmons, R. A. (1999). The psychology of ultimate concerns: motivation and spirituality in personality. New York, NY, USA: Guilford Press. Glasner, S. V., Cox W. M., Klinger, E., & Parish, C. (2001). The relation of motivational structure to posttreatment drinking behavior in a male alcoholic sample. Paper presented at the annual meeting of the American Society of Addiction Medicine, Los Angeles, April 2001. Khavari, K., & Farber, P. (1978). The Khavari Alcohol Test. Journal of Studies on Alcohol, 39, 1525 – 1539. Klinger, E. (1977). Meaning and void: inner experience and the incentives in people’s lives. Minneapolis: University of Minnesota Press. Klinger, E., & Cox, W. M. (1986). Motivational predictors of alcoholics’ responses to inpatient treatment. Advances in Alcohol and Substance Abuse, 6(1), 35 – 44. Klinger, E., Cox, W. M., & Blount, J. P. (1995). Motivational Structure Questionnaire (MSQ). In J. P. Allen, & M. Columbus (Eds.), Assessing alcohol problems: a guide for clinicians and researchers (pp. 399 – 411). Washington, DC: U.S. Department of Health and Human Services. Loewenstein, G. F., Weber, E. U., Hsee, C. K., & Welch, N. (2001). Risk as feelings. Psychological Bulletin, 127, 267 – 286. Man, F., Stuchlı´kova´, I., & Klinger, E. (1998). Motivational structure of alcoholic and nonalcoholic Czech men. Psychological Reports, 82, 1091 – 1106. McConnaughy, E. A., Prochaska, J. O., & Velicer, W. F. (1983). Stages of change in psychotherapy: measurement and sample profiles. Psychotherapy: Theory, Research, and Practice, 20, 368 – 375. Mellers, B. A. (2000). Choice and the relative pleasure of consequences. Psychological Bulletin, 126, 910 – 924. Michalak, J., Heidenreich, T., & Hoyer, J. (in preparation). Goal conflicts: concepts, results and consequences for psychotherapeutic treatment. In W. M. Cox & E. Klinger (Eds.), Handbook of motivational counseling: motivating people for change. London: Wiley. Perri, M. G. (1985). Self-change strategies for the control of smoking, obesity, and problem drinking. In S. Shiffman, & T. A. Wills (Eds.), Coping and substance use (pp. 295 – 317). Orlando, FL: Academic Press. Prochaska, J. O., & DiClemente, C. C. (1986). Toward a comprehensive model of change. In W. R. Miller, & N. Heather (Eds.), Treating addictive behaviors: processes of change. New York: Plenum. Prochaska, J. O., & DiClemente, C. C. (1992). In search of how people change: applications to addictive behaviors. American Psychologist, 47(9), 1102 – 1114. Schroer, B. M. (2001). Zielaktivierung und Zielkla¨rung (ZAK): evaluation einer gruppentherapeutischen Kurzinterventon in der Entzugsbehandlung alkoholabha¨ngiger Menschen [Goal activation and goal clarification (ZAK): evaluation of a group therapeutic brief intervention in the addiction treatment of alcohol-dependent people]. Unpublished doctoral dissertation, Westfa¨llischen Wilhelms-Universita¨t Universita¨t, Mu¨nster, Germany. Schroer, B. M., Fuhrmann, A., & de Jong-Meyer, R. (in preparation). Systematic motivational counseling in groups: helping clients clarify and activate their goals. In W. M. Cox & E. Klinger (Eds.), Handbook of motivational counseling: motivating people for change. London: Wiley. Selzer, M. L., Vinokur, A., & van Rooijen, L. (1975). A self-administered Short Michigan Alcoholism Screening Test (SMAST). Journal of Studies on Alcohol, 36, 117 – 126.
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Tiffany, S. T. (1990). A cognitive model of drug urges and drug-use behavior; role of automatic and nonautomatic processes. Psychological Review, 97, 147 – 168. Tiffany, S. T. (1995). The role of cognitive factors in reactivity to drug cues. In D. C. Drummond (Ed.), Addictive behaviour: cue exposure theory and practice ( pp. 137 – 165). Chichester, England, UK: Wiley. Tucker, J. A., Vuchinich, R. E., & Harris, C. V. (1985). Determinants of substance abuse relapse. In M. Galizio, & S. A. Maisto (Eds.), Determinants of substance abuse: biological, psychological, and environmental factors (pp. 383 – 421). New York: Plenum. Vaillant, G. E. (1983). The natural course of alcoholism: causes, patterns, and paths to recovery. Cambridge, MA: Harvard University Press. Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: the PANAS scales. Journal of Personality and Social Psychology, 54(6), 1063 – 1070. Wills, T. A., Vaccaro, D., & McNamara, G. (1994). Novelty seeking, risk taking, and related constructs as predictors of adolescent substance use: an application of Cloninger’s theory. Journal of Substance Abuse, 6, 1 – 20. Zhou, F. C., Zhang, J. K., Lumeng, L., & Li, T.-K. (1995). Mesolimbic dopamine system in alcohol-preferring rats. Alcohol, 12, 403 – 412.
Motivational structure Relationships with substance use and processes of change W. Miles Coxa,*, Eric Klingerb a
School of Psychology, University of Wales, Bangor, Bangor, LL57 2DG Gwynedd, South Wales, UK b University of Minnesota, Morris, MN, USA
Abstract The motivational model stresses that substance misuse occurs in the context of the satisfactions and frustrations that people derive from incentives in other areas of their lives. Therefore, it is important to assess substance users’ motivational structure, that is, the patterns by which they strive for these incentives. This article presents a technique for assessing motivational structure, through which people’s motivation to use substances can better be understood. Results of studies using the assessment suggest the following: (a) Unless university students with alcohol-related problems have adaptive motivational structures, they are less able to control their drinking. (b) Alcohol abusers’ motivational structure leads them to experience less life satisfaction than does university students’ motivational structure. (c) In treatment, substance abusers with more adaptive motivation show less problem denial and more motivation for change than those with a more maladaptive pattern. (d) Alcohol abusers with healthier motivational structures show better immediate responses to treatment and have better long-term outcomes than those with less healthy patterns. (e) Systematic Motivational Counseling (SMC) improves motivational structure and reduces substance use. These results support the motivational model. D 2002 Elsevier Science Ltd. All rights reserved. Keywords: Motivational structure; Motivational assessment; Substance abuse; Alcohol abuse
1. Introduction The motivational model (Cox & Klinger, 1988, 1990) emphasizes that drinking alcohol and other substance use must be viewed in the context of the other incentives in people’s * Corresponding author. Tel.: +44-1248-38-3774; fax: +44-1248-38-2599. E-mail address: [email protected] (W.M. Cox). 0306-4603/02/$ – see front matter D 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 4 6 0 3 ( 0 2 ) 0 0 2 9 0 - 3
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lives. Nevertheless, the model takes into account a variety of factors that influence people’s motivations to drink alcohol and use other substances, including biological, psychological, environmental, and cultural variables. All of these factors contribute to people’s expectations about how using substances or not doing so will bring about changes in their affect. Within the model, the balance between people’s expected positive and negative affective consequences of using substances forms the final common pathway—the proximate link in the causal chain—that determines actual substance use. People’s decisions about substance use are not necessarily explicitly rational or even conscious (as others have also emphasized, Tiffany, 1990, 1995). Rather, they involve processes that intertwine rational and emotional components (e.g., Damasio, 1994; Loewenstein, Weber, Hsee, & Welch, 2001; Mellers, 2000). Nor are these decisions made in isolation from other life areas. An important influence on these substance-use decisions is the emotional satisfaction that the person derives from other areas of life. If a person is unable to find satisfaction from other positive incentives, he or she is more likely to turn to alcohol or other substances as a way to gain pleasure or find emotional relief. When the model was originally developed, there already was some evidence to support this view. For instance, it seemed that people would be more likely to recover from a serious drinking problem if their lives were fulfilling in terms of personal relationships, work, finances, and physical and emotional health (Klinger, 1977; Tucker, Vuchinich, & Harris, 1985) and if they could find satisfying activities to pursue as alternatives to drinking alcohol, such as hobbies, physical exercise, or enjoying particular snack foods and nonalcoholic beverages (Perri, 1985; Vaillant,1983, p. 190). Substance use thus depends on the totality and properties of an individual’s current goal pursuits, which we call the individual’s motivational structure and to measure which Klinger, Cox, and Blount (1995) developed the Motivational Structure Questionnaire (MSQ). Respondents taking the MSQ first describe the positive things in their lives that they want to achieve and the negative things that they want to get rid of, prevent, or avoid. They then use rating scales to characterize these goals and their relationships to them. Using the MSQ, we have identified ‘‘adaptive’’ and ‘‘maladaptive’’ motivational structures. In general, respondents with an adaptive motivational structure can identify positive goals to which they are committed, and they expect to derive emotional satisfaction from achieving them and feel optimistic about doing so. Respondents with a maladaptive motivational structure lack one or more of the components necessary for strong motivation. For instance, they might not expect to derive much emotional benefit from achieving their goals even if successful, or they may not perceive much chance of succeeding. As discussed later, we have found that adaptive and maladaptive motivational structures are related to various aspects of substance abuse, including patterns of use, problem recognition, motivation for change, and posttreatment functioning. We have recently adapted the MSQ to make it shorter and more user-friendly. This version is called the Personal Concerns Inventory (PCI; Cox & Klinger, 2000). The PCI is very similar in structure and concept to the MSQ, although the language and some of the scales have been modified and some of the scales are different. The purpose of this article is to introduce the PCI and to summarize some of the previous research on alcohol and other substance use that used this technique for assessing motivational structure.
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2. The Personal Concerns Inventory Respondents are introduced to the PCI by being told simply that we are interested in having them take an inventory of (a) the concerns that they have in different areas of their life and (b) the steps that they would like to take in order to resolve these concerns. The rationale for wanting to know about substance users’ concerns, they are told, is that it might be easier for them to change their use if their important concerns were resolved. Finally, we explain that by ‘‘concerns’’ we do not mean only problems. True, people might have concerns about unpleasant things that they want to ‘‘get rid of,’’ ‘‘prevent,’’ or ‘‘avoid,’’ but they might also have concerns about pleasant things that they want to ‘‘get,’’ ‘‘obtain,’’ or ‘‘accomplish.’’ Respondents are next presented with a list of 11 areas of life in which people often have important concerns. The areas are (1) Home and Household Matters; (2) Employment and Finances; (3) Partner, Family, and Relatives; (4) Friends and Acquaintances; (5) Love, Intimacy, and Sexual Matters, (6) Self-Changes; (7) Education and Training; (8) Health and Medical Matters; (9) Substance Use; (10) Spiritual Matters; and (11) Hobbies, Pastimes, and Recreation. A category called ‘‘Other Areas’’ is also listed, in case a respondent has a concern that is not related to one of the other 11 areas. Respondents are asked to read through the list, thinking carefully about any concerns that they might have in each of the areas. Next, respondents’ attention is called to the PCI Answer Booklet, a page from which is shown in Fig. 1. They are instructed to do three things. First, they are asked to briefly describe their important concerns in each area of life in the spaces provided at the left of the answer sheet. Although each area of life has spaces for as many as six concerns to be listed (front and backside of the answer sheet), a given respondent might have only one concern to describe (or no concern at all) in a particular area. In other areas of life, he or she might have two, three, or more concerns. Second, they are asked to describe what they would like to do in order to resolve each concern—that is, how they would like things to turn out. Third, respondents’ attention is directed to a set of rating scales (see Table 1). Each scale ranges from 0 (none at all) to 10 (the most that I can imagine). They are told to choose the number from each scale that best describes how they feel about each of the goals that they have described in Step 2. The completed questionnaire enables one to calculate motivational indices, from which one can draw each respondent’s motivational profile, which simply consists of an index plotted for each of the corresponding rating scales. The indices are either the ratings averaged for each scale across all of the life areas, or they are averaged for each life area separately, depending on the depth of analysis that is needed. In the latter case, there would be a profile for each of the areas in which the person named any concerns. More elaborate indices can also be calculated. For example, a respondent’s ‘‘Ambivalence’’ index takes into account both the Happiness and Unhappiness ratings for each concern. The index is calculated in such a way that as the difference between these two ratings decreases, the Ambivalence index increases. An example of a goal reflecting ambivalence is that of a respondent who wrote, ‘‘I know that I could benefit a lot from getting to know myself better, but I am afraid of what I would find out.’’ The Commitment/Expected Reward Correspondence index is calculated as the discrepancy between a respondent’s stated
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Fig. 1. A sample page from the answer sheet of the Personal Concerns Inventory (Cox & Klinger, 2000).
commitment to goal pursuits and a function of the product of his or her expected chances of succeeding times anticipated happiness if successful. High scores on this index reflect either strong commitments with low expected chances and/or low expected happiness, or they reflect low commitments with high expected chances and/or high expected happiness. For
Table 1 Rating scale from the Personal Concerns Inventory (Cox & Klinger, 2000) Importance: How important is it to me for things to turn out the way I want? How likely: How likely is it that things will turn out the way I want? Control: How much control do I have in causing things to turn out the way I want? What to do: Do I know what steps to take to make things turn out the way I want? Happiness: How much happiness would I get if things turn out the way I want? Unhappiness: Sometimes we feel unhappy, even if things turn out the way we want. How unhappy would I feel if things turn out the way I want? Commitment: How committed do I feel to make things turn out the way I want? When will it happen? How long will it take for things to turn out the way I want? Will alcohol/drugs help? Will using alcohol or drugs help things to turn out the way I want? Will alcohol/drugs interfere? Will using alcohol or drugs interfere with things turning out the way I want? All ratings are made on a 0 – 10 scale which ranges from 0 (not important at all) to 10 (very important).
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instance, one person said that he would like to get a good job (he expected that he would feel happy if he could and he felt committed to doing so), but he also said, ‘‘It is highly unlikely that I will get a job due to my lack of confidence.’’ The Composite Emotional Intensity index consists of the sum of the respondent’s Happiness and Unhappiness ratings for each concern averaged across all of the concerns. 2.1. Goal facilitation and interference The PCI Rating Scales are used to evaluate goal strivings individually. People’s goals, however, do not occur in isolation. Each goal that a person is striving to achieve can affect that person’s success with other goals. One goal might facilitate success with other goals, whereas another goal might interfere with them. Still another goal might have little or no effect on other goals. It is important to identify how an individual’s goals influence one another, because goal conflicts are associated with both poorer physical health and diminished subjective well-being (Emmons, 1999, p. 73ff; Michalak, Heidenreich, & Hoyer, in preparation). Two goals from one respondent that would facilitate each other were: ‘‘I want to stop using heroin’’ and ‘‘I would like to be able to educate my children about drugs and the harm they can cause, but I can’t do this while I am still using.’’ In order to identify patterns of facilitation and interference among a person’s different goals, we ask him or her to complete a Goal Matrix (designed after Emmons, 1986) in the following manner. After respondents have completed the PCI, they select and rank the five goals that they consider to be most important. In turn, they complete the Goal Matrix for these five goals by rating the degree to which they believe that each goal will help with or hinder the achievement of each of the other goals. A total score is then calculated for each goal to indicate its net pattern of facilitation of or interference with the person’s other important goals. When the Goal Matrix reveals goals that are expected to facilitate other goals (and both sets of goals are judged to be appropriate and realistic), it will likely be to the clients’ benefit to pursue them, and they are encouraged to do so. When, on the other hand, the Goal Matrix identifies goals that are expected to interfere with the attainment of other goals, the goal conflicts will need to be resolved. 2.2. Computer administration We have also developed a computer-administered version of the PCI, which is probably the most user-friendly version of all. Respondents interact with a computer as they describe their concerns and goals, rate their goals along 10 dimensions, and complete the Goal Matrix. The screens in the computer-administered PCI are presented in Appendix A. These show that the assessment process is the same as with the paper-and-pencil format. That is, respondents describe their concerns and corresponding goals in their own words, typing them into the computer. Respondents then describe each goal along the same dimensions as presented above for the paper-and-pencil version. Finally, the computer generates motivational profiles for each. When the PCI is used with substance abusers in treatment, additional details can be produced, such as a treatment-plan form for each person vis-a`-vis the person’s goals, and
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places for progress notes to be added about the achievement of these goals. Examples of these are shown on the screens in Appendix A. 2.3. Using the PCI clinically The PCI has proven to be quite useful in working clinically with clients with alcohol and other drug misuse. Besides providing counselors with an assessment of their clients’ motivation, the PCI provides a way to identify clients’ needs, screen them for admission to a particular treatment program, plan their intervention, set specific treatment goals, initiate case consultations with other professionals, and monitor clients’ progress. It can also be therapeutic for clients to complete the PCI, even if no additional use is made of the results. In fact, in their clinical work in both inpatient units and private practice, Schroer, Fuhrmann, and de Jong-Meyer (Schroer, 2001; Schroer, Fuhrmann, & de Jong-Meyer, in preparation) routinely have clients evaluate their current concerns (in the manner of the PCI) as a therapeutic intervention in and of itself. The version of the assessment that they use more closely resembles the MSQ (Klinger et al., 1995) than the newer PCI. Clients work in groups across several sessions, or in some cases, they finish the work individually in their free time or at home. In the group context, the first session generally involves completing Steps 1 and 2 (describing individual current concerns and the goal strivings that correspond to them). During a subsequent session, clients use the rating scales to evaluate their goal strivings, and they are also asked to complete the Goal Matrix. The purpose of the entire exercise is for clients themselves to assess their current concerns; however, the therapeutic benefits of doing so are apparent. A recent formal evaluation supports these impressions. Schroer (2001) directly compared the impact of the MSQ-based intervention with that of a group socialcompetence intervention that focused on self-assertiveness, as well as a group that used both approaches. All three treatment conditions supplemented standard treatment components and all produced statistically significant reductions in alcohol use as well as improvements in certain quality-of-life indicators. Although the MSQ-based conditions tended toward greater reductions in alcohol use, the differences as assessed in variance analyses fell short of significance. However, the percentages of patients abstinent on the 6-month follow-up were 29% of the two groups that used the MSQ-based procedure versus 12% of the social competency training group ( P < .05). Moreover, the self-assertiveness training required much more therapeutic involvement than did the MSQ-based procedure, which was administered in only three sessions. Systematic Motivational Counseling (SMC; Cox et al., in press; Cox & Klinger, in preparation; Cox, Klinger, & Blount, 1997) is an additional clinical technique based on the MSQ or the PCI technique. It uses treatment components that are selected for each client on the basis of that person’s motivational profile. Consider, for example, the person whose profile is shown as Example 1 in Appendix A. Striking features are the person’s low sense of control over goal achievements, not knowing what to do to achieve them, and being pessimistic about succeeding. At the same time, this person feels that the longed-for goals are highly important, would bring great happiness, and to which he or she feels more than average commitment. The counselor would aim to help a person like this gain a sense of
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excitement and self-efficacy about goal achievements. For example, the counseling could begin by trying to help the person find new incentives to pursue and enjoy, and by using goalladder exercises to help insure success in reaching longer-range goals. By contrast, another person might have unrealistically high expectations about goal achievements, expending fruitless effort trying to make things happen that eventually are unlikely to succeed. The counselor would likely try to help this person identify and resolve conflicts among the current goals and relinquish the ones that are unlikely to succeed or not bring emotional satisfaction. Evaluation of the SMC technique has shown that it brings improvements in clients’ motivational structure (from more maladaptive to more adaptive patterns), with concomitant improvements in their psychological functioning and use of drugs of abuse (Cox et al., in press). An evaluation was performed with traumatically brain-injured patients drawn from predominantly lower socioeconomic strata in Chicago. Between the beginning and the end of treatment (12 sessions over an average of 10 months), 47% of the drinkers in the SMC group became abstinent, as compared to 18% of the comparison group ( P < .05). Although the motivational changes were maintained over a follow-up interval averaging 9 months, enough SMC patients resumed drinking to make the follow-up comparison nonsignificant. By the follow-up, however, the SMC group had significantly reduced the number of substances they used more than was true of the comparison group. The results suggest that SMC should not be terminated abruptly but should be extended to occasional booster sessions, especially, as in the case of these patients, where their prognosis is poor on health and demographic grounds.
3. Research based on the PCI technique We have used the PCI technique in a variety of studies with both nonclinical participants and those who abuse substances. In these studies, we have assessed how motivational structure is related to patterns of use in the nonclinical samples, problem recognition and motivational for change in substance abusers, and long-term outcome in substance abusers following formal treatment. 3.1. University students’ motivational structure and alcohol use University students’ excessive use of alcohol is a problem of great concern in many countries worldwide. Cox et al. (2002), therefore, undertook a study to evaluate the motivational patterns that underlie students’ problematic drinking. We hypothesized that healthy, adaptive motivational patterns would be associated with lower alcohol consumption. If this were found true, it would underscore the importance of interventions for problemdrinking students that focus specifically on altering their motivational structure rather than only on their drinking behavior per se. Altogether, 370 participants were tested in four countries—the Czech Republic, Norway, the Netherlands, and the United States. Their mean age was 20.75 years (S.D. = 3.08; 66.1% females), and they drank a mean of 6.37 (S.D. = 8.62) standard drinks of alcohol per week. Participants in the four countries were administered the Khavari Alcohol Test (KAT, Khavari & Farber, 1978), the Short Michigan
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Alcoholism Screening Test (SMAST, Selzer, Vinokur, & van Rooijen, 1975), the Positive Affect Negative Affect Scale (PANAS, Watson, Clark, & Tellegen, 1988), and the MSQ. Factor analysis of the MSQ indices yielded a two-factor solution, one factor of which reflects an adaptive motivational structure; the other factor reflects a more maladaptive motivational structure. The adaptive factor had loadings on Active Role, Commitment, Joy, Sorrow, and Chances of Success. Participants with high scores on the this factor (a) actively pursued nondrinking goals, (b) had strong commitment to these goals, (c) expected strong joy from attaining the goals and considerable sorrow if they could not attain them, and (d) were optimistic about achieving them. The maladaptive factor loaded positively on Appetitive Action and Active Role, but negatively on Joy and Sorrow. That is, participants with high scores on this factor actively pursued goals, which they regarded as positive, even though they expected to experience little happiness from attaining their goals and little sorrow if they could not attain them. In addition, they pursued their goals whether or not they thought that they would actually succeed in attaining them. In other words, such participants seemed to approach goal strivings in an unrealistic manner and to have an attitude of indifference about achieving them. Further analyses revealed that participants’ country membership did not interact with either their demographic characteristics (age, gender), motivational structure (MSQ Factor 1, Factor 2), affect (PANAS positive affect, negative affect scores), or alcohol-related problems (SMAST) in determining the quantity and frequency of their alcohol consumption. Thus, country membership did not moderate relationships of the other variables with participants’ drinking behavior. However, assessing interactions of the MSQ variables, Factor 1 and Factor 2, with each of the other variables revealed that there was a highly significant interaction between MSQ Factor 1 and SMAST scores. It was clear, therefore, that the hypothesized relationship between adaptive motivation and alcohol consumption depended on the level of alcohol-related problems that participants had experienced. To identify the source of the interaction, participants were classified as those with ‘‘problems’’ or those with ‘‘no problems’’ on the basis of their SMAST scores, and the predictors of alcohol consumption were analyzed separately for the two groups. The regression analysis of participants without alcohol-related problems revealed two significant, unique predictors of alcohol use—gender and negative affect. Males and those with strong negative affect drank more than the other participants. For these participants, there were no relationships between drinking and motivational structure. On the other hand, among the participants with alcohol-related problems, adaptive motivation was a significant predictor of alcohol consumption after country membership and the demographic and affective variables had been controlled. In fact, 98% of the covariation between low adaptive motivation and high alcohol consumption was accounted for by participants’ level of alcohol-related problems, and the negative association between the two variables was highly consistent across the four countries. In summary, the results of this study revealed that as students’ alcohol-related problems increased, the strength of the inverse relationship between adaptive motivation and their alcohol consumption increased markedly. It would appear that having an adaptive motivational structure better enables students who have experienced problems with their drinking to alter it. By contrast, students, who as a result of dysfunctional motivational patterns are
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unable to gain sufficient emotional satisfaction from their goal pursuits in other areas of life, would seem to themselves to have less to lose by continuing their pattern of excessive drinking. In fact, these are probably the students who tend to rely on alcohol as a way to cope with their other life problems, which they are unable to resolve. 3.2. Comparing university students’ and alcohol abusers’ motivational structure Comparisons of alcoholic patients with demographically similar groups are hard to come by. The fall of communism in Czechoslovakia provided a brief window of opportunity to do this (Man, Stuchlı´kova´, & Klinger, 1998), because the leveling effects of communist policies on incomes and social services made it easier than later to find demographically similar groups, and these effects continued briefly after communism fell. Thus, the nonalcoholic group consisted of university students demographically very similar to the alcoholic group. All participants took a Czech version of the MSQ, the patients a few days before beginning treatment. Compared with the students, the patients not only reported 40% fewer goals and reported slightly less average commitment to them, but also reported less average commitment relative to the return they expected from goal-striving (return being expressed as a product of expected joy at goal-attainment times subjective probability of success). It is as if they needed greater expected reward to become committed to goals than was true of the students. This finding is consistent with other findings that alcoholic-preferring animals’ reward mechanisms convey less pleasure for a given size of reward (Crabbe, Belknap, & Buck, 1994; Zhou, Zhang, Lumeng, & Li, 1995) and that alcoholic humans evince less reward dependence (i.e., responsiveness to reward; Wills, Vaccaro, & McNamara, 1994). The parallel finding with the MSQ thus suggests that, whether for genetic reasons or as a result of chronic alcohol consumption (and very likely both), the motivational structure of alcoholic individuals is burdened by less ability to derive emotional satisfaction from attaining nonchemical goals, which would handicap these in competition with substance use. 3.3. Substance abusers’ problem recognition and motivation for change In addiction treatment and research, it has become popular to focus on substance abusers’ stage of change and to choose an intervention on the basis of the stage in which the abuser currently is (Prochaska & DiClemente, 1986, 1992). Accordingly, Cox, Blount, Bair, and Hosier (2000) sought to identify the motivational context in which substance abusers pass through the precontemplation, contemplation, action, and maintenance stages of change. Theoretically, we expected that substance abusers would be more ready for change if they anticipated finding emotional satisfaction through other areas of life as an alternative to using substances of abuse (Cox & Klinger, 1988, 1990). Therefore, readiness to change was predicted to be associated with adaptive motivational structures that would allow access to such alternative incentives. Participants were 77 consecutive admissions to an inpatient detoxification and rehabilitation program, all of whom had a diagnosis of substance abuse or dependence. They completed a short form of the MSQ (Klinger et al., 1995) and a short form of the University
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of Rhode Island Change Assessment (URICA, McConnaughy, Prochaska, & Velicer, 1983). Factor analysis of the URICA yielded two factors, which we called ‘‘Determination to Change’’ and ‘‘Problem Denial.’’ From factor analysis of the MSQ indices, two factors were derived, similar to the ‘‘adaptive’’ and ‘‘maladaptive’’ factors from the Cox et al. (2002) study with university students. Regarding relationships between the URICA and MSQ factors, regression analysis revealed that the adaptive motivational structure factor was a negative predictor of problem denial. In other words, participants who were adaptively motivated were more likely than others to acknowledge that there was a problem with their abuse of substances. The adaptive factor was also a positive predictor of determination to change; the adaptively motivated participants, that is, both recognized the problem and were motivated to change it. In conclusion, these results again support the premise that high motivation to change problematic substance use will arise from the perceived ability to access satisfying incentives in other areas of life (Cox & Klinger, 1988, 1990). 3.4. Motivational structure and treatment outcome Three investigations have probed the relationships between motivational structure and outcomes of treatment for alcoholism. In the first (Klinger & Cox, 1986), 60 alcoholic inpatients took the Interview Questionnaire, the immediate, very similar ancestor of the MSQ, within 8 days after intake. Outcome data (therapists’ judgments) available on 53 of them indicated that 26 could be considered to have achieved a successful treatment outcome and 27 not. The successful patients had more concerns that indicated their embracing of treatment and fewer concerns about avoiding alcohol. They also expected to attain their goals on average sooner than was true for the unsuccessful patients. Motivational structure thus showed a modest degree of predictiveness of immediate response to treatment. Another investigation (Glasner, Cox, Klinger, & Parish, 2001) cluster-analyzed MSQs of 202 alcoholic veterans entering a 30-day treatment program, identifying two clusters, which were significantly related to posttreatment drinking patterns assessed at 12-month follow-up. One cluster, which was characterized by a more active pursuit of attainable, nonchemical goals, reported more feelings of guilt upon relapse and was more likely to relapse in social drinking settings. The other cluster, marked by a more passive pursuit of nonchemical goals that were on average more often inappropriate or unrealistic, was more likely to drink heavily when they relapsed, tended more toward binge drinking, experienced stronger mood changes in response to drinking, and manifested more externalizing behaviors while drinking, such as illegal acts, arguing, and fighting. Here, again, a healthier motivational structure was associated with a different, socially less undesirable drinking outcome. Finally, a demonstration project to assess the utility of SMC (Cox et al., in press) found a significant association between changes in motivational structure as assessed by the MSQ and changes in substance use. The participants here were traumatically brain-injured, chemically dependent patients of rehabilitation programs. Over an average of 19 months from start of treatment, increased commitment to nonchemical goals, joy anticipated at goal attainment,
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sorrow anticipated if goals cannot be attained, and chances of success were associated with significant reductions in the number of substances used. Additionally, patients in SMC were significantly more often abstinent at the end of treatment than was true of a comparison group who received only standard rehabilitation. Although this difference partly dissipated during follow-up, the SMC patients reduced the number of substances used significantly more by the end of follow-up than was true of the comparison group. Their negative affect decreased significantly. They also manifested significant changes in motivational structure from start to follow-up, with significant increases in appetitive (approach) goals, active goal pursuit, anticipated joy upon goal attainment, anticipated sorrow if goals cannot be attained, and time available for beginning goal pursuit, and a significant decrease in unhappiness about attaining goals (i.e., ambivalence). There were no corresponding changes in the comparison group. The direction of the motivational changes by the SMC group consistently indicates improvements in their motivational structure. It thus appears that SMC was a useful method for modifying motivational structure, with associated changes in affect and substance use.
4. General conclusions The results of these investigations are generally consistent with the motivational model. Granted that the determinants of substance use are many and complex, their effects are funneled through a common motivational pathway, individuals’ expectancies regarding the eventual changes in affect produced by any given course of action. The MSQ and the closely related PCI are reliable and valid measures of individuals’ motivational structure, yielding scores that are associated with and predict everyday behaviors, including substance use. SMC, a treatment procedure built around the MSQ and PCI, shows promising signs of effectiveness in changing motivational structure and buttressing response to treatment.
Appendix A. Sample Screens from the Computer-Administered Personal Concerns Inventory (PCI; Cox & Klinger, 2000)
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