Literature Review: Acceptance and Motivation Inquiry

Literature Review

Acceptance / Motivation Inquiry (AMI)

Lex E Santí, LCSW, MFA

Introduction

Client engagement in psychotherapy is a dynamic process shaped by numerous interacting variables—motivation, readiness, emotional openness, external pressures, and the acceptance of a potential diagnosis. While extensive research has examined the mechanisms of change and the therapeutic relationship (Norcross & Lambert, 2019; Wampold, 2015), a notable gap remains: few assessment tools measure both a client’s motivation and acceptance of diagnosis prior to the first session, nor do they sufficiently guide therapists in tailoring early interventions based on client orientation.

Early renderings of the AMi

This literature review examines how psychology and psychotherapy have historically conceptualized and assessed motivation, readiness, and acceptance. Key theoretical models—Stages of Change (Prochaska & DiClemente, 1983), Self-Determination Theory (Deci & Ryan, 1985), Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999), and Motivational Interviewing (Miller & Rollnick, 1991)—offer foundational understandings of internal drive, ambivalence, and the role of psychological flexibility in treatment. Motivational Interviewing, in particular, emphasizes client-centered, directive communication strategies to elicit and strengthen motivation for change, especially in ambivalent or resistant clients.

Complementary clinical tools like the Working Alliance Inventory (Horvath & Greenberg, 1989), Readiness to Change Questionnaire (Rollnick et al., 1992), and the University of Rhode Island Change Assessment (URICA) (McConnaughy et al., 1983) primarily assess alliance and readiness after therapy begins, often missing critical insights about initial engagement.

Recent developments in research have begun to probe deeper into how clients conceptualize themselves in relation to therapy. The Perceived Acceptance Scale (PAS) (Marigold, Holmes, & Ross, 2007) measures the degree to which individuals feel accepted by others, linking acceptance to psychological well-being and openness in relationships. The Illness Identity Questionnaire (IIQ) (Oris et al., 2018) assesses how individuals incorporate a diagnosis or condition into their identity, distinguishing between adaptive (e.g., acceptance, enrichment) and maladaptive (e.g., engulfment, rejection) identity styles. These instruments suggest that acceptance is not a simple yes-or-no state but a complex, identity-based orientation that may influence how one participates in psychotherapy.

Similarly, the Insight Scale (David et al., 1995) quantifies the extent to which clients recognize they have a mental health condition, accept this diagnosis, and believe in the need for treatment. This scale is particularly relevant for individuals navigating the early stages of diagnosis, offering clinicians a window into internalized attitudes that may predict resistance or openness. Additionally, Keyes’ (2005) Complete State Model of Mental Health introduces a two-axis model—mental illness and mental health as distinct but correlated continua—thereby affirming that the absence of pathology does not imply the presence of flourishing. His work advocates for a broader conceptualization of well-being that aligns with motivational and identity-based assessments.

Numerous tools have been developed to assess client readiness, motivation, insight, and acceptance—variables strongly associated with engagement and outcomes in psychotherapy. These tools vary in focus, timing, and theoretical underpinnings. Some are stage-based models of change, while others assess relational alliance or symptom distress. However, few instruments combine assessments of both motivation and diagnostic acceptance in a unified, pre-treatment format. This section summarizes several prominent tools currently used in clinical practice. It considers factors such as what brought the client to therapy, their motivation to engage, perceived obstacles, and their overall congruence with the idea of therapy and diagnosis. The AMI positions these variables as central—not secondary—to therapeutic attunement and alliance. By making client motivation to be in therapy and acceptance of diagnosis explicit and observable from the outset, the AMI offers a fresh lens for engagement, helping therapists meet clients not only where they are, but who they are as they arrive.

Theoretical Foundations

Client readiness for therapy emerges from a complex interplay between internal motivation, acceptance of having a condition or issue that may benefit from treatment, and the perceived relevance or value of pursuing change through the therapeutic process. Foundational theories offer a scaffold for understanding these dimensions.

• Stages of Change Model (Prochaska & DiClemente, 1983) conceptualizes readiness as fluid, identifying phases through which individuals progress toward action—precontemplation, contemplation, preparation, action, and maintenance. It has been particularly influential in addiction treatment and motivational interviewing, offering a non-pathologizing approach to ambivalence.

• Self-Determination Theory (Deci & Ryan, 1985) proposes that motivation exists on a continuum from extrinsic (e.g., compliance due to external pressure) to intrinsic (e.g., a desire for personal growth). It emphasizes autonomy, competence, and relatedness as core psychological needs fundamental to sustainable motivation.

• Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, & Wilson, 1999) frames acceptance as an active process—a willingness to engage with difficult emotions in service of meaningful life goals. Core ACT processes include cognitive defusion, experiential avoidance, and psychological flexibility.

• Common factors theory (e.g., Lambert, 1992; Wampold, 2001; Norcross, 2011) emphasizes shared therapeutic elements—such as the therapeutic alliance, client hope, empathy, and expectancy of improvement—as core contributors to treatment success, regardless of modality.

• Mindfulness approaches (Kabat-Zinn, 1990; Segal et al., 2002) emphasize present-moment awareness and nonjudgmental acceptance. They improve emotional regulation, reduce rumination, and enhance psychological well-being.

• Motivational Interviewing (MI) (Miller & Rollnick, 1991; 2013) is a client-centered, directive method for enhancing intrinsic motivation to change by helping clients explore and resolve ambivalence. Grounded in respect for autonomy and the stages of change, MI is especially effective in early therapy engagement where resistance or mixed motivation is common. It informs the AMI’s attention to internal vs. external referral, client ambivalence, and the value of eliciting rather than imposing change.

• Existential therapy emphasizes human freedom, responsibility, and the search for meaning in the face of life’s inherent uncertainties. Philosophical foundations—from Kierkegaard and Sartre to Frankl, May, and Yalom—inform clinical practice that helps clients confront core anxieties, reexamine motivations, and find meaning—even in diagnosis—thus fostering insight, engagement, and agency.

Together, these frameworks—including motivational models, mindfulness approaches, existential therapy, and diagnostic insight tools—guide the conceptual underpinning of the Acceptance and Motivation Inquiry (AMI) by illuminating how clients locate themselves in relation to change, identity, and therapeutic possibility.

Clinical Measures and Assessment Tools

Numerous tools have been developed to assess client readiness, motivation, insight, and acceptance—critical variables in predicting engagement and outcomes in psychotherapy. However, few tools assess both motivational states and acceptance of care within a unified framework at therapy onset. This section summarizes several prominent instruments.

3.1 University of Rhode Island Change Assessment (URICA)

Developed by DiClemente and Hughes (1990), the URICA is a self-report measure that evaluates stages of change—precontemplation, contemplation, action, and maintenance. It is widely used in addiction treatment and behavioral health but can be time-consuming and may not capture emotional or relational readiness for therapy.

3.2 Readiness to Change Questionnaire (RCQ)

Created by Rollnick et al. (1992), the RCQ is a brief, stage-based measure grounded in the same theoretical framework as the URICA. It is commonly used in health psychology and substance use contexts, offering a faster but more limited assessment of motivational readiness.

3.3 Working Alliance Inventory (WAI)

Developed by Horvath & Greenberg (1989), the WAI measures the strength of the therapeutic alliance through task agreement, goal alignment, and relational bond. While a robust predictor of outcomes, it is designed for use once therapy has begun and does not assess initial motivational or acceptance variables.

3.4 Treatment Motivation Questionnaire (TMQ)

Based on Self-Determination Theory, the TMQ (Ryan, Plant, & O’Malley, 1995) evaluates four motivational types: external regulation, introjection, identification, and intrinsic motivation. Though conceptually robust, it is primarily used in substance use settings and does not explicitly measure acceptance.

3.5 Illness Identity Questionnaire (IIQ)

The IIQ (Oris et al., 2016) identifies four ways individuals relate to a chronic condition: rejection, engulfment, acceptance, and enrichment. Initially developed for somatic illness, it provides insights into identity integration processes increasingly relevant in mental health settings.

3.6 Insight Scales

The Birchwood Insight Scale (Birchwood et al., 1994) and the Insight Scale (Marková et al., 2003) assess recognition of mental illness, attribution of symptoms, and treatment compliance. These instruments provide a cognitive perspective on diagnostic acknowledgment, though they may not fully capture emotional or identity-based dimensions of acceptance.

3.7 Session Rating Scale (SRS)

The SRS (Duncan et al., 2003) is a brief, four-item tool used to evaluate the quality of the therapeutic alliance at the end of each session. It assesses relational bond, agreement on goals and tasks, and overall fit. As a post-session measure, it does not capture pre-treatment motivational or acceptance variables.

3.8 Longitudinal and Outcome Measures

Other commonly used measures include:

• Outcome Questionnaire-45 (OQ-45) (Lambert et al., 1996) – tracks symptom change and interpersonal functioning.

• PHQ-9 / GAD-7 – monitor depression and anxiety symptoms.

• CORE-OM – assesses psychological distress across multiple domains.

These tools are important for monitoring progress but are primarily symptom-focused; they do not assess clients’ initial readiness or acceptance stance at therapy entry.

Gaps in the Literature

Despite a proliferation of theoretical models and psychometric tools aimed at understanding client behavior in psychotherapy, notable limitations persist in how clinical psychology and social work assess motivation and acceptance at the outset of care. These limitations have real implications for therapeutic alliance, treatment planning, and client outcomes.

4.1 Fragmentation of Constructs

Current assessment tools tend to isolate either motivation or readiness, rarely integrating both with a client’s emotional acceptance of help or diagnosis. Instruments like the URICA and RCQ emphasize behavioral stages of change, while tools like the TMQ assess motivational origins (e.g., internal vs. external). However, few measures inquire into how the client feels about therapy itself—whether they believe in the process, trust clinicians, or feel emotionally safe enough to engage. This split between cognitive motivation and emotional/diagnostic readiness creates an incomplete picture of the client’s therapeutic posture.

Even broader frameworks like Keyes’ (2005) Complete State Model of Mental Health, while useful at a population level, do not provide clinicians with micro-level, session-ready tools for assessing how an individual relates to therapy at the outset. The AMI fills this theoretical and clinical gap by bridging internal motivation, diagnostic acceptance, and relational stance into a single framework, offering conceptual coherence and clinical usability.

4.2 Post-Hoc Focus on Alliance

The bulk of alliance research, including widely used tools like the WAI and SRS, takes place after therapy has begun. While these instruments provide valuable insights into therapist-client dynamics—such as goal agreement, task collaboration, and relational bond—they are designed to assess the strength of the therapeutic alliance within or after sessions, not before, nor are they multi-dimensional. As such, they offer limited predictive utility for initial engagement.

This post-hoc orientation may partly explain why early dropout remains a persistent challenge. Rates as high as 20–57% in community mental health settings (Swift & Greenberg, 2012) show early termination often occurs before a strong alliance can form—precisely when predictive insight into a client’s readiness and acceptance would be most valuable.

4.3 Overemphasis on Pathology and Technique

Traditional intake procedures often prioritize diagnostic criteria, risk assessment, and symptom inventories, leaving little room for evaluating a client’s subjective experience of seeking help. This reflects a broader issue in the mental health system: the assumption that once a client arrives at therapy, they are “ready” for it. Yet many clients enter treatment ambivalently, pressured by others, or carrying negative prior experiences with therapists, medical systems, or authority figures.

By failing to explicitly assess these variables, clinicians may unintentionally misread a client’s resistance or detachment as defiance, pathology, or lack of insight—rather than as a signal of unmet relational or motivational needs.

4.4 Inattention to Fit and Worldview Alignment

Little research exists on how value alignment, cultural worldview, and therapeutic orientation impact early-stage engagement. Clients may arrive open to support but skeptical of Western therapeutic models, suspicious of authority, or seeking spiritual rather than psychological guidance. Tools that fail to inquire about such preferences miss the opportunity to adapt the approach, refer appropriately, or co-construct a meaningful process.

The AMI addresses this directly by asking clients not only why they’re seeking therapy but also how they feel about therapy itself—questions that can reveal critical mismatches before they derail treatment.

4.5 Lack of Clinician-Focused Application Tools

Many existing assessments are created for research purposes or academic evaluation rather than real-time clinical utility. The language is often technical or inaccessible, requiring scoring and interpretation that do not fit easily into fast-paced outpatient, community, or private practice settings. There is a need for a brief, accessible, client-centered tool that offers immediate value to therapists without increasing administrative burden.

Summary: The absence of integrated, pre-treatment assessments for motivation, acceptance, and fit results in preventable alliance ruptures, premature dropout, and suboptimal treatment planning. By addressing these gaps, the AMI aims to shift the field toward a more responsive, personalized, and human-centered approach to beginning therapy.

5. Contribution of the Acceptance and Motivation Inquiry (AMI)

The Acceptance and Motivation Inquiry (AMI) was created to fill a crucial limitation in mental health practice: the absence of a practical, pre-treatment tool that assesses both a client’s motivation to change and their acceptance of their diagnosis. While traditional tools tend to focus narrowly on either stage of change, alliance strength, or internal drive, the AMI offers a more holistic view of the client’s orientation toward therapy itself—before treatment begins.

Rendering of the typologies

Developed through years of clinical observation, feedback from supervisees, and iterative use in diverse therapeutic settings, the AMI reflects a grounded, practice-based contribution to the field. It integrates insights from motivational, humanistic, and relational theories, while remaining brief, accessible, and scalable across clinical environments.

At the heart of the AMI is the recognition that motivation and acceptance are distinct but interrelated constructs:

• Motivation speaks to the desire to change, often shaped by internal readiness, external pressures, or urgency.

• Acceptance refers to internal identification with or resistance to the diagnostic label or concept of “having a problem.”

The AMI allows for differentiated client profiles, recognizing that a person may be highly motivated to seek change yet struggle to accept that they have a mental health condition—or vice versa. Sample items that assess motivation include: “I feel ready to do the work of therapy,” and “I am here mostly because someone else thinks I should be.” Items reflecting diagnostic acceptance include: “I believe something is going on with me that needs attention,” and “I’m not sure I really have a problem.” This dual-axis clarity helps clinicians tailor their initial stance—whether that means validating uncertainty, exploring meaning around diagnosis, or pacing interventions in line with the client’s internal readiness and self-perception.

Unlike longer instruments like the URICA or academically dense ones like the TMQ, the AMI is:

• Brief (30 items or fewer)

• Client-centered, using accessible language

• Self-administered, typically taking 5–10 minutes

• Immediately interpretable, offering therapists insight before session one

Its delivery format—online, paper, or verbal—makes it adaptable to settings from university counseling centers to private practice to telehealth platforms. It has been used in intakes, group sessions, and training workshops to help clinicians avoid mismatched interventions or alliance ruptures.

In practice, clinicians may follow up AMI responses with reflective prompts based on client responses, such as: “I see you strongly agreed with the statement ‘I’m unsure I even need therapy.’ Can you say more about that?” These follow-ups are not part of the AMI itself but illustrate how it can spark collaborative dialogue. In this way, the AMI is not only a metric but a conversation-starter that empowers clients as co-creators of the therapeutic process.

The AMI also holds promise in supervision, training, and outcome research:

• In supervision, it helps early-career clinicians better attune to motivational and acceptance cues.

• In training, it models a relational and reflective stance.

• In research, it may predict early dropout, alliance ruptures, or mismatches between approach and client readiness.

Preliminary use suggests AMI data correlates with observed patterns in engagement, though further psychometric validation is underway.

By offering a brief, relationally attuned, and theoretically integrated tool, the AMI expands a clinician’s ability to understand a client’s internal state before formal treatment begins. It aligns with personalized, trauma-informed care and begins with a simple premise: each client enters therapy from somewhere, and understanding that starting point matters.

Interpretive Note on Extremes and Clinical Flexibility

A common misinterpretation of the AMI visual framework is the assumption that the Seeker quadrant—high in both motivation and acceptance—represents the ideal or healthiest client profile. In practice, however, clients at any extreme of the scale, including Seekers, may be operating from a rigid, identity-fused stance. For instance, a client who strongly identifies with their diagnosis and is highly motivated to pursue treatment may over-pathologize themselves, exhibit inflexibility, or become over-reliant on therapy as an identity anchor.

Similarly, those at the extremes of skepticism, detachment, or philosophical resignation may resist relational engagement or meaningful experimentation with new patterns. In this sense, the AMI is not designed to celebrate typologies, but to illuminate where therapeutic work may be most needed—at the edges, where motivational and cognitive-emotional frames are more fixed. True growth often begins not at the poles, but toward the center of the matrix, where motivation and acceptance are held with curiosity and openness rather than certainty or resistance.

6.1 Embracing Fluid Identities, Not Fixed Types

At the heart of the AMI are four distinct categories that represent different client postures toward therapy:

• Seeker (high motivation, high acceptance)

• Skeptic (high motivation, low acceptance)

• Curmudgeon (low motivation, high acceptance)

• Unaccountable / Naysayer (low motivation, low acceptance)

These categories are not diagnostic or prescriptive—they are reflective tools. They offer clients a chance to explore how they are relating to therapy at a given moment, and how that stance might shift over time. The AMI encourages clients to view these categories as fluid, not fixed; most people contain aspects of each depending on context, history, and which part of self is showing up.

Importantly, the goal is not to become a Seeker, nor is one category synonymous with wellness. Each stance has value, vulnerability, and meaning. A Curmudgeon may offer deeply grounded insight but resist new behavior; a Skeptic may hunger for change while struggling to trust the process. And the Unaccountable may question and deny that there is an issue at all but with time and alliance grow to change. Rather than judging these positions, the AMI helps make them visible, speakable, and workable.

6.2 Client-Led Reflection, Therapist-Facilitated Dialogue

Therapists are not encouraged to label clients as belonging to a category. Instead, clients are invited to view the AMI framework and self-reflect: Where do I see myself right now? What part of me feels aligned—or misaligned—with therapy? Sometimes a client identifies clearly with a category; other times, a therapist may gently offer a reflective observation that invites reconsideration. This process honors client agency while making space for relational honesty.

This approach also makes room for internal multiplicity and the nuanced interplay of parts within the self. Clients may express seemingly contradictory stances: “Part of me is a total Curmudgeon about therapy, but another part really wants to be here.” Such expressions reflect a broader therapeutic truth—that identity is not monolithic, but composed of layered voices, shaped by experience, habit, and longing. Within mindfulness traditions and Taoist thought, identity is seen not as a static construct but as a flow—formed by repeated responses and dissolvable through conscious attention. This aligns with the Internal Family Systems model (Schwartz, 1995), which views the psyche as a system of parts, each with its own perspective, bound together in patterns of protection and vulnerability. The AMI scale becomes a reflective mirror in this context, helping clients identify and soften the internal positions they hold toward therapy, without forcing premature resolution.

6.3 A Tool for Clinical Calibration

By providing this shared language and structure, the AMI enables therapists to adjust their stance based on how the client presents:

• A Seeker may benefit from pacing and reflection on diagnosis as identity.

• A Skeptic might need transparency, consent-based processes, or cultural attunement.

• A Curmudgeon may require motivational exploration and clear boundaries.

• A Naysayer might need patience, creative modalities, or alternative frames.

Rather than assume readiness, the AMI allows therapists to begin with humility and curiosity, using the client’s own reflection as the foundation for clinical strategy.

6.4 Supporting Transformative Process

The AMI resists the medical model’s binary of “ready vs. resistant” and instead offers a framework for meaningful transformation. It centers the client’s subjective experience, making room for complexity, contradiction, and growth. Because it is brief, relational, and non-pathologizing, it can be used at intake, in supervision, or as a recurring check-in throughout treatment.

7. Conclusion and Future Directions

As the field of psychotherapy continues to evolve toward more personalized, trauma-informed, and collaborative approaches, it is essential to have tools that reflect the full complexity of how clients enter the therapeutic process. This literature review has highlighted a persistent gap: while theories like the Stages of Change, Self-Determination Theory, and ACT have deepened our understanding of motivation, and while tools like the WAI and URICA have expanded our ability to assess engagement, none fully capture the relational, emotional, and motivational state of clients before therapy begins.

The Acceptance and Motivation Inquiry (AMI) offers a vital contribution to the clinical landscape by providing a brief, client-centered, and flexible assessment that integrates both motivation to change and acceptance of care. Its use of the four reflective categories—Seeker, Skeptic, Curmudgeon, and Naysayer—gives clients a language to explore how they relate to therapy and how that relationship might shift. It also allows therapists to adjust their clinical approach based on relational stance, not just symptom presentation.

Crucially, the AMI is not a tool for categorizing clients into fixed identities or measuring success by movement toward a particular type. Instead, it affirms that health and growth often emerge from a greater flexibility of position, an ability to inhabit different roles, and an awareness of one’s own ambivalence or defenses. In doing so, the AMI aligns with the most humanistic and liberatory aims of therapy: to support people in becoming more fully aware, more fully empowered, and more fully themselves.

Future Directions

The potential uses of the AMI span several domains:

• Clinical Practice: Continued use in intake and early engagement to reduce dropout, increase alliance, and inform pacing.

• Supervision and Training: Helping new clinicians understand motivational dynamics and relational stance through client-centered reflection.

• Research: Validating the AMI’s psychometric properties and studying correlations between category patterns and treatment outcomes.

• Group Work and Psychoeducation: Using the AMI categories to facilitate discussions about readiness, resistance, and relational patterns in group therapy or workshop settings.

• Program Development: Applying AMI data to inform service design, triage systems, or therapist-client matching processes.

As therapists and researchers increasingly recognize that how a client arrives to therapy shapes what is possible in treatment, tools like the AMI offer not only assessment but transformation—by inviting therapists to ask not “What’s wrong with you?” but “Where are you coming from—and how can we meet you there?”

Limitations and Future Adaptations

While the AMI provides a novel framework for assessing client engagement at the outset of therapy, it is important to acknowledge its current conceptual limitations and areas for growth. The two-axis model—motivation and acceptance—yields four core categories (Seeker, Skeptic, Curmudgeon, Naysayer) that serve as archetypal entry points, but categorical frameworks inevitably simplify the diversity and fluidity of real client experiences.

Clients may embody blended qualities, shift postures across sessions, or present contextually influenced resistance that does not align cleanly with a single quadrant. Cultural, systemic, or trauma-related barriers may shape behavior in ways not fully captured by the current model. Further research is needed to understand how clients across cultures, genders, and neurotypes interpret and respond to the scale.

Possible future adaptations include:

• Dimensional scoring to plot nuanced profiles along motivation and acceptance axes.

• Emergent subtypes discovered via cluster or factor analysis.

• Contextual overlays to capture systemic constraints and cultural meaning-making.

• Visual tools and client vignettes to avoid the perception of static “types.”

Ultimately, the strength of the AMI lies not in categorical precision but in its ability to foster reflective dialogue, attuned strategy, and relational honesty from the start of care. Its continued development will rely on embracing feedback, exploring complexity, and remaining accountable to the diverse realities of those seeking therapy.

Appendix A: Acceptance and Motivation Inquiry (AMI) Scale

Overview

The Acceptance and Motivation Inquiry (AMI) is a 30-item self-report tool designed to assess a client’s orientation toward therapy based on two distinct but interrelated dimensions: Motivation and Acceptance. It is intended to be used as a pre-treatment assessment to help therapists better understand how clients approach therapeutic work and how closely they identify with having a condition that may benefit from treatment.

Scoring Format

Clients respond to each item using a −10 to +10 Likert-style scale:

• +10 = Strong agreement or resonance

• 0 = Neutral / Unsure

• −10 = Strong disagreement or resistance

This bipolar scale captures both direction and intensity of the client’s response, offering a dynamic view of motivational readiness and acceptance of diagnosis. Higher scores reflect greater alignment with motivation or acceptance; lower scores may indicate ambivalence, resistance, or diagnostic detachment.

AMI Scale Items

Motivation Items (1–15)

1. On a scale of 0–10, how motivated are you to engage in therapy right now?

2. How much time each week are you willing to dedicate to your growth or healing?

3. On a scale of 1–10, how willing are you to try things that may be new, uncomfortable, or unfamiliar to you?

4. To what extent do you believe hard work pays off in emotional or psychological healing?

5. To what extent do you agree that putting effort into self-work is likely to be helpful in your life?

6. I am someone who tends to take initiative when facing problems.

7. I believe that change is possible for me.

8. I am taking active steps to improve my life.

9. I believe therapy can help people like me.

10. I often reflect on how my behaviors affect my life.

11. I want to understand myself better.

12. I know what I want to work on in therapy.

13. I believe I can develop insight through honest conversation.

14. I am ready to take responsibility for the patterns in my life.

15. I am here to grow.

Acceptance Items (16–30)

16. I believe something is going on with me that needs attention.

17. I see patterns in my life that concern me.

18. I believe I need support.

19. I sometimes question whether my problems are real. (reverse coded)

20. I struggle to see what’s wrong. (reverse coded)

21. I think my struggles are just how I am. (reverse coded)

22. I have mixed feelings about getting help. (reverse coded)

23. I feel uncertain about what therapy is for. (reverse coded)

24. I sometimes think others are overreacting to my behavior. (reverse coded)

25. I feel misunderstood by people trying to help me. (reverse coded)

26. I am here mostly because someone else thinks I should be. (reverse coded)

27. I often wonder if therapy is a waste of time. (reverse coded)

28. I don’t really believe in mental health labels. (reverse coded)

29. I question whether anything is really wrong. (reverse coded)

30. I don’t think anything can help me. (reverse coded)

References

(Selected references cited in the review — full list available on request.)

• Boss, M. (1963). Psychoanalysis and Daseinsanalysis. Basic Books.

• Deci, E. L., & Ryan, R. M. (1985). Intrinsic Motivation and Self-Determination in Human Behavior.

• Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy.

• Horvath, A. O., & Greenberg, L. S. (1989). Working Alliance Inventory.

• Kabat-Zinn, J. (1990). Full Catastrophe Living.

• Keyes, C. L. M. (2005). Complete State Model of Mental Health.

• Miller, W. R., & Rollnick, S. (1991; 2013). Motivational Interviewing.

• Prochaska, J. O., & DiClemente, C. C. (1983). Stages of Change.

• Yalom, I. D. (1980). Existential Psychotherapy.