So , who wants to be here ? A survey of patients ’ motives for seeking psychotherapy services and their expected un-involvement in therapy

Results: While most patients appear to start therapy on their own volition (76%), a significant proportion also feel compelled to seek services because of external pressures (38%). The more patients were motivated by external forces to seek treatment, the more disinclined they were to become engaged in the work of therapy; greater endorsement of internal motives was associated with reduced unwillingness to work in therapy.


INTRODUCTION
Psychotherapy can be hard work, and the patient's motivation to seek treatment may be a critical factor in their capacity to engage in, and profit from, such work.Indeed, positive and lasting change may be more likely to occur when a patient feels personally invested -as opposed to feeling coerced -and actively engaged in the therapeutic process [1][2][3].Self-determination theory [4] has gained considerable attention in the literature as a conceptualization of motivation that is applicable to psychotherapy.This perspective suggests that motivation, at a basic level, can be classified as autonomous or controlled [5].Behaviours that are autonomously (i.e.intrinsically) motivated are experienced as self-initiated and personally endorsed.Controlled (i.e. Archives of Psychiatry and Psychotherapy, 2018; 3: 26-30 extrinsic) motivation is experienced when an individual feels pressured to engage in a behaviour because of outside forces.
Ryan and colleagues [5] argue that internally motivated patients should be more willing to commit to the tasks of therapy and tolerate working through the inherent, but necessary, challenges of the psychotherapeutic endeavour.Some research suggests that a patient's motivation is related to the intent to pursue therapy [6], external judges' ratings of patients' working capacity [7], patients' collaboration in therapy [8] and positive outcomes [9].Yet empirical investigations of the influence of patients' motivations on their expected involvement in the therapeutic process remain scarce.
The present study surveyed psychiatric outpatients regarding their motives (internal vs. external) for seeking psychotherapy and their expected involvement, or lack of involvement, in the work of therapy in order to help begin addressing this gap in the literature.The study was not developed to test specific hypotheses, but instead to conduct a preliminary survey that could provide some insight into the issue of patient motivations and expectations, and set possible directions for more formal and comprehensive investigations in the future.

METHOD
Participants were recruited from three psychiatric outpatient clinics offering psychotherapy and pharmacotherapy in two provinces of Canada.At each clinic, all consecutive new patients over the age of 17, with English language proficiency, and who provided informed consent, were included.Selection criteria for study participation were not imposed in order to have the most clinically representative sample possible.The total sample included 343 patients.Information about diagnoses was not collected.Participants completed a brief survey consisting of two items enquiring about their motives for seeking therapy and six items regarding their expectations for non-involvement in therapy (Table 1).The Brief Symptom Inventory-18 [10] was then used for assessment of general psychiatric distress and the Desirability scale of the Personality Research Form [11] for assessment of social desirability.Descriptive statistics were used to characterize responses to the survey items.Partial correlations were calculated between responses to the motivation items and the non-involvement items, controlling for the potentially confounding influence of age, general psychiatric distress and social desirability.As shown in Table 1, three-quarters (75.5%) of respondents indicated an internal motive for seeking therapy, whereas slightly more than one-third (37.7%) reported being motivated by external forces (because respondents can be motivated by both factors, the total percentage is higher than 100%).
Regarding expectations of becoming uninvolved in therapy, 17.6% of respondents indicated that they would likely quit if therapy became too difficult, 16.9% would quit if therapy became boring or tedious, 23.3% would prefer to just take medications, 9.3% indicated that they thought the therapist should do most of the work in therapy, 16.6% reported feeling unprepared to make major life changes, and 18.9% believed that stress caused by therapy would indicate that it is not the right treatment for them.
Table 2 shows the partial correlations between motives for therapy and expectations of disengagement from the work of therapy.Findings demonstrated that greater endorsement of an external influence behind seeking treatment was significantly associated with all of the non-involvement items, indicating higher expectations of not becoming involved in the work of therapy.Yet, even among those patients who strongly endorsed an externally motivating factor (responded 'strongly agree'), upwards of 20% had low expectations of not working in therapy (see Table 3).Conversely, greater endorsement of an internal motive for seeking treatment was significantly and negatively associated with 4 of the 6 non-involvement items, reflecting lower expectations of not working in therapy.Among patients with high internal motivation (responded 'strongly agree'), very few presented with high expectations of not becoming involved in the work of therapy (see Table 3).

Discussion
Although motivation for therapy has long been recognized as a critical factor for the success of psychotherapy, relatively few studies have investigated this topic with regard to patients' expectations for involvement in treatment.
The findings of the present study revealed that the more patients were motivated by external forces to seek treatment, the more disinclined they were to become engaged in the work of therapy.Such expected un-involvement in therapy decreased with greater endorsement of an internal motive for pursuing treatment.These findings are consistent with and add to those derived from the seminal work of Pelletier and colleagues [6], as well as more recent findings demonstrating that intrinsically motivated patients are more likely to report an internal locus of control, greater self-esteem and positive mood, and more positive experiences in therapy [8,12,13].
Considered within the framework of self-determination theory, for individuals to develop positive expectations about therapeutic engagement, they must perceive that they are exercising an autonomous decision to approach treatment [4].Patients motivated by intrinsic forces are more likely to invest in the assimilation of learning and behavioural change that can lead to positive outcomes [3].Conversely, patients who lack this perspective -feeling influenced by external pressures such as demands of significant others -are more likely to experience ambivalence about commencing therapy, diminished commitment to persisting with treatment, and instability throughout the therapeutic process because they have not internalized a personal accountability for the process of change itself.Successful outcomes are more unlikely in such circumstances.
The findings of the present study should be considered in the context of various limitations.This includes the use of survey items that were developed for the specific purpose of the study (in order to conduct the survey in a feasible manner in a busy clinical setting) rather than using more comprehensive and validated measures of the constructs of interest.This limited our perspectives of the types of motivations and expectations that could have potentially been assessed.It would be interesting to consider different types of external pressures that patients perceive as the source of motivation for treatment.A related assessment issue is that this study addressed patients' expectations from a pessimistic perspective only.While such an approach is innovative and contributes unique findings to the literature, it would be desirable to consider both optimistic and pessimistic expectancies simultaneously.The study was also limited by an absence of diagnostic information for the participants, thus potentially constraining our ability to clearly generalize our findings to specific populations or presenting issues.
Despite their preliminary nature, the relevance of the findings from the present study is notable, given the research evidence substantiating the considerable influence that patient motivations and expectations have on the success of psychotherapy [14,15].The findings suggest that patients who are more externally motivated may be particularly doubtful about the relevance and/or success of therapy and may require more persuasion that treatment can indeed be of benefit to them.Once patients feel personally invested in therapy, they are more likely to endure some of the challenges involved and work constructively in treatment to achieve a better state of functioning.

Table 2 .
Partial correlations between motivations for therapy and expectations for un-involvement in therapy a a Controlling for age, general psychiatric distress and social desirability.*p ≤ 0.05; ** p ≤ 0.01; *** p ≤ 0.001

Table 3 .
Motivations for therapy and expectations for un-involvement in therapy