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2019
Impact of Self-Determined Motivation on Work Behavior and
Impact of Self-Determined Motivation on Work Behavior and
Response to Cognitive Remediation in Individuals with
Response to Cognitive Remediation in Individuals with
Schizophrenia
Schizophrenia
Desmond Spann
Minnesota State University, Mankato
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Recommended Citation
Recommended Citation
Spann, D. (2019). Impact of self-determined motivation on work behavior and response to cognitive
remediation in individuals with schizophrenia [Master’s thesis, Minnesota State University, Mankato].
Cornerstone: A Collection of Scholarly and Creative Works for Minnesota State University, Mankato.
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Cornerstone: A Collection of Scholarly and Creative Works for Minnesota State University, Mankato.
Impact of Self-Determined Motivation on Work Behavior and Response to Cognitive
Remediation in Individuals with Schizophrenia
By
Desmond Spann
A Thesis Submitted in Partial Fulfillment of the
Minnesota State University, Mankato
Requirements for the Degree of
Master of Arts
In
Clinical Psychology
Minnesota State University, Mankato
Mankato, Minnesota
August 2019
i
August 14th, 2019
Impact of Self-Determined Motivation on Working Behavior and Response to Cognitive
Remediation for Individuals with Schizophrenia
Desmond Spann
This thesis has been examined and approved by the following members of the student’s
committee
________________________________
Dr. Dan Houlihan, PhD
Advisor
________________________________
Dr. Jeffrey Buchanan, PhD
Committee Member
________________________________
Dr. Paul Mackie, PhD
Committee Member
ii
Table of Contents
Abstract……………………………………………………………………………………………iii
Introduction………………………………………………………………………………………..1
History of Negative Symptoms.……………………………………………………………1
Motivational Deficits………………………………………………………………………3
Self-Determination Theory………………………………………………………………..7
Past Investigation of SDT within Schizophrenia…………………………………………12
Current Investigation…………………………………………………………………….14
Method……………………………………………………………………………………………15
Archival Data Procedure…………………………………………………………………15
Participants……………………………………………………………………………….16
Materials…………………………………………………………………………………17
Results……………………………………………………………………………………………20
Aim 1: Type, Level, Sustainability of Motivation……………………………………….20
Aim 2: Relationships with Motivation Orientations……………………………………..22
Aim 3: Differences between High and Low Motivation Groups…………………………25
Discussion………………………………………………………………………………………..29
References………………………………………………………………………………………..36
Tables…………………………………………………………………………………………….40
Appendix…………………………………………………………………………………………49
iii
Abstract
Research has implicated motivational deficits as having a severe impact on functional outcomes
and quality of life for individuals with schizophrenia. There has been a call for investigation on
how these motivational deficits impact different aspects of the therapeutic process for these
individuals. A popular model of motivation used in recent investigation with schizophrenia has
been Self-Determination Theory. This theory tries to describe why individuals undertake specific
goals and behaviors, with the focus being the content of goal-directed outcomes and the
regulatory processes with which outcomes are pursued.. The goal of this investigation is to
examine the impact of self-determined motivation on participation in a cognitive remediation
intervention program for a group of individuals with schizophrenia.
Results suggest there was some stability for motivation throughout the program. Participants
experienced an increase in intrinsic motivation and a decrease in both extrinsic and amotivation
during their time in the program. Self-determined motivation had consistent significant positive
relationships with aspects of better participant experience and work behavior. Relationships with
treatment response were found to be inconsistent. There were significant differences between
aspects of intrinsic and extrinsic motivation when it came to elements of participant experience,
work behavior, and treatment response with self-determined motivation associated with better
performance.
Keywords: Schizophrenia, Negative Symptoms, Motivation, Self-Determination The
1
Introduction
Negative symptoms within the diagnostic criteria for schizophrenia describe a loss of
typical functioning (Kirkpatrick, Fenton, Carpenter, & Marder, 2006). Included under the
umbrella of the definition of negative symptoms within the field of psychology today are blunted
affect, poverty of speech, asociality, avolition, and anhedonia (Foussias & Remington, 2010).
The symptoms of hallucinations and delusions may be more readily associated with the term
schizophrenia in society today, but recent investigation has determined that these negative
symptoms are core features of schizophrenia and can be just as debilitating as the experience of
positive symptoms (Barch & Treadway, 2014; Kirkpatrick et al., 2006.)
History of Negative Symptoms
Discussion of these deficits has a long history. In Kraepelin’s description of dementia
praecox he observed a “weakening of mental processes resulting in deficits” (Jablensky, 2010).
This definition allowed for better description of the experience individuals had with the disorder,
as it allowed for an illustration which better captured what happened during the course of the
disorder. Though description of negative symptoms predated the coining of the term
“schizophrenia”, the main focus of research began with positive symptoms. The
psychopharmacological revolution within psychological treatment observed in the 1950s drove
the focus into positive symptomology (Foussias & Remington, 2010). Antipsychotic medication
allowed for abrupt alleviation of these symptoms which accompany schizophrenia, so it seems
logical as to why they were the main focus for investigation. This trend within research
continued for decades until the work of Carpenter (1988) and Crow (1980) shed light on the
importance of negative symptoms.
2
Carpenter (1988) and associates were the first to scientifically confirm negative
symptoms were a separate aspect of psychopathology with their own therapeutic implications.
This allowed for negative symptoms to be viewed as a separate construct that needed further
investigation. Crow (1980) concluded there were distinct types of schizophrenia based off the
presentation of either positive or negative symptoms. Type 1 was associated with the presence of
mainly positive symptoms, while Type 2 was associated with the presence of mainly negative
symptoms. The typology view has been disregarded, and the field today has pushed to describe
the experience of schizophrenia on a spectrum, but that does not mean negative symptoms are
not seen as a separate aspect of the disorder.
A number of models have been used to investigate the structural validity of negative
symptoms, and this research has confirmed negative symptoms repeatedly load on a factor
separate of positive and disorganized symptoms (Blanchard & Cohen, 2006; Strauss et al., 2013).
These investigations have also allowed for the revelation that negative symptoms themselves are
multidimensional instead of unitary (Blanchard & Cohen, 2006; see also Strauss et al., 2013).
This has aided in the creation of specific negative symptomology associated with deficits in
functioning as well as assessment measures to help further describe the experience. Additional
factor analysis has created two main clusters that encompass all symptoms within the concept.
The first cluster is themed “diminished expressivity” and includes restricted affect and alogia,
while the second cluster is themed “motivational deficits” and includes avolition, anhedonia, and
asociality (Strauss, Waltz, & Gold, 2014).
Focusing investigation on negative symptoms has gained momentum in recent years.
There is now compelling evidence regarding the clinical and theoretical importance of negative
symptoms within the field of psychology today (Blanchard & Cohen, 2006). Much of this has
3
been driven by findings which have associated negative symptoms with poorer recovery,
functional outcomes, and treatment response for individuals with schizophrenia (Horan, Kring,
Gur, Reise, & Blanchard, 2011; Kirkpatrick et al., 2006; Strauss, Harrow, Grossman, & Rosen,
2010). There is a consensus within the field that negative symptoms are an area of therapeutic
focus themselves (Kirkpatrick et al., 2006). Psychopharmacological interventions are commonly
used to help alleviate the experience of hallucinations and delusion due to the biological basis of
the symptoms. The impact of antipsychotic medication on positive symptomology has not seen
any transfer into the area of negative symptomology. This observation has shed light on the idea
that the two aspects of symptoms do not share the same underlying pharmacology (Kirkpatrick et
al., 2006). This information has driven further investigation into the specific impact negative
symptoms have on individuals with schizophrenia. Though it is important to investigate the full
breadth of negative symptoms, recent research has theorized that the domain of motivational
deficits has a bigger impact on areas of functional outcome, quality of life, and recovery than
diminished expressivity (Strauss et al., 2014).
Motivational Deficits
Deficits in motivation and initiating goal-directed behavior are seen as core features of
the experience of schizophrenia (Waltz & Gold, 2016). Research within this area has changed in
recent years due to increased understanding of the processes driving the deficits. There was a
belief within the field that motivational deficits were tied to ahedonic symptoms, which are best
defined as limited capacity for experiencing pleasure. The explanation of why individuals with
schizophrenia did not participate in goal-directed activities was because these activities were not
found to be pleasurable in the moment and lowered initiation of any behavior tied to the activity.
Research does back the notion that individuals with schizophrenia have a reduction of interests,
4
desires, goals, and purposeful or self-initiated acts (Fervaha, Foussias, Agid, & Remington,
2015; Foussias & Remington, 2008; Strauss & Gold, 2012). Recent investigation has revealed a
more complicated process than just a limited capacity for experiencing pleasure. The consensus
within the field now is that underlying disturbances in reward anticipation and learning, value
representation, and effort-cost computation are driving deficits in motivation (Strauss et al.,
2014).
Research on the prefrontal cortex and basil ganglia, two areas of the brain which are
prominent with learning, have shed light on the cognitive impairments that influence the
motivational deficits found in individuals with schizophrenia. Goal-directed behaviors are reliant
on several elements, which include not only the hedonic experience or “liking” of reward, but
also the anticipation of rewards, development and sustained representation of the reward, and
guiding and planning behavior toward future reward (Schlosser et al., 2014). Investigation with
individuals with schizophrenia has found a deficit in many of these basic elements. Strauss,
Waltz, and Gold (2014) conducted a literature review that highlights these many deficits. First,
individuals with schizophrenia show an impairment in anticipating rewards by having difficulty
with predicting upcoming rewards. Studies have shown they have the ability when predictive
cues are given, but without them, there is no activation within the area for predicting any
upcoming rewards from behavior or the environment. Tied with this, individuals with
schizophrenia display an impairment with generating, maintaining, and updating mental
representations of value. Due to deficits in the prefrontal cortex, specially work behavior, the
individual displays problems with creating an idea about what the value of a behavior or activity
will be. Not only do they display troubles in creating a representation, but also once one is made,
they have a difficult time keeping the current representation of value as well as changing it based
5
on new information. Another factor which plays into value representation is the deficit these
individuals have in making rapid behavior changes in response to feedback. Further analysis
shows these individuals are more likely to learn from negative feedback when compared to
positive feedback. The individual will shape their behavior based on what they perceive as
avoiding punishment rather than past experiences that have resulted in rewards. Finally,
individuals with schizophrenia display some deficits in their decision making. It is believed this
is driven by how the individual “explores their environment” as well as the computation of
“effort versus cost” in behavior and activities. It is believed individuals are more likely to repeat
actions than “explore” and try new ones that could net a better outcome. There is also research
which has shown a deficit in the ability to correctly compute how much effort a behavior or
activity will take versus the cost or outcome of said behavior or activity.
Reviewing the literature on goal directed behavior and the difficulties individuals with
schizophrenia experience with its basic elements, it is easy to illustrate the motivational deficits
experienced by these individuals. Initiating a behavior would be difficult if there were a
disruption in the representation or anticipating of value of that behavior. There would be very
little meaning behind the behavior itself. Also, there would not be a drive to change behavior
more rapidly because the meaning behind the behavior is more likely to be based on avoiding
punishment. This ??? could cause a stagnation in behavior and foster lower motivation. Further
impact on motivation and initiation of goal-directed behavior could be observed when coupled
with difficulties in decision making. Specifically, these motivational deficits would have a major
influence on behavior that is tied to functioning for these individuals due to the disorder. It
would cause disruption in working towards goals which are seen as pleasurable, productive
6
occupational work, engaging in therapy, and impairment in cognitive performance (Brach,
2005).
As highlighted previously, motivational deficits are theorized to have a greater impact on
quality of life than any other negative symptom (Strauss et al., 2014). Research has confirmed
motivational deficits are tied to worse community functioning, more dysfunction, and higher
rates of comorbidity with anxiety and mood disorders (Fervaha et al., 2015; Schlosser et al.,
2014; Tobe et al., 2016). Intrinsic motivation provides internal regulation of behavior based off
an individual’s likes and values, while amotivation is initiating a behavior without intent (Deci &
Ryan, 2000b). Behavior has intent behind it and is regulated by either intrinsic or extrinsic
motivation, depending on whether the regulation is coming internally or externally. In
comparison, amotivation lacks any kind of regulation. Research has shown intrinsic motivation,
tied to improved functioning, is reported less in individuals with schizophrenia while
amotivation, tied to poorer functioning, is reported more. This higher level of amotivation has
severe impacts for individuals with schizophrenia, as it has a direct impact on functional
outcome, and specifically, that of role performance, household adjustment, and social
functioning (Foussias & Remington, 2008).
There has been a call for more research within the area of motivational deficits to further
illustrate the impact on individuals with schizophrenia (Strauss et al., 2014). There is a need for
continued information on how concepts of motivation are related to specific areas of life
including social, educational, and occupational functioning . Initially the belief within the field
was motivation displayed a construct difficult to quantify and study and the results of any
investigation would be too subjective to generalize the findings (Barch, 2008). Many reliable and
7
valid measures used to assess levels of motivation have been created in recent years, which
address these former concerns.
The most important area is believed to be investigating how motivational deficits impact
treatment. As psychopharmacology has become the preference for improving the experience of
positive symptoms, there has been no carry over to negative symptoms ,and specifically, that of
motivation (Tobe, 2016). Token economies have been used in the past research on cognitive
tasks for individuals with schizophrenia, but the results indicate a problem with generalizability,
as the monetary rewards did not improve overall cognitive functioning (Barch, 2008). This
revelation suggests that intrinsic motivation may have more utility for treatment than extrinsic
motivation. It is important to be able to translate models of motivation directly into studies of
patients with schizophrenia (Strauss et al., 2014). Not only will this allow for some description of
the impact motivational deficits will have on treatment interventions, but also point at specifc
aspects of interventions which can be added or changed to combat these deficits. A model of
motivation that has gained popularity recently when investigating these deficits for individuals
with schizophrenia has been Self-Determination Theory (SDT) developed by Dr. Edward Deci
and Dr. Richard Ryan (2000b).
Self-Determination Theory
Deci and Ryan (2000b) gave a complete overview of Self-Determination theory in their
article titled, “The “what” and “why” of goal pursuits: Human needs and the self-determination
of behavior”. Contemporary beliefs about motivation assume behaviors are initiated to the extent
to which they will lead to desired outcomes and goals. It is the basic premise that an individual is
more likely engage in and continue a behavior or activity because it will bring a desired
outcome. The behavior has been reinforced by a positive experience. Where SDT begins to break
8
away from contemporary thoughts is the distinguishing of types of goals and outcomes and the
impact on affective and behavioral consequences. The main questions which are trying to be
answered about behavior through SDT are simply, “what?” and “why?”. SDT focuses on the
content of goals to gain more information and understanding. Instead of believing two equally
valued goals would have the same performance and affective response, SDT breaks down goals
into content and the regulatory processes these outcomes are pursued. To address the why of
behavior, SDT postulates that there are innate psychological needs which help integrate the
content of goals and the regulatory processes. These needs act as the psychological driving force
behind which regulatory process are chosen within a goal pursuit. Specifically, the needs of
autonomy, competence, and relatedness are the three discussed in SDT. These needs are seen as
the most important for ongoing psychological growth, integrity, and well-being. The most
effective functioning and optimal development are associated with the satisfaction of these three
basic needs from the environment. If any of these needs are not met, the consequence would be
decreased functioning and development.
SDT shares some commonality with drive theories because of the discussion of satisfying
needs, but there is one main difference between them. This difference is SDT focuses on
psychological needs, while drive theories focus on physiological needs. Motivation within a
drive theory is based off a physiological experience due to some reduction from a set point or
homeostasis within a given need. The experience of thirst for an athlete is a good example. The
athlete undertakes whatever physical activity is needed to play their given sport. This physical
exertion causes the individual to experience some level of dehydration. The body then alerts the
individual of this dehydration by causing them to feel thirsty. The individual then drinks water
until they have satisfied this need of hydration back to their set-point and the feeling of thirst
9
goes away. Drive theory is based off of some reduction of a set-point for a need. SDT postulates
the set-point for an individual is growth and believes humans are naturally inclined towards
growth and activities that satisfy psychological needs (Deci & Ryan, 2000b). When specifically
discussing the three main needs of autonomy, competency, and relatedness, SDT postulates it is
adaptive for individuals to engage in interesting activities, excursive compacities, and pursue
connectedness (Deci & Ryan, 2000b).
The main purpose of these psychological needs is to bring meaning to the process of
intrinsic motivation. Deci and Ryan (2000b) postulate individuals are naturally inclined to
optimal development and growth and actively engage in their environment to do so. Intrinsic
motivation is seen as the optimal psychological growth function. Intrinsically motivated
behaviors are associated with the most effective functioning. Intrinsically motivated activities are
defined as, “those that individuals find interesting and would do in the absence of operationally
separable consequences” (Deci & Ryan, 2000b). Research has shown the needs of autonomy,
competence, and relatedness provide the most sufficient definition of intrinsic motivation. The
need of autonomy illustrates an individual being able to undertake activities naturally based off
of inner values and interests. This is where the term, “self-determined” is derived from.
Autonomy describes behavior that is determined solely off of the self and inner interest, and
intrinsically motivated behaviors are viewed as the prototype of autonomous activities. The need
of competence describes the individual having not only the feeling of self-determination behind a
behavior, but also having the skills needed to undertake the behavior. Research has shown
feedback following a task enhances intrinsic motivation compared to no feedback at all (as cited
in Deci & Ryan, 2000b). The feedback taps into the need of competence and allows the
individual information to illustrate their competencies within a certain activity. Finally, the need
10
of relatedness describes the aspect of social cohesion within the building of the self. Research
has shown intrinsic motivation is associated with social cohesion. A simple way to think about
this relationship is through attachment theory and with intrinsic motivation being more likely to
develop in the context of secure attachment which fosters relatedness. If there is the underlying
sense of security, individuals will feel autonomous and competent with their behavior.
Deci and Ryan (2000b) state that depending on if these three needs are satisfied or if any
one or more are not fulfilled, the individual will create one of three causality orientations which
will guide and regulate goal-directed behavior. These are the regulatory processes that were
discussed earlier. SDT illustrates this process of regulating behavior with the use of a spectrum
with one end being self-determined behavior and the opposite end being non-self-determined
behavior. The first causality orientation is “Autonomous” and falls under the umbrella of self-
determined. This orientation is essentially intrinsic motivation as it regulates behavior on interest
and self-endorsed values. Along with the aspect of intrinsic motivation, well integrated extrinsic
regulation is found within this orientation. This is essentially the idea that if an individual can
identify the importance of external rewards, which come as part of a behavior, and then integrate
with aspects of the self, this can mimic intrinsic motivation. A good example of this is exercise.
Becoming physically fit through the means of frequent physical exercise has many external
rewards such as health and body aesthetic benefits. Integration of these rewards would be the
individual understanding the importance of working out to their overall health and well-being
and making that an aspect of their self-concept. Therefore, being a healthy person is in their self-
concept, so the external rewards are no longer driving the behavior and they are engaging in
physical activity based solely off of internal values. This Autonomous orientation is created
through the satisfaction of all three psychological needs. It’s assumed this is the case because
11
Autonomous orientation is essentially intrinsic motivation. Also, because of this association and
satisfaction of the three needs, this orientation is viewed as providing the most effective
functioning and promotion of growth and well-being.
The second causality orientation discussed by Deci and Ryan (2000b) is the “Controlled”
orientation. This orientation is essentially extrinsic motivation, as behavior is regulated by
external pressures and how it is perceived that one should behave. The Controlled orientation is
found within the middle of the spectrum for SDT. There is the possibility that this orientation is
regulated by the same external factors as Autonomous, but integration of importance of the
regulator is missing. These regulators do not become part of an individual’s self-concept, so they
are still seen as external pressure instead of internal values. The needs of competence and
relatedness are satisfied, but the need for autonomy is not fulfilled. The individual can still
receive information about their competencies and have a sense of social cohesion, but their goal-
directed behaviors are being regulated by outside pressures instead of internal values and beliefs.
It is likely the individual may be more likely to regulate their behavior based on avoiding
punishment instead of gaining rewards, which would have direct consequence for goal-directed
behavior due to lack of internal drive.
The third and final orientation discussed by Deci and Ryan (2000b) is the “Amotivation”
orientation. This orientation may also be described as the “Impersonally” orientation. The basic
definition of this orientation is not behaving intentionally and having focus on ineffective
indicators within the environment. This orientation is found on the opposite end of Autonomous
and is essentially seen as non-self-determined behavior. Using the Autonomous and Controlled
orientation as comparison, behavior from the Amotivation orientation has no regulation from
either internal values and interests or external pressures. Whether goal-direct behavior is
12
regulated internally or externally, there is intention within doing the behavior itself. There may
be some intrinsic value, or it may allow the person to avoid punishment and this provides
meaning behind the behavior. Behavior regulated by the Amotivation orientation lacks this
meaning for the individual. There is no intention undertaking a behavior, because there is a lack
of any regulation either internally or externally. All three of the psychological needs are not met.
The individual is not regulating goal-directed behavior based off of self-determination, is not
competent in the skills needed to undertake the behavior, and is not connected to the larger social
structure surrounding them. The individual would just be doing the behavior without fully
understanding the behavior and the reason why they are doing it. There would be no drive either
internally or externally due to lack of reward. A good example would be a student pursuing good
grades. A student who falls within the Autonomous orientation would pursue good grades
because they enjoy school and good performance in school is part of their self-concept. A student
who falls within the Controlled orientation would pursue good grades due to gaining allowance
from their parents or they may feel some social pressure from their peers to do so. A student who
falls within the Amotivation orientation would have no regulation behind pursuing good grades
and this specific goal-directed behavior would lack intention and likely be stopped.
Past Investigation of SDT within Schizophrenia
The research which has been done within the area of schizophrenia and SDT has focused
on satisfaction of the three psychological needs, understanding the nature of the causality
orientation within the population, and their impact on goal creation and functional outcomes.
Breitborde, Kleinlein, and Srihari (2012) provide information on the satisfaction of the three
psychological needs for individuals with first-episode psychosis. The investigation compared the
report of a group of individuals diagnosed with first episode psychosis to a group of same aged
13
healthy controls to understand the nature of need satisfaction. The investigation demonstrated
that the group with first-episode psychosis reported significantly less satisfaction of all three
psychological needs than healthy controls. Barch, Treadway, and Schoen (2014) investigated the
nature of the causality orientation for individuals with schizophrenia and the association of these
orientations to community and work functioning. They found that individuals with schizophrenia
were significantly more likely to be in the Amotivation orientation compared to healthy controls
and the Amotivation orientation was correlated with poorer functioning in both community and
work roles. Tobe et al. (2016) also investigated the nature of the causality orientation for
individuals with schizophrenia, focusing on the association with social functioning. They found
that Autonomous orientation was significantly lower for individuals with schizophrenia and this
orientation was the strongest predictor of social functioning. Gard et al. (2014) examined the
construction of goals for individuals with schizophrenia through the lens of SDT and how the
needs and causality orientation impacted these goals. They discovered individuals with
schizophrenia were less motivated to fulfill the needs of autonomy and competency when
compared to healthy controls. An interesting finding was for the need of relatedness; there was
no difference between individuals with schizophrenia and healthy controls. The investigation
also concluded individuals with schizophrenia were significantly more likely to have goals based
in disconnection and disengagement, which has association with the Amotivation orientation.
Current Investigation
As highlighted, there has been a call for further investigation within the area of
motivational deficits for individuals with schizophrenia in order to understand the full impact of
these deficits across various factors. SDT has gained popularity within investigation, as it adds
thorough definition and meaning to the motivation process that drives goal-directed behavior. It
14
was believed motivation was too large of a construct to measure and examine, but SDT gives an
opportunity to break down goal-directed behavior into the simple aspects of what and why.
Much of the investigation that has been conducted has been on the nature of the needs and
causality orientations and how they impact overall functioning for individuals with
schizophrenia. As discussed, it is also important to explore models of motivation in relation to
treatment response. This focus will provide important insight into how motivational deficits
impact the process of treatment. The main goal of this investigation is to examine how
motivation orientations as defined by self-determination theory impact the therapeutic process
for individuals with schizophrenia. The study design is a secondary data analysis using an
archival data set from a cognitive remediation efficacy clinical trial. This archival data set
includes self-report measures of motivation and participant experience, as well as, an objective
measure of work performance. These constructs were assessed at multiple points throughout the
program. This data will allow for an analysis that not only covers behavior gains made due to an
intervention, but also many other important facets that accompany treatment response. The first
aim of this investigation is to evaluate motivational levels and sustainability of motivation during
the cognitive remediation program in patients with schizophrenia. The main areas of interest
within this aim are understanding if participants are motivated for cognitive remediation training,
what type of orientation, and how motivation changes over the course of the program. The
second aim is to examine relationships between motivational orientations and participant
experience, observed work performance, and change in cognitive performance. This will provide
information on the influence of motivation that may be had within the areas of personal
experience, work behavior, and treatment gains. The final aim is to examine how individuals
differ in the aspects of participant experience, observed work performance and change in
15
cognitive performance based off of differences in the motivational orientations. The goals are to
understand the exact nature of the relationships between the motivational orientations and the
identified outcomes and to determine if there are significant differences in outcomes associated
with type and level of motivational orientation.
Method
Archival Data Procedure
The archival data set used for this investigation comes from a randomized, double-blind,
active placebo-controlled, parallel groups clinical trial of a 48-session cognitive remediation
program. Focus of this clinical trial was to examine the efficacy of using cognitive remediation
as an intervention for working memory deficits for a group of individuals with schizophrenia.
The program included three 60-minute sessions weekly at the Minneapolis Veterans Affairs
Health Care System (VAHCS). Participants were paid for their attendance. Participants were
randomly assigned to either the treatment condition of cognitive remediation or the active-
placebo control condition, a computer skills class. This analysis will focus on the data from the
participants who finished the active-treatment condition. This will allow for illustration of the
impact of motivation for the cognitive remediation intervention itself and not the placebo control
condition.
The cognitive remediation program that was chosen included the word n-back task. The
n-back task is a computer program that acts as a training tool and measures working memory
ability. Participants decide whether a stimulus in a sequence is the same or different from one
that appeared “n” items ago (Kane, Conway, Miura, & Coleflesh, 2007). The participants within
this study had words as the stimulus for the task. They were presented with a word for a few
16
seconds, the screen would go blank, and then another word would appear on the screen. The task
was to decide if this new word matched the previous word that was shown on the computer
screen. This process continues, and the participant evaluates each new word that appears. This
would be an example of “1-back,” as the evaluation only consisted of the initial two words,
comparing the current word with one word back. As the participant does better, the word for
comparison keeps moving back further. “2-back” would have the participant compare the current
word with the word that appeared two previous. “3-back” would be three and the process
continues. The program does not advance the participant to a new stage until they get enough
correct answers in the current stage they are in. If they move up and answer too many questions
wrong, the participant is moved back down.
There were many measures that were completed during the program. Self-report
measures of motivation were assessed at baseline and post cognitive remediation training, while
subjective experience and objective work behavior were assessed at 3, 9, and 16 weeks during
the program. These measures will be fully explained shortly.
Participants
Table 1 displays the results of the participant characteristics. Sixty-six participants (51
Male, 15 Female) with schizophrenia between the ages of 24-60 (M = 46.08, SD = 9.45)
completed the active-treatment condition. As explained earlier, only participants who completed
the active-treatment condition were included in this analysis. Participants were recruited by the
Minneapolis VAHCS from the surrounding Twin Cities area. All participants met diagnostic
criteria for schizophrenia according to the DSM-IV and clinical symptoms of schizophrenia were
confirmed using the expanded Brief Psychiatric Rating Scale (BPRS), the Scale for the
Assessment of Negative Symptoms (SANS), and the Scale for the Assessment of Positive
17
Symptoms (SAPS). The average age of disorder onset was 25.83 (SD = 8.01) while the average
duration of disorder in years was 20.27 (SD = 11.32). The majority of the sample was White
(70%) followed by a small percent being African American (27%) and American Indian (3%).
Materials
Self-Determined Motivation. Self-Determined Motivation was measured using the
Treatment Self-Regulation Questionnaire (TSRQ). The self-report questionnaire measures why
individuals do or would do a healthy behavior (Williams, Deci, & Ryan, 1999) such as entering
treatment and following the program, changing unhealthy behavior, and other health-relevant
behaviors (Williams et al., 1999). The TSRQ is based in SDT as it allows for the assessment of
the degree which an individual’s healthy behavior is self-determined. Participants answer
questions on a 7-point scale (1 = Not True at All; 7 = Very True) and these rating are broken
down into subscales for the three regulatory orientations of Autonomous, Controlled, and
Amotivation. The TSRQ allows for the creation of a 4th regulatory style of “Relative
Autonomous” which measures the amount of Autonomous motivation present in comparison to
Controlled motivation (Williams et al., 1999). The Relative Autonomous orientation is
illustrating only intrinsic motivation while controlling for any integration of controlled regulators
within the self that could cross over from the Controlled orientation. The questions and length of
the questionnaire were modified to fit with the cognitive remediation treatment, which is
commonly done with the TSRQ. There are many elements of healthy behavior that could be
assessed with the measure and there is room to modify it to meet the specific demands of the
behavior in question. Participants completed the 19-item questionnaire both at baseline and post
cognitive remediation. Internal consistency across location and behaviors with Cronbach’s Alpha
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being found to be at least .73 for each orientation as well as validity has been supported though
invariance analysis (Levesque et al., 2007).
The averages for each motivational orientation were calculated to fall within the 7-point
scale used by participants. This was in large part due to the disparities in the number of questions
for each orientation. Both Autonomous and Controlled motivation had six questions for
participants to answer while Amotivation had only three. It was deemed appropriate to find the
average rating a participant would give for each motivational orientation for use in the analysis.
Participant Experience. Participant Experience was measured using the Intrinsic
Motivation Inventory (IMI). This 37-item self-report inventory assesses the participants’
subjective experience for the target activity within an investigation (Deci & Ryan, 2000a).
Participants use a 7-point scale (1 = Not True at All; 7 = Very True) to answer questions
regarding their experience with the activity being used within the specific investigation.
Assessment of the IMI was taken at 3, 9, and 16 weeks during the program. These answers allow
for ratings of six different domains of personal experience, but this analysis will only focus on
the domains of interest and enjoyment, perceived competence, effort and importance, and value.
Interest and Enjoyment is the variable that most directly assesses intrinsic motivation for the
participant (Deci & Ryan, 2000). The variables of perceived competence, effort and importance,
and value all give information regarding the participants’ beliefs of their skills for the program as
well as their overall opinion of how useful the program will be. These variables allow for the
analysis of aspects being focused on within this study, because they best represent the experience
with the cognitive remediation program itself. Domains or pressure and choice describe the
impact of extraneous variables outside of the intervention program, and thus, were excluded
from this analysis. The IMI has been found to be a valid and reliable measure for use within
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cognitive tasks with good internal consistency (.92) and test-retest reliability (.77; Deci & Ryan,
2000). Just like the TSRQ, the averages of the variables of the IMI were calculated to fall within
the 7-point scale due to disparities between the number of questions used to assess each variable.
Work Behavior. The Work Behavior Inventory (WBI) assesses objective participant
work behavior. This 36-item standardized assessment was designed specifically to measure work
performance for individuals with severe mental illness. The inventory covers 5 sub-scales, but
this analysis will only include Work Habits, Work Quality, Global, and Total Ratings. Again, the
narrowing of the domains is to focus on those that best represent the experience with the
cognitive remediation program itself. These domains will best allow for an illustration of the
participants’ work behavior in the cognitive remediation program. The domains of social skills,
cooperativeness, and personal presentation are seen as variables that represent social aspects of
the participants’ behavior that are not as necessary for completing cognitive remediation. The use
of the Total Rating variable will allow for some analysis of the variables that were not of focus.
Research team members present for the cognitive remediation sessions rated performance of the
participants on a 5-point scale (1 = Consistently Inferior and/or Inconsistent Performance; 5 =
Consistently Superior and/or Consistent Performance). Each of the variables had seven
questions giving a possible total of 35. The variable, Global Rating, was just one question at the
end of the assessment that was evaluated using the 5-point scale. The Total Rating was simply
the addition of all of the questions together with the possible score being 175. Lab members took
assessments of work behavior at three, nine, and sixteen weeks during the program. Inter-rater
reliability and internal-consistency have been found to fall within the good to excellent range
(Bryson, Bell, Lysaker, & Zito, 1997).
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Treatment Response. Treatment response for this analysis was assessed using
performance from the word n-back task and the MATRICS Consensuses Cognitive Battery
(MCCB). The N-back score for participants was recorded after each cognitive training session.
D-prime is a measure of sensitivity that reflects accuracy of performance. D-prime scores were
transformed to place performance on different versions of the N-back task on the same scale.
The transformed D-prime scores from Weeks 2 and 3 were averaged together to represent
baseline while the D-prime scores for Weeks 15 and 16 were averaged to represent the
completion. This was seen as a way to control for individuals underperforming in the first and
last weeks due to first experience with the task and possible diminished effort with the
completion of the program. A program change variable was created by subtracting the average of
weeks two and three from the average of the last two weeks to represent how much change
happened within the program.
The MCCB is a cognitive assessment that measures an individual’s overall cognitive
functioning. It includes subscales that measure not only working memory, but also attention and
vigilance, speed of processing, verbal language, visual learning, problem solving, and social
cognition. The MCCB was administered at both baseline and post cognitive remediation training.
A change variable was made subtracting a composite overall score (age and gender corrected T-
score) at baseline from the post cognitive remediation score. Having both performance on the
cognitive remediation task and overall cognitive functioning allows for a more in-depth analysis
of the impact of self-determined motivation for participants within the clinical trial.
Results
Aim 1: Type, Level, Sustainability of Motivation
