Motive-oriented relationship building

1. Introduction

Version followed: the Bern Plan Analysis–based "Motive-Oriented Therapeutic Relationship" (MOTR; earlier "complementary relationship building", Grawe 1992) as described by Caspar (2019 chapter; 2018 German textbook) and operationalised in the Bern/Lausanne trials (Kramer et al., 2014; Kramer, Fisher & Zilcha-Mano, 2022). It is supplemented by Grawe's needs-based variant (Stucki & Grawe, 2007) and the current Klaus-Grawe-Institut (KGI) training handouts. The KGI "Beziehungsgestaltung II" module also adds Sachse's motive/"game" tables for personality disorders; these are labelled where used. [source: Kramer et al. 2014; Kramer et al. 2022; Stucki & Grawe 2007; KGI BG II handout; KGI Plananalyse handout (Krieger 2023)]

MOTR is not a standalone therapy. It is a prescriptive principle for shaping the therapeutic relationship, and it is built into whatever method you already use (CBT, psychodynamic, general psychiatric management, DBT groups, internet guidance). The therapist uses a case formulation (Plan Analysis) to infer the goals ("Plans") behind the patient's behaviour, including problem behaviour. The therapist then responds complementarily to the acceptable motives higher up in that hierarchy, not to the problematic means. [source: Kramer et al. 2022; Caspar 2019 abstract]

Core idea of change: when the patient's important motives are satisfied inside the relationship, problem behaviour in therapy loses its motivational basis. It may persist from habit but becomes rarer and weaker. This frees both parties' resources for the actual problems and provides corrective relational experiences. It also builds the trust ("relationship credit") the therapist later spends on challenging and confrontational work. [source: KGI Plananalyse handout; Kramer et al. 2022; KGI BG II handout] Caspar warns that reluctant, reactive giving in to patient pressure produces a "bottomless pit". The point is to give proactively and accurately, not to yield. [source: Caspar 2008, Eur Psychiatry abstract]

2. Framework

MOTR has no fixed session protocol. The sources describe a sequence that runs alongside the host therapy. Session counts below come from the trials and are not prescriptions. [source: Kramer et al. 2014; KGI BG II handout] [uncertain: Caspar's 2018 textbook and 2019 chapter may give a fuller sequence]

Phase A: information gathering and first formulation (intake, session 1).

Goal: collect instrumental behaviours (verbal, nonverbal, reported, the impact on you) and build a first Plan structure or mini-structure up to the basic needs.
In the RCT the intake session was the data source for the Plan Analysis. Therapists had a supervision session right after intake to derive the offer. [source: Kramer et al. 2014]
Ask directly about relational wishes and fears in session 1. [source: Stucki & Grawe 2007]
Move on when you have at least a working hypothesis of 2–3 acceptable motives that you can name and that you are willing to serve. [synthesis]

Phase B: proactive relationship offer (from session 1–2 onward, "infused" throughout).

Goal: satisfy the identified motives through how you behave (nonverbal, structure, choices) and what you say (validation, self-disclosure, agenda, explanations). Pass relationship tests and build relationship credit.
In the BPD trial, MOTR was added to 10 weekly sessions of general psychiatric management, from session 2 to session 10. It was used "when indicated", not as a separate session block. A second supervision took place in the second half of treatment. [source: Kramer et al. 2014]
In a narcissistic personality disorder case, MOTR ran across a 7-session pre-therapy phase. [source: Kramer, Berthoud, Keller & Caspar 2014, abstract]

Phase C: problem work on the base of the relationship.

Goal: use the credit to work on content: confrontation, clarification, behavioural experiments and the host method's techniques, while staying motive-oriented moment by moment.
For personality disorders the KGI module follows Sachse's sequence: complementary relationship building → developing a work contract → clarification → schema work → transfer. It sets the order as: intensive motive-oriented relationship building first, then a shared understanding of the disorder, then an assessment of change motivation, and only then problem work with empathic confrontation. [source: KGI BG II handout]

Phase D (continuous): revise the formulation.

Track which Plans are activated in each sequence and update the structure. Check your perceptions in supervision or intervision. [source: Kramer et al. 2022; Stucki & Grawe 2007]

Criteria for moving from relationship building to confrontation. The sources give the order but no operational cut-offs. [uncertain] Practical indicators [synthesis]:

Testing behaviour has dropped.
The patient brings their own topics and accepts the agenda.
The alliance feels stable after a minor disagreement.
You can name the patient's central motive to them and they recognise it.

If confrontation triggers a sharp rise in problem behaviour, step back to Phase B. [synthesis]

Format. Individual therapy is the main setting. The approach has been adapted to DBT skills groups (an MOTR group rating scale, 2017) and to guidance in internet-based interventions (2022). [source: BORIS publication list, titles only] [uncertain: these adaptations]

3. Guiding principles

Complement Plans, not problem behaviour. Respond to the purpose a behaviour serves, not its surface content. In practice: when the patient attacks, ask "what is this for?" before you reply. [source: Kramer et al. 2022; KGI BG II]
"As high in the hierarchy as necessary, but as low as possible." Pick a Plan level close enough to the behaviour to be specific to this patient, but high enough that you do not reinforce the problematic means. In practice: serve "get the best possible treatment", not "criticise the therapist". [source: Kramer et al. 2022]
The acceptability test. Go up the hierarchy until you reach a motive you can genuinely serve without unduly limiting or overstraining yourself. KGI phrases it as asking whether you are high enough to live with it. In practice: if you feel resentment while "complementing", you are still too low. [source: KGI Plananalyse handout; KGI BG II; Kramer et al. 2022]
Needs are never the problem; means are. Basic needs (attachment, orientation/control, self-esteem, pleasure/avoiding pain) are legitimate. Only the strategies used to meet them are problematic. In practice: validate the need explicitly while you leave the means unrewarded. [source: KGI Plananalyse handout; Stucki & Grawe 2007]
Satisfied motives disarm problem behaviour. In practice: when a patient keeps fighting for something, give it on the motive level and watch the fight lose its point. [source: KGI Plananalyse handout]
Proactive, not reactive. Offer what the patient needs before they must extract it through problem behaviour. Yielding under pressure feeds the cycle. In practice: begin the session by meeting the control need (agenda, choice) rather than waiting for a power struggle. [source: Caspar 2008 abstract; Kramer et al. 2022]
Individual tailoring. The offer must be built differently for each patient from their own Plan structure. Disorder prototypes are only starting hypotheses. In practice: two patients with the same diagnosis may need opposite degrees of structure. [source: Kramer et al. 2014; KGI BG II]
Moment-by-moment responsiveness. Track which Plans are active right now and adjust within the session. In practice: when a patient shifts from seeking closeness to defending autonomy, shift from warmth to giving choices. [source: Kramer et al. 2022]
Balance safety and challenge. The relationship should give enough security to allow challenge, not replace challenge. In practice: a warm session with no problem activation is not the goal. [source: KGI Plananalyse handout (Caspar's balance model)]
Shape both HOW and WHAT. The offer covers nonverbal and paraverbal behaviour, degree of structure and choices (how), plus self-disclosure, agenda-setting, explanations, summaries and homework (what). In practice: plan both channels, not only your words. [source: KGI Plananalyse handout; Kramer et al. 2022]
Genuine, not a trick. The offer rests on understanding and on validating real needs. In practice: only say what you mean; patients with personality disorders detect insincerity. [source: KGI BG II]
Don't reinforce problematic Plans. Meet needs "without reinforcing problematic Plans, behaviours or experiences". In practice: do not admire grandiosity; recognise the person behind it. [source: Kramer et al. 2014]
Your reactions are data, but biased data. Use your feelings and action urges as a "resonance body", tie them to observable behaviour, and check them against your own motives and relationship style. In practice: note "I want to withdraw" and look for what the patient did just before. [source: Stucki & Grawe 2007]
Pass tests: answer the wish, not the fear. Later, talk about the testing itself. In practice: stay calm and reliable when the patient tries to provoke rejection. [source: KGI BG II]
Transparency. Explain what you do, when and why. In practice: announce techniques and check readiness before you start. [source: Stucki & Grawe 2007; KGI BG II]
Efficiency. MOTR is meant to cost no extra effort. The better the offer fits, the less of it is needed. In practice: a few precise motive-oriented moments beat diffuse niceness. [source: KGI BG II]
Transtheoretical. Plan Analysis and MOTR can be combined with any school. In practice: keep your method and change the relational delivery. [source: Kramer et al. 2022]

4. Intervention inventory

The inventory has three parts: formulation tools (A), the in-session relationship offer (B), and integration and quality control (C). The full Plan Analysis procedure is in Caspar's textbook, which is not drawn on here. The steps below come from the KGI course handout (Krieger 2023, based on Caspar 2018) and the published case articles. [uncertain: finer rules in Caspar 2018 / 2022 may differ]

A. Formulation tools

A1. Plan Analysis (full Plan structure)

Purpose / when: The core case formulation. Use it after the intake, or the first 1–2 sessions, for any patient. It is essential when the relationship is likely to be difficult (personality disorders, high interactional strain). [source: Kramer et al. 2014; KGI Plananalyse handout]
Steps:
1. Collect instrumental behaviours from the first session: verbal content, nonverbal and paraverbal behaviour (weight it heavily, as it is less controlled), reported behaviour in daily life, introspective reports and fantasies, third-party reports, and the impact on you. One published case used about 15 behaviours from session 1. [source: Kramer et al. 2022; KGI Plananalyse handout; Westermann et al. 2015]
2. Write behaviours in the indicative (e.g. "talks over the therapist", "apologises repeatedly").
3. For each behaviour, ask the guiding questions [source: KGI Plananalyse handout, paraphrased]:
  - What is this behaviour for? What purpose might it serve?
  - What feelings and impressions does it create in me and in others?
  - What reactions does the person want to evoke?
  - What self-image are they presenting or protecting?
  - What behaviour from me or others would not fit, and so is being prevented?
4. Write each inferred Plan as a self-directed imperative (e.g. "keep control of the conversation", "make sure the other stays oriented to you"). The imperative is a notation convention and does not imply the Plan is conscious. Word it so it characterises this person. A Plan may target the self-concept ("be special") or the impression on others ("show that you are special"). [source: KGI Plananalyse handout; Kramer et al. 2022]
5. Link Plans upward as means → ends, so that one Plan can serve several higher Plans. Continue up to the basic needs: attachment, orientation/control, self-esteem, pleasure/avoiding pain. One published case had 28 Plans under 5 top-level motives. [source: Kramer et al. 2022; KGI Plananalyse handout]
6. Work bottom-up (behaviour → Plan) and then top-down: "How does this person meet their need for X?" This finds missing Plans and means. Then look for confirming behaviour in later sessions. [source: KGI Plananalyse handout]
7. Draw it as a structure, not a list, with lines showing what serves what. The absolute height on the page is pragmatic.
8. Mark the acceptable motives (see A4).
Example language (to yourself or in supervision): (illustrative) "He corrects every summary I make. Possible Plan: 'make sure you are understood exactly'. Above that: 'stay in control', serving orientation/control."
Watch for:
- Plans are hypotheses (constructs), not facts. Situation context can change the meaning of a behaviour.
- Stay close to the data.
- It is working when the structure predicts the patient's next reactions and helps you choose responses. [source: Westermann et al. 2015; Kramer et al. 2022]

A2. Mini Plan Analysis of a single problem behaviour

Purpose / when: A quick formulation of one difficult behaviour (e.g. lateness, attacks, sitting in your chair) when there is no time for a full structure, or in the middle of treatment when a new behaviour appears. [source: KGI Plananalyse handout]
Steps:
1. Describe the behaviour concretely.
2. Ask "what for?" two or three times, writing each answer as an imperative.
3. Stop at the first level that is no longer problematic. Going higher loses specificity. [source: Westermann et al. 2015]
4. List 2–3 ways to serve that motive proactively elsewhere in the session.
Example language: (illustrative) "Refuses homework → 'don't let anyone dictate to you' → 'stay autonomous'. Offer: let her design the exercise."
Watch for: Hypotheses that only explain one behaviour. Look for a second behaviour that the same Plan would predict.

A3. Emotion analysis within the Plan structure

Purpose / when: Use when a strong, puzzling or missing emotion appears. Emotions show which Plans are blocked. [source: KGI Plananalyse handout]
Steps:
1. Define the emotion and describe the triggering situation.
2. Identify the blocked or threatened Plan. Typical links: blocked autonomy → anger; blocked closeness → sadness or anxiety; lost control → helplessness; threatened self-esteem → shame.
3. Ask which other Plans shape which emotion appears. If the emotion seems implausible, look for Plans preventing the more plausible one. For example, anger may cover a more feared self-esteem injury; KGI cites Grawe's point that any emotion can hold a more feared one at bay.
4. Identify coping Plans aimed at the emotion (fighting, avoiding, distracting, denying).
5. Check whether the emotion itself serves a purpose (e.g. evoking care, being spared demands).
Example language (to patient): (illustrative) "When your partner decided the holiday without you, it sounds as if something important was being taken out of your hands."
Watch for: Not every emotion is instrumental; do not imply the patient is "using" feelings. [source: KGI Plananalyse handout; KGI BG II] [synthesis on wording caution]

A4. Selecting the level to complement ("acceptable motive")

Purpose / when: The decision that turns the formulation into a relationship offer. Do it for every activated problem behaviour. [source: Kramer et al. 2022; Westermann et al. 2015]
Steps:
1. Start at the problem behaviour and go up one level at a time.
2. At each level, ask whether this motive is unproblematic and whether you could serve it wholeheartedly without being unduly limited or overstrained.
3. Stop at the lowest level that passes. Example: a patient's hostile criticism of treatment serves "get the best possible treatment", which you can serve. [source: Kramer et al. 2022]
4. If you still feel resistance at a level, go one higher. [source: KGI BG II / Plananalyse handout]
Example language: (illustrative) to yourself: "I can't support 'devalue the therapist', but I can fully support 'make sure you get competent help'."
Watch for:
- Too low: you end up reinforcing means (e.g. arguing about medication each time, which gives the patient the control experience). [source: Westermann et al. 2015]
- Too high ("wants to feel good"): generic and useless.

A5. Direct motive inquiry in the first session

Purpose / when: In session 1, as a complement to inference. It is fast, and it is itself a motive-oriented signal ("your wishes matter"). [source: Stucki & Grawe 2007]
Steps:
1. Ask what would help the patient feel comfortable in therapy and with you.
2. Ask what the worst thing you could do as their therapist would be.
3. Ask about past helpful and unhelpful helpers.
4. Record the answers as approach and avoidance goals in the worksheet (A8).
Example language: (illustrative, paraphrasing Stucki & Grawe's two questions) "What would make it easier for you to feel at ease here with me?" … "And what's the worst thing I could do as your therapist?"
Watch for: Motives are largely implicit, and patients may blame others or rationalise. Treat the answers as one data source among several. [source: Stucki & Grawe 2007; KGI Plananalyse handout]

A6. Motivational questionnaires (FAMOS, INK)

Purpose / when: An optional structured check on approach and avoidance goals, and on how far they are fulfilled. Use it at intake when feasible. [source: Stucki & Grawe 2007; KGI Plananalyse handout]
Steps:
1. Administer the FAMOS (Grosse Holtforth & Grawe). It is a self-report of motivational schemata with 14 approach scales (e.g. intimacy, recognition, autonomy, control) and 9 avoidance scales (e.g. humiliation, criticism, dependence, helplessness). It gives summary scores for approach and avoidance intensity.
2. Optionally administer the INK (incongruence questionnaire), which measures how far the goals are currently met.
3. Compare the highest scales with your Plan hypotheses.
(Items are not reproduced here; the instruments are obtained through their authors and publishers.) [uncertain: current availability and licensing not checked]
Watch for: Questionnaires capture only consciously accessible goals.

A7. Using your own reactions ("resonance body")

Purpose / when: Continuously, and especially with interpersonally difficult patients. [source: Stucki & Grawe 2007]
Steps:
1. Notice your feelings, thoughts and action urges (e.g. the urge to defend, rescue, withdraw or lecture).
2. Link each one to a specific observable patient behaviour that just occurred.
3. Ask what reaction that behaviour may be designed to evoke (see A1, questions 2–3).
4. Check for distortion: your own motives, sore spots and habitual style. For example, therapists with a dominant style tend to see patients as more dominant and quarrelsome.
5. Verify your impressions in supervision or intervision.
Example language (self-note): (illustrative) "I feel pushed to prove my competence. He just listed three therapists who failed him. Plan hypothesis: 'make sure you are not let down again'."
Watch for: Do not try to eliminate countertransference, because it has diagnostic value. Do not act it out either. [source: Stucki & Grawe 2007]

A8. Relationship-offer worksheet

Purpose / when: Turn the formulation into a written plan before the next session. Do it after intake and update it after supervision. [source: KGI BG II handout]
Steps: Write short entries under these headings (adapted from the KGI handout's fields):
- self-schema and outward self-presentation
- how the patient activates others (images and appeals)
- important approach goals → your "do" behaviours
- important avoidance goals → your "don't" behaviours
- likely tests, each with the wish, the fear and the corrective response
- your intended inner stance
- 2–3 "interpreter sentences": short lines that tell the patient explicitly, in their own currency, that the motive is honoured (see B2)
Example language: (illustrative) Approach goal: recognition → Do: ask about her expertise at work. Avoid: humiliation → Don't: correct her in front of her partner in a couples session.
Watch for: A worksheet full of generic niceness. Each entry should be specific to this patient.

A9. Prototype hypotheses (disorder-specific starting points)

Purpose / when: When there is little time or data, start from prototypical motive patterns and refine them individually. [source: Stucki & Grawe 2007; KGI BG II; KGI Plananalyse handout]
Steps:
1. Pick a candidate prototype. Sources:
  - Caspar's prototypical depression Plan structure (avoid rejection, maintain perfectionism, obtain being spared and understanding, withdraw).
  - Sachse's personality-disorder table as taught at KGI. Examples: dependent → reliability and solidarity; narcissistic → recognition, importance and autonomy; paranoid → boundaries and autonomy; histrionic → importance and solidarity; avoidant → recognition and importance.
  - Grandjean et al. (2021) for a prototypical narcissistic personality disorder Plan structure.
2. Mark which elements you have actually observed.
3. Discard the elements that do not fit.
Watch for: Prototypes help only if they plausibly fit the individual. [source: Westermann et al. 2015] The personality-disorder table is from Sachse's clarification-oriented therapy, not from Caspar's Plan Analysis proper. [source: KGI BG II]

B. In-session relationship offer

B1. Need-based relationship behaviour (Grawe's four basic needs)

Purpose / when: The baseline offer for every patient, weighted toward the needs that are most frustrated or most active in this patient. [source: Stucki & Grawe 2007; KGI BG II]
Steps: Choose the 1–2 dominant needs, then apply the matching behaviours.
- Orientation/control.
  - Do: explain the process; involve the patient in decisions; offer choices; check readiness before any technique; take up their suggestions; dose problem activation and difficulty so they are neither over- nor under-challenged.
  - Don't: decide alone; set goals for them; pressure them; be vague.
- Attachment.
  - Do: be their advocate; frame the work as "together"; show understanding and appreciation; lean in, keep eye contact, nod; listen actively; self-disclose appropriately.
  - Don't: be late or forget appointments; forget key facts; criticise or devalue; show nonverbal distance; answer personal questions defensively.
- Self-esteem.
  - Do: show interest; let them talk about what they do well; praise and reinforce successes; emphasise healthy parts; attribute success to their abilities.
  - Don't: look unimpressed; downplay progress; stress hierarchy; attribute failure to their deficits.
- Pleasure / avoiding pain.
  - Do: allow positive feelings, relaxation and shared laughter; savour successes; vary the session format; keep the room pleasant.
  - Don't: focus only on negatives; analyse every failure; look bored or check the clock; run rigidly identical sessions.
Example language: (illustrative)
- Control: "We could start with the conflict at work or with the sleep problem. Which would you prefer? And tell me if something I suggest doesn't fit."
- Self-esteem: "You made that phone call even though you were dreading it. That took courage."
- Pleasure: "Before we move on, stay with that pride for a moment. Where do you notice it?"
Watch for:
- Positive feelings must not crowd out necessary problem activation (see the balance principle).
- It is working when the patient brings more of their own material and signals comfort through posture and voice.

B2. Motive-specific complementary offers and "interpreter sentences"

Purpose / when: Use with patients whose relational motives are pronounced, especially personality disorders. You state your relationship message explicitly, in the patient's own "currency". [source: KGI BG II (Sachse-based); Caspar 2008 title]
Steps: Identify the motive, then deliver the matching complementary behaviour and an explicit message.
- Recognition: don't evaluate; acknowledge resources; avoid treating them in terms of deficits. Message: you are fine as you are and need not perform.
- Importance: take them seriously; ask follow-up questions; refer back to what they said last time.
- Solidarity: stay present, not annoyed, when they struggle; don't take on assignments from third parties against them.
- Reliability: inform them proactively about changes and cancellations; stay calm when they are angry. Message: I won't send you away.
- Autonomy: be transparent about what you do and why; offer interventions as options; let them decide.
- Boundaries: respect their limits; don't go deeper than invited; give them an explicit "stop" right.
Example language: (illustrative)
- Importance: "Last week you mentioned your sister's visit. How did it go?"
- Reliability: "I'm glad you tell me you're annoyed with me. That helps us."
- Autonomy: "You know your life best. I can offer two options, and you decide."
- Boundaries: "You can say stop at any point and we will stop."
Watch for:
- Sentences must be true for you. If not, you are below the acceptable level (A4).
- Do not use the sentences to reward the problematic "game" (images and appeals). Address the motive behind it.

B3. Naming and validating the motive while leaving the means unrewarded

Purpose / when: In the moment, when problem behaviour is activated (criticism, demands, devaluation, self-deprecation). [source: Kramer et al. 2022; Caspar 2008 abstract (validation of the motive, criticism of the behaviour, as in DBT)]
Steps:
1. Identify the activated Plan (A2/A4).
2. Name the acceptable motive explicitly and check it back with the patient.
3. Affirm that it is legitimate.
4. Do not answer the surface content in kind: don't defend, counter-attack or comply with the means.
5. Continue the task in a way that serves the motive.
Example language: Kramer et al. (2022) report a therapist reframing hostile criticism as the motive: "It sounds like it is so important to you to have the best possible treatment." (illustrative continuation) "…and I want that for you too. Let's look at what would make this session most useful."
Watch for: Sarcasm, or a "therapist-y" tone, turns validation into a put-down. It is working when the patient's voice softens and they elaborate rather than escalate.

B4. Nonverbal and paraverbal complementarity

Purpose / when: Throughout every session. MOTR is rated separately for verbal and nonverbal behaviour, and nonverbal behaviour often carries the offer. [source: Kramer et al. 2014; Kramer et al. 2022; Stucki & Grawe 2007]
Steps:
1. Match posture, distance, voice and tempo to the activated Plan.
2. For closeness and attachment motives: lean in, use open arms, nod, smile, keep a warm, engaged voice.
3. For control and autonomy motives: avoid crowding, keep a calm and competent tone, and give space for the patient to lead.
4. Watch your own withdrawal signals, such as crossed arms or minimal engagement, which characterised a weak MOTR sequence in the published case.
Example language: non-verbal; (illustrative) slow down your speech and lower its volume when a control-oriented patient starts to escalate.
Watch for: Stucki & Grawe cite Mehrabian's percentages on the weight of nonverbal cues. Treat those figures as illustrative, not precise. [uncertain]

B5. Adapting structure and technique delivery (the HOW)

Purpose / when: Whenever you introduce a technique (exposure, imagery, relaxation, role-play) or decide how much to structure the session. [source: KGI Plananalyse handout; Westermann et al. 2015]
Steps:
1. Check the dominant need.
2. For a strong control need: use a clear agenda, announce each step, and offer control-preserving variants. Caspar's example (via KGI) is asking the patient to fix their gaze on a spot on the ceiling instead of closing their eyes.
3. For a strong autonomy need: offer choices, structure less, encourage the patient to experiment.
4. For a strong closeness need: be warmer, more caring and more self-disclosing.
5. Always check readiness before starting a technique.
Example language: (illustrative) "For this exercise some people close their eyes. You can also keep them open and rest them on a point on the ceiling. Whichever feels better."
Watch for: For exposure and imagery techniques, follow the host method's own consent and safety steps. Adapting the delivery does not replace them. [synthesis]

B6. Adapting content (the WHAT)

Purpose / when: In planning self-disclosure, agenda-setting, explanations, summaries and homework. [source: KGI Plananalyse handout; Kramer et al. 2022]
Steps:
1. For each content element, ask which active Plan it serves or threatens.
2. Agenda: co-construct it for control and autonomy motives.
3. Explanations: give fuller rationales for orientation needs.
4. Summaries: use the patient's own words for importance and recognition motives.
5. Homework: let the patient design it for autonomy motives; keep it small and success-prone for self-esteem motives.
6. Self-disclosure: use more for attachment motives, and use it sparingly for boundary motives.
Example language: (illustrative) "Let me summarise in your words, and correct me where I've got it wrong."
Watch for: Homework that is not done often signals a threatened autonomy or self-esteem Plan rather than low motivation (see section 5).

B7. Responding to problem behaviour on the motive level ("changing levels")

Purpose / when: When interactional problem behaviour appears, such as dominance, sitting in your chair, refusing questions, medication refusal or devaluation. [source: KGI BG II; Westermann et al. 2015]
Steps:
1. Do not escalate at the content level (insisting, removing them from the chair, arguing the pros and cons again).
2. Identify the motive (e.g. keep control, avoid unpleasant questions, show strength).
3. Serve it elsewhere and non-contingently, so the problem behaviour becomes unnecessary. Examples:
  - Let the patient talk about their strengths and give positive feedback.
  - Widen their choices in other areas when autonomy drives medication refusal.
  - Schedule regular short contacts that are not contingent on crises when attachment drives the behaviour.
4. Prioritise the patient's most valued motives rather than everything at once.
Example language: (illustrative) to a patient taking over the session: "You clearly have a good sense of what you need here. Tell me what you'd put at the top of today's list."
Watch for:
- Responding contingently (giving the motive exactly when the problem behaviour occurs) reinforces it. Give it proactively at other times. [source: Westermann et al. 2015]
- In psychosis, challenging a belief that serves self-esteem or orientation before offering alternatives risks anxiety and rupture. [source: Westermann et al. 2015]

B8. Passing relationship tests and metacommunicating about them

Purpose / when: When a patient (often unconsciously) tests whether you will confirm a feared relational expectation. Examples: provoking rejection, testing reliability with lateness, inviting criticism. [source: KGI BG II, citing Grawe's consistency view and Sampson & Weiss]
Steps:
1. Identify the wish (to be accepted in line with an important goal) and the fear (the expected bad response).
2. Respond to the wish, not the fear: stay calm, reliable and non-judgemental.
3. Expect repetition, and do not take the bait.
4. Once the relationship is stable, metacommunicate about the testing pattern itself.
Example language: (illustrative) Early: "You're angry that I changed the time. I'm glad you tell me. I'm not going anywhere." Later: "I've noticed that when things get close here, something happens that checks whether I'll stay. Does that ring a bell from elsewhere?"
Watch for:
- Failing a test confirms the fear and risks rupture or dropout. Passing it allows a corrective experience.
- Metacommunicating too early can feel like exposure or criticism. [source: KGI BG II] [synthesis on timing]

B9. Building relationship credit, then confronting

Purpose / when: Before and during challenging work: empathic confrontation, clarification, behavioural experiments, challenging beliefs. [source: KGI BG II; Westermann et al. 2015]
Steps:
1. Invest in proactive MOTR first, so that confrontation lands on a secure base.
2. Develop a shared understanding of the problem and check change motivation.
3. Confront the means (the cost of the strategy) while explicitly affirming the motive.
4. Watch the alliance; step back to B1–B7 if it drops.
Example language: (illustrative) "It makes complete sense that you want to be taken seriously; that matters. And I wonder whether raising your voice at your boss gets you that, or the opposite."
Watch for: How much MOTR versus confrontation is optimal is an open question in the Bern group's own work (conference title, 2010–2012). [uncertain]

B10. Talking with the patient about Plans

Purpose / when: When you share the formulation to build understanding of the problem or of the relational pattern. [source: KGI Plananalyse handout]
Steps:
1. Use everyday words, not technical terms, and a few elements at a time.
2. Present the Plan as an understandable intention with a cost.
3. Invite correction.
Example language: (illustrative) "It looks as if staying in charge has been a way of keeping yourself safe, and at the same time it leaves you doing everything alone. Does that fit?"
Watch for: The KGI handout notes that talking about Plans is a skill that needs practice. Rationalising patients may agree intellectually without any felt shift.

C. Integration and quality control

C1. Self-rating your MOTR moment by moment

Purpose / when: For review of recorded sessions and supervision. [source: Kramer et al. 2014; Kramer et al. 2022]
Steps:
1. Pick sequences from a recording.
2. Note up to three acceptable Plans active in each sequence.
3. Rate your verbal and nonverbal behaviour separately on how motive-oriented it was. The research scale runs from −3 (not at all) to +3 (fully). In the RCT, MOTR therapists averaged about +1.5.
4. Identify sequences rated below zero and what Plans were active then.
Watch for: The published case found control and autonomy Plans hardest to respond to. Rate those moments carefully. (The research manual itself is not drawn on.) [uncertain]

C2. Level check (content / processing / relationship)

Purpose / when: When a session goes nowhere or conflict escalates. The KGI module teaches Sachse's three levels to locate the problem. [source: KGI BG II]
Steps:
1. Ask whether the current problem is about content (the topic), processing (how the patient handles the topic: trivialising, "I don't know", side-tracking, constructions of unsolvability) or the relationship (images, appeals, tests).
2. If it is a relationship problem, switch to MOTR (B2–B8) instead of pushing content.
3. If it is a processing problem, clarify the avoidant strategy before returning to content.
Watch for: Content-level interventions with a relational problem escalate the conflict. This is the KGI's typical "level error".

C3. Training and supervision formats

Purpose / when: To learn MOTR as a procedural skill, not just declarative knowledge. [source: Stucki & Grawe 2007; Kramer et al. 2014; Kramer et al. 2022]
Steps:
1. Use role-plays on formulated cases, co-therapy and direct coaching.
2. Analyse your own session videos.
3. Do case-related self-experience: examine your reactions to a patient in light of your own biography and relational style.
4. In the RCT, therapists had supervision from the model developer after intake and in the second half of treatment.
Watch for: Formal training is offered through the Bern postgraduate programmes and the Klaus-Grawe-Institut. [source: KGI handouts] [uncertain: current course formats not checked]

5. Handling problems

The sources mainly cover escalation, tests and level errors. Most other guidance below is marked [synthesis]: it applies the MOTR principles to common problems the sources don't address directly.

Escalating power struggles (dominance, taking over, refusing questions).

Do not fight on the content level. Switch to the motive level (keep control, avoid exposure, show strength).
Give control proactively: agenda choice, permission to skip a question, asking for their expertise.
[source: KGI BG II; KGI Plananalyse handout]

Hostile criticism or devaluation of you or the treatment.

Reframe it as an acceptable motive (e.g. getting the best treatment) and affirm that motive. Do not defend yourself or retaliate.
If you can't do this genuinely, you are too low in the hierarchy: go one level up.
[source: Kramer et al. 2022; KGI BG II]
Debrief your own reactions in supervision. Inexperienced therapists can be overwhelmed by heavy criticism. [source: Stucki & Grawe 2007]

Repeated testing (lateness, provocations, "you'll give up on me too").

Answer the wish, not the fear. Stay reliable.
Later, metacommunicate about the pattern (B8).
[source: KGI BG II]

"Bottomless pit": the patient demands more and more.

You are probably giving reactively, under pressure. Shift to proactive, non-contingent need satisfaction, aimed at the specific motive rather than at the demand.
Hold your frame on the means.
[source: Caspar 2008 abstract; Westermann et al. 2015]

Stuck: the session goes nowhere, "I don't know", side-tracking.

Run the level check (C2). If processing is the problem, clarify the avoidant strategy. If the relationship is the problem, use MOTR before returning to content.
[source: KGI BG II]

Non-adherence to homework or medication.

Do a mini Plan Analysis (A2) before assuming low motivation. Typical candidates:
- autonomy ("don't be told what to do") → let the patient design the task, or widen their choices elsewhere
- self-esteem (fear of failing) → smaller, success-prone tasks
- attachment → non-contingent contact
Avoid re-arguing at every refusal, because this can reinforce the control experience.
[source: Westermann et al. 2015 for medication] [synthesis for homework]

Overwhelm or emotional flooding.

Lower problem activation and difficulty. This is the orientation/control rule of not over-challenging.
Give choice over pace, and use control-preserving variants of techniques (B5).
[source: Stucki & Grawe 2007; KGI Plananalyse handout] [synthesis on application to flooding]

Ruptures.

Treat a rupture as a likely failed test or a threatened Plan. Ask which Plan your intervention blocked: anger often signals blocked autonomy, shame signals threatened self-esteem (A3).
Name the motive, acknowledge your part, and offer the complementary response.
[synthesis from KGI Plananalyse handout emotion rules and KGI BG II test model]

Control and autonomy motives are hardest to complement.

In the published case, the therapist was least motive-oriented when control and independence Plans were active. Expect this and prepare explicit control-giving moves in advance.
[source: Kramer et al. 2022]

Your own resentment, or feeling manipulated.

This signals that you are complementing too low (serving the means) or that the offer is not genuine. Go up a level.
Separate the patient's behaviour from your sore spots. Use supervision and video review.
[source: KGI handouts; Stucki & Grawe 2007]

Over-gratification without progress.

MOTR aims at a balance of safety and challenge, not comfort alone. Once relationship credit is built, introduce confrontation of the means (B9).
[source: KGI Plananalyse handout; KGI BG II] [synthesis on timing]

Mis-formulation.

If the offer does not soften the problem behaviour after several sessions, the Plan hypothesis may be wrong. Collect more data (especially nonverbal), consider alternative Plans and test them.
Prototypes are only starting points.
[source: Westermann et al. 2015; Kramer et al. 2022] [synthesis]

Psychosis.

Do not challenge delusional beliefs that serve self-esteem or orientation before building alternative sources of self-esteem and affiliation. Standard normalising may backfire when a belief strongly serves self-esteem.
With blunted affect, rely more on the Plan structure than on in-session feedback.
[source: Westermann et al. 2015]

Suicidality and self-harm.

MOTR does not replace standard risk assessment, safety planning or lethal-means counselling. Follow your service protocol.
MOTR can guide how you deliver these. For example, involve a control-motivated patient in co-writing the safety plan, and keep reliable contact for attachment motives. Never make safety measures contingent on the relationship offer.
[synthesis] [uncertain: not addressed in the sources]

Group or online settings.

Adaptations exist: an MOTR scale for DBT groups (2017) and MOTR-tailored guidance in internet interventions (2022). They are not drawn on here, so consult them before adapting.
[uncertain]

Sources

Sources: