Self-Determination Theory in Practice

University of MichiganGeoffrey Williams, MD, PhD

Healthy Living Center, University of Rochester, Rochester, New York, US

May 13, 2013

Causes of Death In the USMokdad et al, JAMA, 2004

Cause Number Percentage

Tobacco 435,000 18%

Diet & Activity 400,000 17%

Alcohol 85,000 4%

Microbial agents 75,000 3%

Toxic agents 55,000 2%

Motor Vehicle Crash 43,000 2%

Firearms 29,000 1%

Sexual Behavior 20,000 1%

Overview of Self-Determination Theory and Health

Self Determination Theory Overview Define Motivation as energy directed toward a goal Assumptions: innate aspects of self, needs Motivation and Medical Professionalism Incentives AND/OR Internalization to motivate change SDT Model for Health Behavior Change Meta-analysis

Randomized controlled trials - SDT Tobacco abstinence Physical activity, weight loss Dental outcomes

Implications for research, medical ethics, clinicians and policy.

Self-Determination Theory

An organismic dialectic-individuals in the context of their social surrounding

Motivation is human energy directed to a goal Uses free choice paradigm Assumptions: humans are innately motivated

toward well-being (e.g., health) and personal growth

Psychological Needs

Needs are defined as:

“psychological nutriments that are essential for ongoing psychological growth, integrity, and well-being”

Deci & Ryan, 2000. Psychological Inquiry, 11, 227-268.

Psychological Needs: Supporting Optimal Motivation

Autonomy the need to feel choiceful and volitional in one’s behavior

Competence the need to feel optimally challenged and capable of

achieving outcomes

Relatedness the need to feel connected to and understood by important

others

Deci & Ryan, 1991, 2000Ryan & Deci, 2000

Autonomy vs Independence Autonomy has two definitions:

– Volition: willingness to act for oneself (even in relation to others’ intentions)

Associated with motivation, positive affect, better health

People can want to stop smoking, and can accept that others want them to stop, too. Consistent with SDT.

– Independence: to act without input from others Inconsistent with SDT—does not meet relatedness

need

Medicine’s Social Surround is our Code of Biomedical Ethics

“These “ethics” are stated obligations of the health profession and its professionals, and are intended to ensure that patients who enter relationships with physicians will find them competent and trustworthy to provide expert advice to the patient and society on matters of health.”

Beauchamp & Childress, 2009

Medical Professionalism – A Physician Charter & Biomedical Ethics

Primacy of patient welfare: a dedication to serving patients’ interests.

Patient autonomy: To empower patients to make informed decisions

Social justice: To eliminate discrimination

ABIM Foundation, 2002

Motivation

Autonomous Motivation Behaviors are chosen and volitional Behaviors are performed for their inherent value

Controlled Motivation Behaviors are pressured or coerced Behaviors are performed for some separable outcome

Ryan & Deci, 2000; Deci & Ryan, 1991, 1995; Sheldon et al., 1997; Nix et al., 1999; Ryan et al., 1995

The Role of Needs Support in Autonomous Motivation

Keys to facilitating autonomy: elicit & acknowledge feelings & perspectives provide a menu of effective options

Emphasize choice when options are present

provide meaningful rationale support patient initiations to change

Expect failure in behavior change, reframe

minimize control

Deci et al., 2006

The Role of Needs Support in Relatedness Motivation

Keys to facilitating relatedness: unconditional positive regard

nonjudgmental stance continued relationship over time

warm positive relationship develop empathy

elicit & acknowledge patient perspective

The Role of Needs Support in Competence Motivation

Keys to facilitating perceived competence: high levels of autonomy be positive that the patient can succeed provide effectance feedback identify barriers skills-building/problem-solving build a plan with appropriate levels of challenge

Needs support is important because…

Internalization

an inherent, proactive process by which autonomous and competence motivations are increased naturally over time

Social Contextual Factors That Undermine Autonomous Motivation

SDT meta-analysis of over 128 RCTS in lab Tangible Rewards Threat of punishment Deadlines Evaluations Competitions

Deci, Koestner & Ryan, 1999

Effects of Rewards and Punishments

Cohen’s d k

All people got expected rewards

-0.36 92

When people got less that max reward

-0.88 6

When some people got no reward

-0.95 1

Verbal Rewards 0.33 21

Deci Koestner & Ryan, 1999

Kennedy et al., 2004

Williams, et al., Diabetes Educator. 2009;35(3):484-92

Path Model:Motivation, Adherence, Health

HCCQ Aut. Motiv. Competence

Qual. of Life

Adhere

Gly. Contr.

HbA1c Gluc.

.42*** .29***.35***

.15*** -.33***

-.31***

.93*** .67***

Fit Indices χ2= 149.5; df= 33 χ2 /df= 4.53 IFI/CFI= .97 TLI= .94 RMSEA= .03

Non HDL Chol

SDT Meta-Analysis

Figure 1. The SDT model of health behavior change adapted from Ryan, et al, 2008

SDT Meta-Analysis

We conducted a meta-analysis of studies within the health care and health promotion contexts based on (figures on next slide)…

SDT model of behaviour change Figure 1; Ryan, Patrick, Deci & Williams, 2008

Ng, Ntoumanis, Thøgersen-Ntoumani, Deci, Ryan, Duda, & Williams (2012). Perspectives on Psychological Science.

SDT Meta-AnalysisMethods

184 data sets from 165 sources (journal articles, theses, etc.)

correlation coefficients were meta-analyzed using methods by Hunter & Schmidt (2004)

Ng, Ntoumanis, Thøgersen-Ntoumani, Deci, Ryan, Duda, & Williams (2012). Perspectives on Psychological Science.

SDT Meta-AnalysisCorrelations- Mental Health

Needs Support Auto. Mot. Perc. Comp.

Depressive Sx -.23 (5) -.06 (6) -.23 (6)

Anxiety -.23 (4) -.09 (3) -.32 (7)

Qual. of Life .22 (2) .22 (1) .40 (2)

Vitality .35 (4) .26 (2) .43 (5)

Auto. Mot. .39 (15) ----- .59 (38)

Perc. Comp. .31 (32) .59 (38) -----

SDT Meta-AnalysisCorrelations-Physical Health

Needs Support Auto. Mot. Perc. Comp.

Tobacco Abs. .12 (4) .16 (6) .29 (3)

Physical Act. .23 (30) .20 (16) .35 (31)

Wt loss .28 (2) .38 (3) .22 (3)

Dental .38 (3) .23 (3) .53 (2)

Med Adhere .08 (2) .11 (4) .17 (3)

Healthy diet .29 (3) .41 (7)) .07 (2)

SDT Meta-Analysis

Figure 3. Path diagram of Williams et al.’s (2002, 2006) model using meta-analyzed correlations (n = 13,356). All paths are significant at p < .05; residual variances are omitted for presentation simplicity.

2 (3) = 76.25, p < .01, CFI = .98, RMSEA = .07, SRMR = .03.

Self-Determination Theory (SDT) Meta-Analysis Limitations

Correlations are bidirectional and thus do not support causal interpretation of the results.

Biomedical Ethics mandates respect for autonomy-thus directionality is irrelevant.

However, 6 previous RCTs with SDT-based health interventions designed to respect patient autonomy have been shown to increase patient perceptions of autonomy and competence and improve outcomes in: tobacco abstinence (Williams et al, J General Internal Medicine, 2006; Williams et al, Health Psychology, 2006; & Williams et

al, Annals of Behavioral Medicine, 2009)

dental outcomes (Halvari & Halvari, Mot.& Emot. , 2006; Health Psych ,In Press)

physical activity (Fortier et al., Psychology of Sport And Exercise, 2007)

weight loss (Silva et al, Medicine & Science in Sports & Exercise, 2011)

Ng, Ntoumanis, Thøgersen-Ntoumani, Deci, Ryan, Duda, & Williams (2012). Perspectives on Psychological Science.

Smoker’s Health Study Design

Randomized controlled trial of 30 mo. N=1,006

Questionnaire assessments: * autonomous motivation * perceived competence * autonomy support

Outcomes:* Took Medication* Tobacco Abstinence at 6, 18, and 30 months* Reduction in % calories from fat, LDL-C

Williams, McGregor et al., Health Psychology. 2006;25(1): 91-101.

The Intervention

The clinical endpoint of the intervention was to guide the patient to making a clear choice about whether he wanted to change or not.

If the patient wanted to stop smoking or change diet then the clinician provided competence training on how to reach that goal.

Baseline Autonomous Motivation

1-month Autonomy

Support

18-month Cessation

.14**

.05+

.40** .34**

.33** .52**

Medication Taking

.19**

.32**

.68**

Note: Model Fit: adequately χ2(248) = 1193.14, p < .001, CFI = .92, IFI = .92, RMSEA = .066 ; Values represent standardized path estimates. + p = .10; * p < .05; ** p < .01.

Baseline Perceived

Competence

6-month Autonomous Motivation

6-month Perceived

Competence

All Patients Odds Ratio PHS Odds Ratio

6-month 7-day Point Prevalence 2.9 2.5

Patients who Did Not Want to Quit Odds Ratio

6-month 7-day Point Prevalence 2.7

All Patients Odds Ratio

12-month Prolonged Abstinence at 18-months 2.6

Patients with Elevated LDL-C Intervention Control p-Value

18-month Change in LDL-C 8.0 mg/dl 4.0 mg/dl < 0.05

Health Outcomes at 6-months and 18-months

Group treatment for overweight and obese women, centered on physical activity motivation and...

...based on Self-Determination Theory

RCT: 1-year intervention + 2-year follow-up (n=239)

Main Outcomes/Mediators: Exercise Motivation (Intrinsic/Autonomous), PA/Exercise (1y), Weight (2 to 3 years)

The “PESO” study

Silva et al. (2008) BMC Public Health 8:234

Silva et al. (2010) J Behav Med 33:110

Silva et al. (2010) Psych Sport Exerc 11: 591

Teixeira et al. (2010) Obesity 18:725

No fixed exercise prescription!

Provide options, active experimentation

Include challenging PA opportunities

Promote personally-meaningful activities

Ask for leadership, autonomy in organizing

Three-month dance curriculum

Walking/pedometers, safety, skills,...

Exercise-specific Elements

Promote Intrinsic Motivation, Autonomy

Silva, Markland, et al., BMC Public Health 2008;8(1), 234.

Physical Activity at 3 years

p

Moderate + Vig. PA (min/wk) 234 221 148 162 0.009

Walking (steps/day) 8837 3661 7999 3823 0.206

Lifestyle PA Index (dif. 0-36 mo) 0.75 0.88 0.39 0.70 0.002

Mean ± SD Mean ± SD

Intervention Control

Minutes of moderate and vigorous PA

Net difference: +86 min/wk

Teixeira et al., (in preparation)

% W

eigh

t Cha

nge

-10

-8

-6

-4

-2

0

2

Intervention Control

Error Bars Show 95.0% CI of Mean

Baseline 12 Months 24 Months 36 Months

- 7.4%

- 1.7% - 2.0%

- 5.6%

- 1.4%

- 3.9%

3-year weight change (completers-only)

Difference: 3.9%

Average: -5.6%

Average: -1.7%

Teixeira et al., (in preparation)

Group treatment for overweight and obese women, changed motivation, phys activity, and weight 36 months after intervention

Autonomy, and Competence Mediated the effect of the Intervention on: PA/Exercise, and Weight

Effect was large enough to be clinically important for diabetes prevention and reducing blood pressure

Summary “PESO”

Dental Study 86 university students (21-35 yrs., X = 27.34

yr., SD = 3.99) A randomised two-group field experiment pre-

and post-measures of: autonomous self-regulation perceived competence oral health outcomes (plaque & gingivites)

Halvari & Halvari, 2006, Motivation & Emotion

.39*** .43*** .13

.41***

-.42*** .49***

.24* .20* .33**

.30**

PlaqueT1

Perceivedcompetence

T3

Autonomy support

T2

Perceivedcompetence

T1

Autonomousmotivation

T3

Autonomousmotivation

T1

GingivitisT1

Healthbehavior

T3

PlaqueT3

GingivitisT3

Munster -Halvari & Halvari (2006). Motivation and Emotion, 30, 294-305

Munster Halvari, et al., (2012). Health Psychology.

Clinical Implications Medical Professionalism, and biomedical

ethics indicate that promoting patient autonomy is a primary outcome of the clinical encounter.

Empirical evidence from 184 health related studies indicate:that supporting psychological needs enhancesautonomy, competence and relatedness which, in turn,predict mental and physical health & QOL

Clinical Implications Health Care Practitioners who learn to support

psychological needs: Elicit perspectives (listen) Acknowledge affect (reflect) Provide effective options for change Provide clear advice (rationale) for change Support initiative for change Minimize control and remain non-judgmental Skills build/problem solve with those willing Provide a positive relationship

May be more likely to motivate change, health, and improve quality of life for their patients.

Research Implications & Summary Interventions may have a greater impact if centered

around facilitating internalization of patient autonomy and competence.

Research may not inform clinical care until it includes the following: Autonomy as an outcome of care With a free choice period in the study design Includes those that don’t want to change

Health Policy Implications

Health policy interventions may have a greater impact if delivered in a manner that supports patient autonomy, competence and relatedness that would facilitate the internalization of a value for the health behavior.

“We recommend adults to get a minimum of 30 minutes of moderate level physical activity most if not all days per weeks, and two 30 minute sessions of resistance training to maintain your health. Are you willing to do that?

Virtual Clinicians

We offer intensive interventions that increase motivation to take medications and make lifestyle changes for Tobacco dependence 4-8 visits 30-300 min. Hyperlipidemia – 6 visits 3 MD, 3 RD Weight Loss – 22 visits

Virtual Clinician

3 NIH grants to develop and test VC’s NIDA – research tool “VCRT”

R21-DA024262

NHLBI – SBIR Clinical Advisory Tool- ICAT

R44HL097506

LM – Virtual Weight Loss RC1-LM010410

Hypotheses Can we deliver intensive intervention

content with a VC for patients? At home In the waiting room On Smart Phone

Can we increase well being and autonomy for same or lower cost?

Can we adapt intervention for culture gender, and race to eliminate disparities?

Next Steps

Behavioral Economics and Motivation based interventions

Effect of presenting health risk information on motivation and adherence

SDT model for change in cholesterol and blood pressure management

Motivation of health care practitioners

Thank You!

Citation

Ng, J., Ntoumanis, N., Thøgersen-Ntoumanis, C., Deci, E. L., Ryan, R. M., Duda, J. L., & Williams, G. C. (2012). Self-Determination Theory applied to health contexts: A meta-analysis. Perspectives on Psychological Science, 7(4), 325-340.

References ABIM Foundation. (2009). Medical professionalism in the new millennium: A physician charter. Annals of

Internal Medicine, 136(3), 243-246. Beauchamp, T. L. & Childress, J. F. (2009). Principles of biomedical ethics. New York: Oxford University Press. Cahill, K., & Perera, R. (2011). Competitions and incentives for smoking cessation (Review). The Cochrane

Library. Deci, E. L., La Guardia, J. G., Moller, A. C., Scheiner, M. J., & Ryan, R. M. (2006). On the benefits of giving as

well as receiving autonomy support: Mutuality in close friendships. Personality and Social Psychology Bulletin, 32, 313-327.

Deci, E. L. & Ryan, R. M. (1991). A motivational approach to self: Integration in personality. In R. Dienstbier (Ed.), Nebraska symposium on motivation: Perspectives on motivation (Vol. 38, pp. 237-288). Lincoln: University of Nebraska Press.

Deci, E. L. & Ryan, R. M. (1995). Human autonomy: The basis for true self-esteem. In M. Kernis (Ed.), Efficacy, agency and self-esteem (pp. 31-49). New York: Plenum Publishing Co.

Deci, E. L. & Ryan, R. M. (2000). The “what” and “why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11, 227-268.

Moller, A. C., McFadden, H. G., Hedeker, D., & Spring, B. (2012). Financial motivation undermines maintenance in an intensive diet & activity intervention. Journal of Obesity, epub ahead of print.

References Ng, J., Ntoumanis, N., Thøgersen-Ntoumanis, C., Deci, E. L., Ryan, R. M., Duda, J. L., & Williams, G. C.

(2012). Self-Determination Theory applied to health contexts: A meta-analysis. Perspectives on Psychological Science, 7(4), 325-340.

Nix, G. A., Ryan, R. M., Manly, J. B., & Deci, E. L. (1999). Revitalization through self-regulation: The effects of autonomous and controlled motivation on happiness and vitality. Journal of Experimental Social Psychology, 35, 266-284.

Ryan, R. M. & Deci, E. L. (2000). Intrinsic and extrinsic motivations: Classic definitions and new directions. Contemporary Educational Psychology, 25, 54-67.

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Ryan, R. M., Deci, E. L., & Grolnick. W. S. (1995). Autonomy, relatedness, and the self: Their relation to development and psychopathology. In D. Cichetti & D. J. Cohen (Eds.), Developmental psychology – Vol. 1: Theory and methods (pp.618-655). New York: Wiley.

Sebire, S. J., Standage, M., & Vansteenkiste, M. (2008). Development and validation of the goal content for exercise questionnaire. Journal of Sport and Exercise Psychology, 30, 353-377.

Sheldon, K. M., Ryan, R. M., Rawsthorne, L. J., & Ilardi, B. (1997). Trait self and true self: Cross-role variation in the big five personality trails and its relations with psychological authenticity and subjective well-being. Journal of Personality and Social Psychology, 73, 1380-1393.

The Contract with Society Nonmaleficence (a norm of avoiding the causation of harm)-

Hippocrates 400 BC Beneficence (a group of norms of pertaining to relieving,

lessening, or preventing harm and providing benefits and balancing benefits against risks and costs). Percival 1802

Justice (a group of norms for fairly distributing benefits, risks, and costs) - 2000 Medical Ethics & Professionalism

Respect for Autonomy (a norm of respecting and supporting autonomous decisions). 2000 AD

Beauchamp & Childress 2009