Motivation and emotion/Book/2010/Depression and motivation

Depression and motivation

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This page is part of the Motivation and emotion textbook. See also: Guidelines.

What is motivation?

This chapter focuses on depression and its relationship with motivation.

Motivation is the initiation, direction, intensity and persistence of behaviour. Motivation is having a desire and willingness to do something and it is a state that is dynamic and temporal (Brown, 2007). The word motivation comes from the Latin word meaning ‘to move’. Therefore, motivation invigorates and energises behaviour (Wright & Wiediger, 2007).

Motivational psychology examines many different aspects of behaviour including choice, latency, intensity, persistence and reaction to the behaviour (Weiner, 1992).

Humans often ask ‘why?’ These are questions about motivation. The search for answers to these questions is part of the study of motivation (Weiner, 1992). The concept of motivation appears across a myriad of different areas in psychology. Motivation lies at the core of psychological concepts. For example, we need to be motivated in order to learn, the child needs to master innate motivation to assist in their development, we are motivated to select informative stimuli from the environment in order to perceive and cognitively comprehend incoming information and we need to be motivated to benefit optimally from psychological treatment and interventions (Weiner). This chapter examines the study of motivation and psychological disorders by specifically examining motivation and depression.

‘Why’ Questions

Studies of motivation are based on the central question:
Why do people initiate, choose or persist in specific actions in certain circumstances?

Everyday Examples of ‘Why’ Questions:
“Why does someone not eat the meal you prepared for them?”

Are they not hungry?
Do they not like the food?
Do they not like you?

“Why does the university student fail their exam?”

Does the student lack the ability?
Did they not study enough?
Were the questions too hard?

(Weiner, 1992)

Activity
How motivated are you?

Try this self motivation assessment tool

Depression

Everyone has days when they experience a depressed mood.

Every one of us has felt depressed at some point in our lives – we feel flat, small exertions of energy make us feel exhausted and we lose our desire to do anything. However, for most of us this is a short-lived and infrequent experience. For those with depression it is the opposite – recurrent, pervasive and deeply disturbing. As depression progresses to a more severe form, the erosion of motivation increases and a complete loss of interest in the surrounding world transpires (Seligman, 1991).

"That's the thing about depression: a human being can survive almost anything, as long as she sees the end in sight. But depression is so insidious, and it compounds daily, that it's impossible to ever see the end. The fog is like a cage without a key."
Elizabeth Wurtzel from the book Prozac Nation

In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, Major Depressive Disorder is characterised by one or more major depressive episodes. An episode is classified as a period of at least two weeks during which there is either a depressed mood or a loss of interest or pleasure. This represents a change from previous functioning (APA, 2000; Dowd, 2004).

Depression is one of the most prevalent mental illness and is estimated to be a leading cause of dysfunction and disability worldwide (Interian, Martinez, Iglesias Rios, Krejci, & Guarnaccia, 2010). According to SANE Australia, one in five Australians will experience a mental illness at some stage in their life. About 6% of the adult population will experience depression (SANE Australia, 2010). Women are significantly more likely compared with men to develop depression and the average age of onset is in the mid 20s (APA, 2000). Consequently, depression is one of the most common mental health problems in young people. A 2007 Australian Bureau of Statistics report showed that the rate of mood disorders was considerably higher for those aged 16 to 44 years (7.6%) than it was for those aged 55-85 years (3.3%) (ABS, 2009). Depression is a very debilitating disorder in many ways – emotionally, motivationally, cognitively, physically and economically. Unlike most other mental disorders, depression can be lethal in the form of suicidal death (Seligman, 1991).

Depression is classified in the current DSM-IV-TR as a mood disorder. Mood disorders are mental disorders where mood disturbance is the prominent feature. The DSM distinguishes between a Major Depressive Episode and Major Depressive Disorder (APA, 2000). For the purposes of this chapter, the two conditions will subsequently be referred to as depression.

Depression Assessment Tools:

Depression Self-Report Questionnaire http://www.blackdoginstitute.org.au/docs/DMI-10.pdf
The Hamilton Rating Scale for Depression (clinician-scored measure) http://www.servier.com/App_Download/Neurosciences/Echelles/HDRS.pdf

For further useful information about depression see:

Black Dog Institute http://www.blackdoginstitute.org.au/
Beyond Blue http://www.beyondblue.org.au
SANE Australia Depression Factsheet http://www.sane.org/information/factsheets-podcasts/178-depression

The Relationship between Motivation and Depression

Having Depression Leads to Lowered Motivation Levels

Intrinsic motivation: the doing of an activity for the inherent satisfaction of the activity itself (Barch et al., p. 776).

Amotivation, or the lack of motivation, is a core feature of depression (Barch, Yodkovik, Sypher-Locke, & Hanewinkel, 2008). More specifically, people with depression lose intrinsic motivation. The DSM-IV-TR includes a range of criteria for a diagnosis of Major Depressive Disorder. Symptoms that relate to motivation include:

marked lowering of self-esteem
increased thoughts of hopelessness and helplessness
loss of interest and pleasure in activities that were previously considered pleasurable
negative thinking
depressed mood
decreased energy and fatigue with very little physical exertion
apathy
feelings of worthlessness
impaired judgment, concentration and decision-making (APA, 2000).

Other deficits in depression not listed in the DSM-IV-TR criteria include strong avoidance tendencies and heightened dependency (Becker, 1974).

The lack of motivation in individuals with depression influences different aspects of behaviour and cognition. For example people with depression struggle to work towards goals that they previously may have found rewarding, they are not able to engage in productive work, interpersonal relationships or hobbies, they are often unable to positively engage in therapy, and their cognition is severely negatively affected (Barch et al., 2008). Cognitive aspects of depression and how this relates to motivation in terms of the Cognitive Theory of Depression will be discussed in more detail later in the chapter.

Amotivation has been systematically positively related to maladaptive outcomes (Vallerand, Pelletier, & Koestner, 2008). Amotivation can come about because the individual feels incompetent performing any task and also because they are not motivated to want the outcome of the task to begin with. People with depression may further experience amotivation because they cannot see the reward value of stimuli which are not present in the current environment (Barch et al., 2008). Without the mental illness this would be possible.

Depression, Neurotransmitters, Hormones and Motivation

Particular neurotransmitters and hormones have important roles in motivation. Depression affects the levels of particular neurotransmitters and hormones which in turn influences the level of motivation. According to the current DSM, the pathophysiology of depression may involve the dysregulation of a variety of neurotransmitter systems such as the dopamine, norepinephrine, serotonin and acetylcholine systems. Further, in some people with depression altered levels of hormones such as elevated glucocorticoid secretion have been found (APA, 2000).

The table below lists key neurotransmitters and hormones and their motivational function.

Neurotransmitters, Hormones and their Motivational Function

Neurotransmitter/ Hormone	Motivational Function
Dopamine	Important for motivation. Important for interest and drive. Needed for a sense of preparedness to meet stressors and challenges. Produces good feelings associated with rewards.
Norepinephrine	Excitatory neurotransmitter. Required for motivation and alertness. Too much norepinephrine connected with stress and anxiety.
Serotonin	Calming neurotransmitter. Has an influence on mood and emotion. Low levels of serotonin linked to depression.
Acetylcholine	Excitatory neurotransmitter. Important for concentration and focus. Plays an important role in thought and memory. Deficits in acetylcholine related to reduced cognitive capacity.
Glucocorticoids	Class of steroid hormones. Example is cortisol which is released as a response to stress. Cortisol is associated with negative affect and lower intellectual functioning.

Note. Table adapted from (Neill, 2010; Thase, 2009).

Does Having a Particular Attributional Style Impact Upon the Likelihood of Depression?

Attributional or explanatory style refers to the way that people explain events in their lives and the forces that people view as being responsible for their success and failure. Attributional styles have an effect on people’s motivation levels (Brown & Siegel, 1988; Nolen-Hoeksema, Girgus, & Seligman, 1986). Perhaps it is intuitively obvious that people with depression are more likely to exhibit a maladaptive style of attribution than people without depression.

However, studies suggest that there is a causal link between particular attributional styles and the development of depression. Abramson, Seligman and Teasdale (1978) suggest that a maladaptive attributional style involving the tendency of an individual to attribute negative events to internal (rather than external), stable (rather than temporary) and global (rather than specific) causes is a predisposing factor for developing depression (as cited in Brown & Siegel, 1988). Attributions to internal causes are viewed as underlying self-esteem deficits while attributions to stable and global factors are respectively linked to the duration and generalisability of symptoms of depression (Brown & Siegel). A person’s style of attribution affects their expectancies, motivation and performance (Abramson, Seligman, & Teasdale, 1978; Anderson, Horowitz, & deSales French, 1983).

A longitudinal study conducted by Nolen-Hoeksema et al. (1986) investigated maladaptive attributional style in children and its link with depression. They found that children with a maladaptive attributional style had higher levels of depression and also higher levels of depression at subsequent testing periods. Specifically, children who tended to explain negative events by internal, stable, and global causes and positive events by external, unstable, and specific causes reported more depression and showed more achievement-related problems compared to children who explained events in the opposite way.

Theories of Motivation and Depression

Cognitive Theory of Depression

"You largely constructed your depression. It wasn't given to you. Therefore, you can deconstruct it.

Albert Ellis

Cognitive theories of depression propose that people’s thoughts, attitudes, inferences and the way in which they deal with these, determine their emotional responses (Joormann, 2009). Beck’s Cognitive Theory of Depression (1976) views depression as a consequence of cognitive distortions that produce a negative triad: negative evaluations of the self, the world and the future (Joormann, 2009; Tucker & Luu, 2007). The theory specifies the processes that bring the cognitive triad into effect and maintain its prominence in cognition distortion. Beck describes a number of factors in this process: “depressed persons are prone to structure their experiences in relatively primitive ways. They tend to make global judgments regarding events that impinge on their lives. The meanings that flood their consciousness are likely to be negative and extreme” (Gilbert, 1992, p. 400).

Everyday Examples of the Negative Triad:

Negative view of the self
“I am a loser”
Negative view of the world “Other people will hurt me if I give them the chance”
Negative view of the future “Things in life will always be bad and will not get any better”

(Dowd, 2004).

The most significant systematic bias in depression cognition is the negative evaluation of the self. People with depression see themselves as worthless because they feel responsible for any deficiencies (Becker, 1974). Beck sees this distorted cognition as a causal variable in depression and describes the affective, physical and motivational accompanying deficits as secondary products (Becker).

Beck’s cognitive model suggests that a person with depression develops certain negative schema through which they view the world (Gilbert, 1992). The schemas of people with depression have themes including loss, separation, failure and worthlessness (Joormann, 2009). These negative schemas dominate the cognition of that person so they come to interpret all failures, even trivial ones, as reflections of their inadequacy (Gilbert; Joormann). The activated negative self-schema has a negative bias on information processing and motivation. A vicious cycle of negative thinking and negative affect develops – the negative thoughts are influenced by the schema and biases in processing initiate and sustain a depressed mood (Joormann; Wang, Brennan, & Holte, 2006). "The more dominant the negative cognition schema becomes, the more cognitive distortions occur and the greater the disturbance of effect and depth of depression" (Gilbert, p. 402).

Research into the cognitive style of depressed individuals supports the presence of a negative bias and the absence of a positive bias (Wang et al., 2006). For example, people with depression have been shown to have automatic bias for negative self-appraisal compared to people without depression (Tucker & Luu, 2007). Meyer and Garcia-Roberts (2007) found that people with severe depression were more likely than others to view their depression as being caused by achievement related reasons and character related reasons. Similarly, other findings suggest that depressed people believe that their depression is caused by a failure to attain personal standards, achieve goals and live up to their potential (Meyer & Garcia-Roberts). This has serious consequences for levels of motivation.

Learned Helplessness Theory

Seligman used dogs in his experimental research to develop the idea of 'learned helplessness.'

Learned helplessness is a state of impaired learning. Martin Seligman (1967) developed this concept after his experimental studies showed that dogs who were given an inescapable shock subsequently failed to escape the shock in a situation where escape was possible. Even if the dogs accidentally made an occasional response that allowed them to escape the shock, they failed to learn this behaviour (Becker, 1974; Klein, Fencil-Morse, & Seligman, 1976; Seligman, 1991). In other words, the dogs learnt to be helpless (Weiner, 1992). In comparison, other dogs in Seligman’s experiment which were given an escapable shock or no prior shock learnt to escape the shock well (Klein et al.).

Learned helplessness occurs in a variety of situations and across different subjects including cats, rats, mice and even humans (Abramson et al., 1978; Klein et al., 1976; Weiner, 1992). Studies of learned helplessness in humans have found that given an inescapable noise or unsolvable problem they fail to escape the noise or solve the problem when it is possible to do so (Abramson et al.). Learning that the response and receiving the shock are not dependent on one another has motivational consequences for the subject. Motivation for the animal or the human to respond is contingent on the incentive of achieving a desirable consequence. However, if this incentive is not there, the animal or human is unmotivated to seek relief (Becker, 1974; Seligman, 1991). This means that the organism believes that there is nothing it can do to alter events and so display helplessness (Weiner).

Learned helplessness has become an important model for depression in humans (Depue & Monroe, 1978; Tucker & Luu, 2007). Klein et al. (1976) argue that learned helplessness and depression are comparable in symptoms, etiology, cure and prevention. Seligman drew a parallel between depression and learned helplessness in terms of six key symptoms (Seligman, 1991).

Six Parallel Symptoms between Depression and Learned Helplessness (Seligman, 1991)

Depression	Learned Helplessness
Lowered initiation of voluntary responses	Animals and people who have experienced uncontrollability show reduced initiation of voluntary responses.
Negative cognitive set	Helpless animals and people have difficulty learning that responses produce outcomes.
Time course	Helplessness dissipates in time when induced by a single session of uncontrollable shock; after multiple sessions, helplessness persists.
Lowered aggression	Helpless animals and humans initiate fewer aggressive and competitive responses, and their dominance status may diminish.
Loss of appetite	Helpless animals eat less, lose weight and are sexually and socially deficient.
Physiological changes	Helpless rats show norepinephrine depletion and helpless cats may be cholinergically over-active.

There are three key deficits of learned helplessness which apply to depression. Firstly, there are motivational deficits (a lowered response initiation or willingness to try because the organism has learnt to expect that their responses will not have an impact on the outcome) and secondly there are cognitive deficits (less of an ability to learn that responding leads to reinforcement). Thirdly, emotional deficits are present; once the person learns that their responses will not have any impact on the outcome, the resulting emotions are energy depleting (Abramson et al., 1978; Klein et al., 1976). Seligman wrote, “the lowered voluntary response initiation that defined learned helplessness is pervasive in depression. It produces passivity, psychomotor retardation, intellectual slowness, and social unresponsiveness; in extreme depression, it can produce stupor” (Depue & Monroe, 1978, p. 11).

Seligman theorised that people with depression display symptoms of learned helplessness, for example unresponsiveness and passivity.

A study by Klein et al. (1976) examined learned helplessness in people with depression. They found that when given unsolvable problems, depressed participants showed poorer performance compared with non-depressed participants. Similarly, Beck, Wenzel, Riskind, Brown, and Steer (2006) conducted a study to investigate the degree to which depressed participants endorsed hopelessness about life events. They found that depressed participants rated worse outcomes as being more likely and best outcomes as being less likely compared to participants with other mental illnesses. Both of these results add to the extensive body of literature supporting the hypothesis that learned helplessness is a crucial aspect of depression.

Interestingly, Klein and Seligman (1976) found that helplessness in depressed people can be prevented or reversed by the experience of success (as cited in Abramson et al., 1978). It is suggested that it is possible to persuade people with depression that they can use strategies to conquer previous failures and so overcome learned helplessness (Anderson et al., 1983). Motivation of the person with depression is a pivotal factor in making this type of approach work. More about motivation and treatment for depression will be examined later in the chapter.

Abraham Maslow’s Hierarchy of Needs

Maslow defined self-actualisation as "the desire for self-fulfillment, namely the tendency for him [the individual] to become actualised in what he is potentially. This tendency might be phrased as the desire to become more and more what one is, to become everything that one is capable of becoming" (Maslow, 1943).

Maslow’s humanistic approach to psychology is relevant to depression and motivation, in particular his Hierarchy of Needs Model (Zalenski & Raspa, 2006). In his book Motivation and Personality (1970), Maslow states that the individual is an integrated whole and hence a theory of motivation needs to cover human needs and goals. The pivotal aspect of Maslow’s theory of motivation is that humans have a hierarchy of needs and that these needs have to be fulfilled in the correct hierarchical order; the lower needs are prerequisites to the higher needs such as self-actualisation. The most basic physiological needs (food, drink, excretion, shelter, sleep and sex) and safety needs (security, protection and stability) are considered basic because their absence is highly motivating (Zalenski & Raspa).

The Hierarchy of Needs Model is suitable for assessing the needs and reaching the human potential of people with depression (Zalenski & Raspa, 2006). Further, the hierarchical approach demonstrates that until basic fears and needs are addressed in someone with depression, no progress will be made towards the upper needs in the model (Zalenski & Rapsa). Achieving these higher needs could be viewed as the ultimate goal of treatment for depression.

The hierarchical levels of esteem and love/belonging needs are relevant to someone with depression. Due to the nature of depression, the person will feel low levels of self-esteem, confidence and achievement and so will be unable to fulfill this need. Further, people with depression often become isolated and unsocial and feel as though no one understands them, loves them or cares about them. Therefore, they will have great difficulty fulfilling the need of love and belonging. A conscious implementation of Maslow’s hierarchy may increase the levels of motivation in someone with depression therefore enhancing outcomes (Wright & Wiediger, 2007; Zalenski & Raspa, 2006).

Self-Determination Theory

Self-Determination Theory is a theory of human motivation, development and wellness (Deci & Ryan, 2008; Markland, Ryan, Tobin, & Rollnick, 2005; Ryan & Deci, 2008). Self-Determination Theory provides principles in order to motivate people to explore life experiences and from this reflective process make changes in goals, behaviours and relationships. The theory investigates how rewards, feedback and positive regard among other factors, enhance self-motivation (Ryan & Deci).

Self-Determination Theory specifies three basic psychological needs from the social environment which are required for optimal growth, integrity, wellness and mental health. Research in various countries illustrates that the satisfaction of the three needs predicts psychological well-being (Deci & Ryan, 2008). The three needs are autonomy, competence and relatedness (Markland et al., 2005; Neighbors, Lewis, Fossos, & Grossband, 2007; Vallerand et al., 2008). The need for competence refers to the need to have confidence in one’s abilities and the ability to have an effect on outcomes. The psychological need for autonomy is a feeling of independence over one’s actions rather than feeling controlled. And finally, the need for relatedness describes the need to experience connectedness with other people and have supportive social relationships (Markland et al.; Neighbors et al.).

Diagram illustrating the three needs proposed by Self-Determination Theory

Self-Determination Theory can also be applied to the treatment of psychological disorders, such as depression, because the central aim of psychotherapy is to motivate and assist the clients to identify, initiate and maintain the process of positive change (Ryan & Deci, 2008). This theory would argue that the etiology of psychological disorders such as depression is based in need deprivation (Ryan & Deci).

Within the theory there is a strong emphasis on autonomy (Ryan & Deci, 2008). This is relevant when considering depression. Self-Determination Theory states that clients with depression who are more autonomously engaged in their therapy, that is, when they have a stronger perceived internal locus of causality regarding the treatment, will experience behavioural changes and therefore more positive therapeutic outcomes. As part of this, the client needs to internalise the responsibility for changing (Ryan & Deci). Michalak, Klappheck, and Kosfelder (2004) studied the autonomy of treatment goals in a group of psychiatric patients. Those who had higher levels of autonomous motivation were found to have more positive therapy outcomes. They argued that autonomy is related to goal progress and so therefore clients with more autonomous goals may be able to overcome barriers to change (as cited in Ryan & Deci).

Motivation and Treatment for Depression

What are the Motivators and Amotivators for People to Seek Help for Depression?

Self-Determination Theory provides descriptions of four motivators that lead people to seek therapeutic help for symptoms of psychological disorders including depression. According to the theory, people have different degrees of each motivation (Ryan & Deci, 2008). Firstly, someone may be motivated by external regulation or pressured by an external force for example family members or the legal system in the form of a court order. Secondly, people may seek treatment due to introjection because of guilt or the need for social approval. Thirdly, people may experience feelings of identifying with the therapeutic goals and therefore autonomously decide to pursue change. Lastly, people may feel a sense of intrinsic motivation and come to treatment with an open curiosity (Ryan & Deci). However, in terms of depression, these last two motivations are not often achieved until later in the course of treatment and generally they are not the initial motivator for the client to seek help.

Fears about antidepressants (for example Prozac) are barriers to seeking help for people with depression.

As well as motivators for people to seek help, Interian et al. (2010) also found factors which had the opposite effect. The biggest amotivator to seek help was based around fears about antidepressants. For example, being discouraged by family or friends to go on medication, fears about the medication being harmful or addictive, fears about having to be on the medication for life and fears about physical side effects were found. The second largest amotivating factor was stigma from the social environment. Stigmas related to people with depression include that it is a weakness, that the person is not resilient and that they have severe problems.

What are the Motivators for Treatment Compliance?

Problems with treatment compliance for depression, particularly regarding adherence to antidepressants, form a major barrier to treatment and recovery (Interian et al., 2010; Westra, 2004). It has been estimated that approximately three quarters of individuals on antidepressants discontinue the course of treatment prematurely (Interian et al). Patients who are prescribed antidepressants are faced with conflicting factors such as their motivation for treatment, the possible adverse side effects, the therapeutic alliance, stigma and possible poor response to treatment (Interian et al).

A study by Interian et al. (2010) discovered that the greatest motivator for antidepressant adherence was the role of treatment providers, in particular psychiatrists. The patients in the study referred to the providers as “partners” and trust was seen as a critical component in the relationship. The second strongest motivator for adherence was the wish to decrease depressive symptoms. The next two motivators were positive influences from their family and friends. As Interian et al. comment, family members are often the ones to initially encourage the patient to seek help and in many instances bring them to the clinic. Family members also often provide reminders to the patient to take medication and provide financial help to buy the medication. Friends have a positive influence as they provide moral support for the patient and are someone to talk to in times of need.

Meyer and Garcia-Roberts (2007) add that it is vital to understand how clients with depression see their symptoms. Their perception of the symptoms is associated with motivation (effort and persistence) to engage with interventions that match their view. For example, someone with depression who believes that their depression is caused by an imbalance of chemicals in the brain, would be expected to be motivated to take antidepressant medication and may be less motivated to undertake cognitive-behavioural therapy.

It is vital to understand the motivators and amotivators for people to seek help and adhere to treatment for depression. This can assist in the way that help and treatment for depression is portrayed and potentially lead to greater outcomes.

Case Study: Lauren

My name is Lauren. I am a 22 year old female with depression. I was diagnosed with depression six months ago and was prescribed antidepressants. I do not want to go on antidepressants because some of my friends told me that they cause severe physical side effects and that once I started I would be addicted. Another friend who also has depression told me that she has been taking them for a year, that nothing has changed and she does not feel any better. I am scared to start taking antidepressants.

Motivational Techniques to Assist in the Treatment of Depression

As we have seen, lack of motivation is a central symptom of depression. Therefore, improving motivation is one aspect of treatment for depression. Motivational change is a key approach. Changing suboptimal forms of motivation into more self-determined and directed ones, can allow people having treatment for depression to experience more adaptive outcomes (Vallerand et al., 2008).

Motivational interviewing is a popular psychotherapeutic approach in the promotion of behavioural change and has been applied in a number of different areas, for example substance addiction and depression (Interian et al., 2010; Markland et al., 2005; Westra, 2004). Motivational interviewing has a client-centred philosophy and a purposely directive approach that attempts to explore the client’s ambivalence or resistance to treatment. It aims to allow the client to make the decision themselves to change, rather than the therapist coercing them to change ( Markland et al.; Ryan & Deci, 2008; Westra). Directly coercing clients to change will not be very effective because this involves the therapist taking a side of the conflict already being experienced by the client. In motivational interviewing, clients will ideally come to a resolution of the conflicting motivations and hence trigger behavioural change, for example seeking and adhering to treatment (Markland et al.).

This client with depression is participating in motivational interviewing to hopefully lead to positive treatment outcomes.

Motivational interviewing emphasises working within the person’s values, for example by aligning behavioural change within the boundaries of personal principles (Interian et al., 2010; Markland et al., 2005). Other core components of motivational interviewing are expressing empathy, helping develop discrepancy, rolling with resistance, supporting efficacy and encouraging the patient to talk about change. The presence of these elements is vital in treating someone with depression. It is important for motivational interviewing to also consider factors such as language, culture and social context in its delivery to ensure compatibility (Interian et al.; Markland et al.).

Specific motivational interviewing techniques for those with depression include reframing the continued use of antidepressants as a way to fight problems (Interian et al., 2010). Additionally, the motivational interviewing approach could address patients’ concerns about antidepressants, ask for permission before providing information, concentrate on asking open-ended questions and focus on using reflective and affirmatory techniques. One of the most important recommendations is to maintain an unstructured format in the interview as studies have found that highly structured motivational interviewing is associated with poor treatment outcomes (Interian et al.).

The role of the therapist in motivational interviewing for someone with depression is to help them clarify their motivation to change or seek help, provide support and alternative views on the problem and assist with ways to implement change. The therapist is also attempting to elicit ‘change talk’ in the client in an effort to transfer the responsibility for change onto the client. Evidence shows that an increase in ‘change talk’ throughout treatment predicts positive treatment outcomes (Markland et al., 2005).

It has been suggested that motivational interviewing could potentially be used in conjunction with other treatments for depression (Westra, 2004). Burke, Arkowitz, and Menchola (2003) conducted a meta-analysis investigating motivational interviewing in clients with a range of conditions including depression. They concluded that in cases where motivational interviewing was used as a prelude to another treatment such as medication, the positive effect was double that of motivational interviewing by itself (as cited in Westra).

Motivational interviewing can be seen to align with Self-Determination Theory (Ryan & Deci, 2008). Both are based on the assumption that humans have an innate tendency for personal growth (Markland et al., 2005). Motivational interviewing supports the three basic needs proposed by the theory as mentioned earlier in the chapter. It supports autonomy through investigating and reflecting, competence through providing relevant information, and relatedness which is demonstrated through a client-therapist relationship based on unconditional positive regard. Research examining the links between Self-Determination Theory and motivational interviewing has found that autonomy support was related to engagement with and attendance to therapy (Ryan & Deci; Markland et al.).

Autonomy support is associated with greater autonomous motivation (Zuroff et al., 2007). It has a crucial role in fostering motivation and internalisation, two key aspects of treatment for depression (Ryan & Deci, 2008). It is concerned with assisting people to see that they can exercise choice in their behaviour. Research has found that autonomy support is made up of a number of factors including understanding, acknowledgement of the client’s perspective, unconditional regard, supporting choices of the client, minimising control and giving rationales for suggestions (Markland et al., 2005; Ryan & Deci).

Autonomy support: the attitudes and practices of a person or a broader social context that facilitate the target individual’s self-organisation and self-regulation of actions and experiences (Ryan & Deci, p. 188).

A study by Zuroff et al. (2007) looked at the importance of autonomy support and autonomous motivation for treatment outcomes of depression. They found that people felt autonomously motivated when they experienced themselves freely choosing goals and they could see that this choice came from within themselves. Results showed that the depressed patients’ views of autonomy support positively predicted autonomous motivation for treatment. Autonomous motivation was found to predict treatment outcomes above a therapeutic alliance. This study adds to extensive research showing that environments which are autonomously supportive foster autonomously motivated behaviour. In turn this behaviour leads to more desirable outcomes in a variety of contexts such as treatment (Vallerand et al., 2008; Zuroff et al.).

Message framingcan also have an impact upon an individual’s decision to adopt a treatment behaviour. Research has looked at whether depressed individuals are differentially motivated to carry out mood repair strategies by approach versus avoidance framed messages (Detweiler-Bedell & Salovey, 2003).

Rothman and Salovey’s (1997) study with depressed individuals found that placing emphasis on the negative consequences of inaction (using a ‘loss frame’) is not a good strategy for creating motivation in these individuals. Rather, they argue that there needs to be a focus on gain-framed messages rather than loss-frame messages because these are more persuasive. An example of a gain-framed message could be “if you complete your homework from therapy, you will feel better.” This is more motivating for the person with depression because a particular action, completing the homework, is highlighted. Results showed that appealing to the desire of avoiding a negative and depressed mood is more persuasive in motivating positive changes in people with depression (as cited in Detweiler-Bedell & Salovey, 2003).

These techniques should be considered as components of the treatment process for someone with depression.

Celebrity Case Study: Geoff Huegill

Swimming champion Geoff Huegill knows what the downward spiral of depression feels like.

He recently revealed that he had battled clinical depression since 2002 and was on and off antidepressants for six years. Huegill recalls after that his retirement in 2004, he stacked on the weight ballooning to 140kg, partied hard and had a diet of junk food. “Instead of going to the pool at 4am, I was hell-bent on staying out until 4am.”

He lacked any motivation and drive and had lost his self-belief and determination that had previously taken him to the Olympics. Huegill says, “I didn’t feel good about anything…I was never happy.”

However, Huegill turned his life around, lost 45kg and returned to the pool. He triumphantly made his comeback to elite swimming at the recent 2010 Commonwealth Games in Delhi winning gold in the 100m butterfly event.

Huegill is now an ambassador for the Black Dog Institute and has recently created a life coaching program to inspire others to turn their life around. Huegill models a sense of intense determination, motivation and zest for life that he wishes to share with others (Craddock, 2010).

Click here to watch a video of Geoff Huegill’s amazing comeback.

Chapter Summary

This chapter focused on the complex link between motivation and depression:

Motivation can be seen as asking why humans think and behave in the way that they do.
We have learnt that depression is among the most common mental disorders.
Amotivation is a central feature and symptom of depression.
The lack of motivation in people with depression has influences across behaviour, cognition and emotion.
This chapter also described the neurotransmitters and hormones that are thought to be affected by depression which in turn has an impact upon people’s level of motivation.
The Cognitive Theory of Depression (Beck, 1976) proposes that depression is a result of cognitive distortions that produce a negative triad.
Seligman’s Learned Helplessness model suggests that depression is caused by uncontrollable situations that lead the person to view their responses as ineffective in getting reinforcement, therefore causing motivational deficits.
Maslow proposes that people with depression struggle to fulfill the lower hierarchical needs of love/belonging and esteem. This consequently effects motivation. Hence, Maslow’s hierarchy should be considered in treatment for depression to increase motivation.
Self-Determination Theory puts forward three needs: autonomy, competence and relatedness which are necessary for an individual to reach optimal growth and avoid mental illness. The emphasis on autonomy is relevant to depression, as people with depression who are more autonomously engaged in treatment have been found to experience more positive outcomes.
Motivators/amotivators for people to seek help and motivators for treatment compliance were examined.
Three motivational techniques to assist in the treatment for depression were discussed:

Motivational interviewing
Autonomy support
Message framing

It is important to understand the role that motivation plays in the treatment process for depression. This is expected to lead to the best possible treatment outcomes for the person affected by depression and their family.

Text Your Knowledge with Five Quick Quiz Questions

References

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External links

Is chocolate a mood stabiliser?

http://www.blackdoginstitute.org.au/docs/Chocolateamoodstabiliser19oct07.pdf

Patients with depression are stopping their medication too early (Sydney Morning Herald article)

http://www.smh.com.au/lifestyle/wellbeing/depression-patients-halt-medication-too-early-20100320-qn7j.html

Is There a Connection between Extrinsic Motivation and Depression in Children? The Importance of Free Play, Deep Play and Self Education

http://www.help-your-child-with-anger.com/extrinsic-motivation.html

Cognitive deficits in depression (A British Journal of Psychiatry Journal Article)

http://bjp.rcpsych.org/cgi/reprint/178/3/200.pdfExter

	2%
	15%
	6%
	20%

	People with depression struggle to reach self-actualisation
	Organisms are helpless when their actions do not influence outcomes
	Depression is the result of a negative triad
	Electric shock therapy is the best way to treat depression

	Autonomy, competence and relatedness
	Autonomy, self-awareness and motivation
	Esteem, competence and friendship
	Autonomy, self-awareness and growth

	Antidepressant fears, Relationship with treatment provider
	Peer pressure, Family support
	Stigma, Guilt
	Therapeutic alliance, Support from friends