Abstract

Learning during skills-based psychosocial treatments for schizophrenia is influenced past the motivating properties of the handling context and the motivational orientation of the client. Given that motivational impairment is a core feature of schizophrenia with significant functional implications, intervention strategies emphasizing extrinsic and/or intrinsic goals may be prescribed to raise skill learning and treatment outcomes. The purpose of this commodity is to consider the part that motivation plays in handling success past evaluating the relationship between motivation and learning during cognitive remediation for schizophrenia. As intrinsic motivation (IM) is most often associated with learning, we will integrate research findings which address 3 master questions: (ane) is IM in schizophrenia static or dynamic, (two) is it possible to manipulate the state of existence intrinsically motivated and if and so do manipulations of IM impact learning? and (3) can motivation theory be translated into clinical practice? This cognition can facilitate treatment strategies to accost the low base charge per unit of IM that is characteristic of schizophrenia and can be practical to cognitive remediation likewise equally other psychosocial interventions which require learning for handling success.

Introduction

Harm in motivation is a core deficit of schizophrenia, which is known to impact psychosocial outcomeane,2 and ability to engage in and benefit from treatment.3,4 Study of the construct of motivation as it applies to schizophrenia is a burgeoning area of research, spurred by interest in delineating the phenomenology of the illness and efforts to develop more effective treatment strategies. The role of motivation for treatment success has been near studied in relationship to behavioral treatments such every bit cerebral remediation, substance abuse, and compliance therapy, but there is increasing involvement in how information technology impacts a range of psychosocial interventions.5–8

Traditionally, the success of psychosocial interventions has been linked to the awareness of the customer that they require the intervention and their ability to larn the skills existence taught. Recovery-based programs teach skills pertinent to social, vocational, neurocognitive, and social cerebral operation, independent living, anger management, symptom management, likewise every bit a host of other specific functional skills. Cognitive capacity is one factor that impacts power to learn, and the neuropsychological deficits so prevalent in schizophrenia have been identified as a rate-limiting factor for treatment outcome in schizophrenia.9–eleven The abilities to pay attention, call back, and procedure the information to be learned are considered disquisitional to handling result.12 Withal, learning is not simply dependent on cognitive capacity but is likewise influenced by instructional techniques and motivation of the client to appoint in the activeness and learn the skills.xiii–15 Arguably, motivation is fundamental to the success of psychosocial treatment interventions precisely considering it is and then essential for learning to take place.

The study of motivation typically assumes that the power to initiate and sustain behavior is ultimately tied to reward processing, and information technology is the potential for gratification or goal attainment that motivates people to engage in a behavior. Rewards can exist external to the individual, such as money, a prize or verbal praise, or rewards can come from the pleasure 1 gets from the task itself or from the sense of satisfaction in completing or engaging in a task. When rewards are external to the individual, one is said to exist extrinsically motivated and when the rewards are within the individual and inherent to task operation, beliefs is intrinsically motivated.5 Environmental contexts pull for different motivations. For example, in vocational settings, extrinsic motivation may play a larger role, while in clinical treatment settings, intrinsic motivation (IM) may be more than predominant. While in that location may be a predominance of i reward orientation over some other in any given setting, it is common for both extrinsic motivation (EM) and IM to be operative. People may work both for a remunerative extrinsic reward and the intrinsic reward that comes when the work interesting; they may go to a treatment dispensary because it makes them experience better (IM) and feeling amend allows them to work and maintain their flat (EM). Although the balance between EM and IM tin can shift over time for any person, the degree of synchrony with the environmental context (ie, the opportunities for rewards) is a fundamental determinant of motivational bulldoze. If the opportunities for rewards in a given context are coinciding with i'south motivations, goal-oriented beliefs is probable to occur. On the other hand, if the rest of motivations fits poorly with the nature of the action, unmotivated behaviors may occur. For example, a person who is largely extrinsically motivated to engage in activities that are associated with intangible outcomes (eg, learning, socializing), may get unmotivated when tangible rewards are non forthcoming.

When considering the role of motivation for treatment success, it is valuable to appreciate the larger context in which psychosocial interventions take place. Cognitive remediation is a psychosocial intervention that like other skills-based treatments for schizophrenia occurs in the context of a learning environment. In both good for you controls and people with schizophrenia, IM is specifically and positively associated with more than learning, greater persistence of learning, and greater engagement in learning activities.4,fifteen–18 The machinery by which IM enhances learning is thought to chronicle to the spontaneous gratifications of needs for competency and autonomy, which occur when people engage in an activity with a full sense of willingness and volition.17 Furthermore, IM is the impetus for an activity due to associations with enjoyment of and positive feelings for that activity, which are usually inspired by personally relevant goals and values.5 Thus both healthy students and patients with psychosis are intrinsically motivated for difficult learning tasks, when they engage in targeted behaviors because of the interest, enjoyment, and the satisfaction derived from their appointment in the activity rather than exclusively due to external rewards. Consequently, intrinsically motivated behaviors are repeated without all-encompassing external rewards or constraints, and therefore, more than likely to be maintained. That is not to say that EM has no part in learning activities—but rather that on balance, when IM is greater, learning outcomes are better. Knowing the essential role of IM in learning and treatment outcomes and appreciating that IM is low in people with schizophrenia,13 it becomes important to understand if, in schizophrenia, IM is static or dynamic, if it is possible to dispense the state of being intrinsically motivated, and if manipulations of IM affect learning. This knowledge tin facilitate treatment strategies to address the low base charge per unit of IM that is characteristic of schizophrenia and in so doing may augment psychosocial treatment outcomes.

Is Intrinsic Motivation Static or Dynamic?

Contempo research in schizophrenia populations suggests that IM is a dynamic process that changes over time. In a recent prospective study, Nakagami and colleagues1 examined IM amidst 130 individuals with schizophrenia or schizoaffective disorder attending customs-based psychosocial rehabilitation programs. A measure of IM was ascertained via clinician-rated items from the Quality of Life Calibration. Data yielded a significant rate of change in this measure of IM over half dozen and 12 months following an initial cess, indicating that IM in schizophrenia naturally varies over time. Importantly, positive changes in IM were strongly associated with positive changes in psychosocial functioning, thereby underscoring the significance of motivation in the context of psychosocial handling. In a separate written report of 57 outpatients with schizophrenia, Choi and Medalia4 used the Intrinsic Motivation Inventory for Schizophrenia Enquiry (IMI-SR), a new adapted self-report measure, and reported on changes in IM in relation to a four-week cerebral training intervention. Results supported the dynamic nature of IM in schizophrenia, although the alter in IM was significant merely in a subgroup that received a motivationally enhanced version of the training chore. These results add together to those reported by Nakagami et al1 in demonstrating that changes in IM can be detected relative to participation in a learning program and that changes are sensitive to the motivational properties of the context in which the learning tasks are embedded. Taken together, these 2 studies provide potent preliminary support for the malleability of IM in schizophrenia and give a basis for time to come studies to replicate and extend the findings by varying the treatment context and sample characteristics, and investigating the convergent validity of methods of assessing IM.

Is It Possible to Manipulate the Land of Being Intrinsically Motivated and Impact Learning Outcomes?

Theoretical Perspectives on IM

The results from Choi and Medalia4 demonstrate non just that IM in schizophrenia is a dynamic procedure but besides that it is malleable, sensitive to environmental manipulation. Theoretical perspectives outlining the contextual determinants of motivation to learn accept provided a footing for empirical report and the development of instructional techniques that increase motivated behavior and learning outcomes. Expectancy-value theory (EVT19) is one widely accepted model of motivation that posits that expectations of success (competency) on a learning task and the perceived value of the task are central determinants of motivation to larn. Self-competency beliefs are influenced by i's assessment of past performance and appraisal of current job backdrop such as job difficulty, concreteness of task goals, and the temporal proximity of goal attainment. Cocky-competency behavior underlie expectations for future success and thus affect the initiation of learning beliefs. Additionally, initiation and maintenance of learning beliefs are impacted by value appraisals, with respect to the involvement and enjoyment of the learning job every bit well as the utility, cost, and attainment value of expected outcomes. Cocky-decision theory (SDTxx–22) is a second widely accustomed model of motivation which, similar EVT, asserts the importance of perceived competency in determining beliefs during learning tasks. Additionally, SDT posits that experiences of personal control and autonomy-supportive relationships during learning are key to appraisals of chore value, which in turn, touch IM and bulldoze motivated behavior.

The motivation theories that were developed to explain learning behavior in nonpsychotic individuals likewise provide an overarching framework to sympathise motivation in schizophrenia.5 In both nonpsychiatric and schizophrenia populations, competency expectations take been establish to determine selection to participate in a learning activity, perseverance on effortful learning tasks, and the degree of learning retention from the activity.23–26 There is evidence that perception of competency in schizophrenia is sensitive to the experience of reduced bureau.26 Furthermore, in schizophrenia, perceptions of competency have been linked to perceptions of task value, lending support to the applicability of EVT for understanding motivation in schizophrenia.26 When a learning exercise is seen as having value in helping one to attain personally relevant goals and the learner experiences control and a sense of agency in the learning situation, IM to learn and learning outcomes may exist enhanced.14,nineteen–26

There is prove to propose that, in general, people with schizophrenia are driven to achieve positive outcomes by the same factors equally nonpsychiatric controls. For example, Barch et al27 demonstrated that nonpsychiatric controls and people with schizophrenia cocky-written report like motivational traits on dimensions of personal mastery and competitive excellence. In addition, relationships betwixt motivational traits, mood, and personality measures were similar between groups, suggesting similar processes underlying motivation. In the report validating the IMI-SR,13 factor and validity analyses of the IMI-SR identified job interest, perceived choice, and task value every bit being integral to the construct of IM in a sample of outpatients with schizophrenia. In the schizophrenia sample, responses on the IMI-SR correlated significantly with additional measures of perceived competency and autonomous regulation, both constructs highly germane to IM in nonpsychiatric controls. Empirical information thus provide testify that the constructs theorized within SDT and EVT to underlie IM in nonpsychiatric populations are applicable to the study of motivation in people with schizophrenia.

Using Intrinsic Goals to Promote IM and Learning in Schizophrenia

Given that constructs underlying IM to appoint in learning tasks are comparable between learners in the general population and those with schizophrenia, techniques to enhance IM may be similarly applied inside learning-based interventions. Educational psychology has studied the application of EVT and SDT to instructional techniques, in gild to enhance learning. Research has emphasized specific elements of the learning context that promote IM and consequently learning. Learning activities are more probable to promote IM and learning when they (one) provide opportunities to personalize tasks (personalization), (2) make the value more obvious past placing tasks within a context that links the learning job to everyday life (contextualization), and (3) promote autonomy by providing opportunities to control aspects of the learning action.iv,28 Enquiry has likewise emphasized qualities of the overall learning environment that promote IM. For example, an autonomy-supportive learning environs is associated with more IM and learning than a decision-making environment.xviii Autonomy may exist supported through the language of instruction as well every bit past acknowledging the learning style and learning goals of each individual.

At that place is evidence from 1 study that these same instructional techniques used to enhance motivation to larn in nonpsychiatric populations are as well constructive in schizophrenia. In a sample of schizophrenia outpatients, Choi and Medaliafour manipulated the opportunities for personalization, choice, and contextualization in a learning activity and found that both IM and learning increased. Specifically, they examined whether outpatients could achieve benefits from an intrinsically motivating instructional arroyo which (1) presents learning materials in a meaningful game-like context, (two) personalizes elements of the learning materials into themes of loftier interest value, and (3) offers choices so patients tin can increase their control over the learning process. Change in motivation and learning was measured in 57 adults with schizophrenia who were randomized to receive ten 30-minute sessions of a math learning game that either had the motivationally enhanced features built into the action, or was stripped of these features. The motivationally enhancing instructional techniques led to significantly greater IM (66% vs 16% increase on the IMI-SR cocky-study inventory) perceived competency (90% vs 18% improvement on a cocky-study inventory), task-specific learning (67% vs 29% increase), and general cerebral gain (55% vs 29% comeback) with effect sizes in the medium to large range (see figure 1). This data is significant on 2 counts: (1) it further demonstrates congruity between the constructs which delineate the quality of IM in schizophrenia and healthy controls and (two) it demonstrates that the deficit in quantity of IM can be successfully addressed with behavioral interventions that capitalize on intrinsically motivating properties of a learning task. IM was low when patients started the study, but intervention strategies which had no cost to use, which did non rely on extrinsic goals, and which were easy to implement, served to enhance both IM and learning. Futurity research is needed to both replicate the findings and elaborate on the sensitivity of patients to motivationally enhancing learning cues.

Fig. 1.

Effects of instructional techniques that use intrinsic rewards

Effects of instructional techniques that apply intrinsic rewards

Fig. one.

Effects of instructional techniques that use intrinsic rewards

Effects of instructional techniques that use intrinsic rewards

Are Extrinsic Goals Needed to Promote IM?

Co-ordinate to SDT and EVT, EM may predominate when the intrinsic goal backdrop of a task, such as interest, utility, and attainment value are non salient. Individuals then evidence low IM and depression base rates of behaviors associated with IM (ie, sustained learning). One treatment arroyo would exist to make the intrinsic goal backdrop of tasks more salient, and Choi and Medalia4 showed that this is constructive to increase learning in schizophrenia. Some other approach for such individuals would exist to utilise extrinsic rewards to reinforce learning during cerebral interventions. The benign role of "soft" extrinsic goals, like certificates and points, is both consistent with general pedagogic practise and, seen through the lens of SDT, may help participants to achieve desired short-term performance goals, thus providing a sense of self-competency which may heighten expectations for hereafter success at mastery goals. For example, a patient may initially take the performance goal of achieving points on a memory activeness and, equally points accrue, may develop a sense of competency that provides motivation to work toward the intrinsic goal of ameliorate cognition. Thus implementation of nonmonetary reinforcements, such equally certificates and points, may, as suggested by Silverstein,29 complement the intrinsic goal properties of learning activities and may be feasibly implemented to enhance engagement and cerebral outcomes. Proponents of this methodology too cite the significance of the autonomy-supportive context in which procedures to shape learning oriented behaviors are used. By enhancing competency and autonomy, information technology is thus argued that EM sets the stage for IM; IM to learn may be fostered to heighten cognitive outcomes.

However, the circumstances and extent to which EM is necessary or sufficient to sustain and generalize persistent cerebral gains in people with schizophrenia is at this point unclear. Nosotros practise non know if there is a differential impact of using "soft" extrinsic goals (eg, points) vs "hard" goals (money). Information propose that positive behavior change initiated through the employ of budgetary compensation during learning activities is not sustained subsequently rewards are withdrawn,30 and the extent to which extrinsic rewards generalize to everyday job performance is express. Furthermore, research is needed to back up the argument by Silverstein29 that low base charge per unit of IM for learning in schizophrenia is a justification for using extrinsic rewards to reinforce learning during cognitive interventions. To appointment, in that location is no evidence that in a treatment setting, base of operations rate of IM in fact moderates change in IM. In the study by Choi and Medalia,4 baseline IM did not predict responsiveness to instructional techniques, as measured by change in IM and cognition. Even in the context of depression involvement, when patients were exposed to IM enhancing interventions that did not employ extrinsic rewards, at that place was an increase in perceived competency for task performance, IM, date, skill-specific learning, and cognitive improvement. Information technology is however possible that the outpatient sample used in that report did non capture the lowest spectrum of IM base rate. Although in that location is testify that the most dumb inpatients do improve when exposed to cognitive remediation that includes manipulations of both EM29 and IM,31 the comparative advantages of these manipulations for subsamples of schizophrenia patients is an area that requires further enquiry. Additionally, hereafter studies that delineate the specific components of the learning context, which optimally raise learning, must also consider whether intervention strategies are feasible to implement and sustain across a range of clinical settings. Monetary rewards are, for case, not necessarily feasible to implement in many clinical contexts.

In sum, learning contexts which back up personal autonomy, enhance opportunities for success, and burrow learning activities in a context that is enjoyable and personally relevant for the accomplishment of valued goals are likely to increase IM and enhance learning outcomes for people with schizophrenia. Experimental data from one study indicates that manipulation of IM alone, without reliance on extrinsic goals and rewards, is enough to raise firsthand and sustained cognitive gains, too as generalization of learned skills to full general cognitive ability. However, both theory and pedagogy support a part for extrinsic goals in learning contexts. Replication studies and research on the potential moderating outcome of base rate on change in IM and learning are needed to more fully sympathise the clinical circumstances when extrinsic and intrinsic goals are all-time used.

Translation of Theory to Clinical Practice

In order to brand meaningful gains in the development of skills-based intervention practices in psychosocial rehabilitation for schizophrenia, information technology is essential that applications of motivation and learning theories are relevant with respect to the contexts in which they are applied. While the motivational system in schizophrenia is responsive to both intrinsic and extrinsic rewards, the effectiveness and feasibility of specific intervention practices may exist dependent on the settings in which they are used. Both cognitive remediation and supported employment programs rely heavily on motivation for successful outcomes. Yet the residue of intrinsic and extrinsic motivation for engaging in these programs differs, thus arguing for prescription of different types of motivational strategies to promote handling gains. Since cognitive remediation is increasingly being paired with supportive employment and other psychosocial interventions, this is a affair of clinical relevance.

Inside the context of cerebral remediation, IM plays a predominant role in enhancing treatment outcomes. Research indicates that the content of learning activities and the motivational context in which learning occurs may exist feasibly designed to foster IM in people with schizophrenia. Perceived competency and expectations for success may be fostered by carefully selecting learning activities that are appropriate to the cognitive chapters of the private, and by titrating the level of difficulty to target more complex abilities. Promoting chore interest, utility, and attainment value may be accomplished by personalizing elements of the learning procedure and contextualizing learning activities and so that training tasks are placed inside the context of brusque and long term goals. Provision of choice and learner command during learning activities provides opportunities for self-direction and fosters autonomy. Interventions that involve "soft" extrinsic goals, like feedback and certificates, are generally given with the intent to promote IM and so that learning outcomes will be enhanced. Within the cerebral remediation context, instructional techniques ultimately strive to foster IM more EM.

Work settings often elicit a different remainder of IM and EM than cognitive remediation settings. Piece of work therapy and vocational rehabilitation programs provide chore placement services and paid work opportunities with concurrent coaching and structured support.32–36 Mayhap, the most obvious source of motivation to work is monetary gain. Budgetary proceeds is in itself an extrinsic reward simply too allows for secondary gain, such every bit the ability to obtain housing and support independent activities of daily living in the customs. Thus, extrinsic rewards are likely valued and highly salient in the context of vocational rehabilitation. Despite vocational successes in sheltered work settings, many participants do not accomplish employment goals in the community36 as evidenced by low rates of competitive chore attainment and task tenure.37,38 Although monetary proceeds is effective in promoting vocational outcomes within a rehabilitation setting, the generalizability of work therapy outcomes appears to be undermined by monetary disincentives to obtain work in the customs, given provision of public inability income support programs.39 Therefore, in addition to the extrinsic goal properties of piece of work, among people with schizophrenia, work may need to have significant intrinsic goal properties such as interest, utility, and attainment value. Like to a learning context in cognitive remediation, information suggest that perceptions of competence and expectations for success contribute to getting and maintaining employment in the community. Study information demonstrate the predictive value of self-appraisals and beliefs40,41 for effective work behavior. Hope and cocky-esteem are positively associated with work performance and outcomes,42 where as external locus of control is negatively associated with rates of competitive employment.40 In addition, vocational rehabilitation studies have demonstrated an reward for work therapy programs which incorporate therapeutic techniques to target self-appraisals and dysfunctional beliefs compared with work therapy programs which provide full general supports equally usual.42,43 These studies indicate that while extrinsic rewards, such every bit budgetary compensation, may exist necessary to promote appointment in a supportive work setting, IM to work may play a key role in promoting the generalization of work behaviors and in sustaining vocational outcomes in the community.

Summary

Motivation is a central determinant of psychosocial handling effect and thus is increasingly existence recognized equally an important target for behavioral interventions. Research to date indicates that in a learning context, motivation systems in schizophrenia are qualitatively like but quantitatively different from those of nonpsychiatric populations. Motivation theory and research from nonpsychiatric populations may thus serve as guideposts for the evolution of strategies to target low levels of IM during learning to broaden treatment outcomes for people with schizophrenia. Research in schizophrenia samples indicates that intrinsic motivation to larn is malleable and can change over fourth dimension. Chiefly, IM responds to interventions designed to augment motivation, and when IM to learn increases, so does the corporeality and persistence of learning. Preliminary research findings suggest that low base charge per unit of IM in a learning context does not moderate response to IM enhancing interventions that are complimentary of extrinsic reward. This suggests that there would be a part for such motivation enhancing techniques in schizophrenia patients who have a range of baseline IM levels. Future research needs to replicate these information and, given that extrinsic rewards may accept a positive affect on learning, analyze the circumstances under which EM may be beneficial and/or necessary to optimally enhance IM and learning outcomes. Current information, however, suggest that EM alone is not sufficient to sustain and generalize persistent cognitive gains in people with schizophrenia.

Given that cognitive remediation is increasingly existence paired with other psychosocial treatments like vocational training, the context-specific functions of motivation need to exist appreciated. In a piece of work context, extrinsic and IM operate in concert to affect vocational outcomes, but effective learning during cerebral remediation may be supported primarily by promoting IM. In both settings, the importance of supporting autonomy during learning is essential to optimally enhance firsthand treatment gains and facilitate the maintenance and generalization of treatment gains to psychosocial performance. This may be applied more than broadly to a range of skills-based interventions in which motivation to learn is essential for handling success.

Funding

This work was supported in part by funding from the Kessel Foundation and Joyce Stern Foundation.

The authors have alleged that there are no conflicts of interest in relation to the subject of this written report.

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© The Author 2022. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Heart. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

© The Author 2022. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Middle. All rights reserved. For permissions, please email: journals.permissions@oup.com.