Self-Determination Theory in the Clinic: Motivating Physical and Mental Health 9780300128666

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Self-Determination Theory in the Clinic

KENNON M. SHELDON GEOFFREY WILLIAMS THOMAS JOINER

Self-Determination Theory in the Clinic M O T I VAT I N G P H Y S I C A L A N D M E N TA L H E A LT H

Yale University Press New Haven & London

Copyright ∫ 2003 by Kennon M. Sheldon, Geoffrey Williams, and Thomas Joiner. All rights reserved. This book may not be reproduced, in whole or in part, including illustrations, in any form (beyond that copying permitted by Sections 107 and 108 of the U.S. Copyright Law and except by reviewers for the public press), without written permission from the publishers. Printed in the United States of America. Library of Congress Cataloging-in-Publication Data Sheldon, Kennon M. (Kennon Marshall) Self-determination theory in the clinic : motivating physical and mental health / Kennon M. Sheldon, Geoffrey Williams, Thomas Joiner. p. cm. Includes bibliographical references and index. isbn 0-300-09544-9 (cloth : alk. paper) 1. Clinical health psychology. 2. Autonomy (Psychology) 3. Health behavior. 4. Psychotherapy. I. Williams, Geoffrey, 1957– II. Joiner, Thomas E. III. Title. r726.7 .s466 2003 616%.001%9—dc21 2002011147 A catalogue record for this book is available from the British Library. The paper in this book meets the guidelines for permanence and durability of the Committee on Production Guidelines for Book Longevity of the Council on Library Resources. 10 9 8 7 6 5 4 3 2 1

Contents

Preface vii Part I. Self-Determination Theory: Concepts and Evidence 1.

Self-Actualization, Society, and Scientific Psychology 3

2.

Self-Determination Theory and Its Supporting Research Base 13

3.

Autonomy Support and Behavioral Internalization: Promoting Ownership of Non-Enjoyable Behaviors 28 Part II. Self-Determination Theory Applied to Medical Practice

4.

Self-Determination Theory and Physical Health 43

5.

Facilitating Health Behavior Change: The Case of Tobacco Dependence 65

6.

Supporting the Internalization of Chronic Disease Management: The Case of Diabetes Mellitus 83

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Contents

Part III. Self-Determination Theory Applied to Mental Health Practice 7.

Self-Determination Theory and Mental Health 109

8.

Facilitating Psychological Change: The Case of Substance Abuse Disorders 126

9.

Supporting Self-Determination in the Treatment of Anxiety and Eating Disorders 142

10.

Supporting Self-Determination in the Treatment of Mood and Personality Disorders 165 Conclusion 184 References 187 Index 199

Preface

In this book we are privileged to report the state of the art regarding an exciting and important theory of human motivation: self-determination theory. This comprehensive theory has been under development for more than thirty years, and its postulates have received voluminous empirical support, derived from the best scientific methodologies (see Deci and Ryan 1985, 1991, 2000). The theory has finally achieved mainstream status within contemporary motivational theory and research. Self-determination theory has several important features. First, it is broad and general enough to encompass many essential issues in social, motivational, and personality psychology. It provides a truly integrative framework in which a large number of questions can be addressed and in which basic dichotomies (self versus society, humanism versus empiricism, freedom versus responsibility) can be resolved. Second, the theory is perfectly tailored for clinical settings, because it focuses not only on how people in positions of knowledge and influence can best motivate their clients but also on how authorities may sometimes unintentionally undermine their clients’ motivation. Third, the theory opens a hopeful window on human nature and potential while acknowledging the many roadblocks that can get in the way of that nature and potential. It is thus consistent both with the new emphasis on a more positive perspective within academic psychology (Seligman and Csik-

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szentmihalyi 2000) and with the attempt to bridge the gulf between traditional experimental psychology and the personal growth and self-help psychologies the book-buying public seeks. In fact, self-determination theory’s emphasis on the experiencing self dovetails very well with new age psychologies while also winnowing and systematizing such perspectives. In the chapters that follow we first present a philosophical, conceptual, and empirical overview to the theory. What does it mean to be an experiencing self, and why does being one matter? In the second and third parts of the book we show how the theory can be applied to maximize client health in both medical and psychotherapeutic domains. Although we (the authors) are acknowledged experts in these research domains, we must confess that we still struggle in motivating the ‘‘real’’ people in our lives (children and spouses included!). This highlights an important point: although the concepts contained here are in one sense very simple, in another sense, they can take a lifetime to integrate into one’s life and practice. We hope that readers will recognize the intuitive appeal of these ideas and benefit from a careful consideration of them.

P A R T

Self-Determination Theory Concepts and Evidence

I

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Self-Actualization, Society, and Scientific Psychology

The term self-actualization catches people’s fancy. It is an alluring idea indeed that we are born with a natural tendency toward growth and goodness and that the only thing standing between our potential and us is an empathic and positive atmosphere. It’s a good bet that, of all the material taught in college psychology courses, self-actualization is one of the few concepts that eventual nonpsychologists actually remember! Odds on this bet are made even better given that the psychology sections of today’s large bookstores are filled with popular titles emphasizing self-actualization themes. But it’s not just nonpsychologists who take to the concept; many applied clinical and counseling psychologists working in settings outside the university, such as private practice and community clinics, also emphasize concepts like personal growth and self-actualization in therapy. Even as the general population resonates with concepts like selfactualization and buys books on related topics, and even though many applied psychologists emphasize the concept, scientific psychology seems, at best, to have forgotten or minimized the approach and, at worst, to have sneeringly rejected it. In a survey, Mayne, Norcross, and Sayette (1994) found that just 10 percent of clinical psychology research faculty considered themselves sympathetic to self-actualization and related views (for example, client-centered or humanistic approaches to therapy). Instead, the clinical research community

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in psychology tends to be much more narrowly focused, using federal grant dollars to develop and empirically validate programmatic treatments for particular disorders. In such work little thought is given to the client’s selfactualization or personal growth. This is perhaps a significant omission, because although the success rates for empirically derived treatments are increasingly good, they are still lower than would be desired. All this makes for an unsatisfactory situation that is tearing at the profession. On one hand, scientific psychologists are pointedly ignoring concepts that have extremely wide appeal, not only to general folk, but to their less research-oriented colleagues, too. Surely, given peoples’ perennial interest in these themes, this group must be missing something important? On the other hand, the general public and many applied clinicians are ignoring the many new, empirically proven ideas and procedures that have emerged for treating an array of mental and physical disorders. What can be done to disseminate these new findings and procedures to the lay public and counseling professionals and, indeed, to improve the new procedures? If this situation is not resolved, we believe that it has the potential to fragment the treatment community, impede the development of better therapeutic techniques, and erode the public’s interest in scientific psychology. If only there were a science of self-actualization, and if only there were niches within empirically validated treatments where concepts like selfactualization might fit! Then there might be greater harmony between the ‘‘hard-nosed’’ research psychologists and the legions of applied psychologists who resonate to concepts like self-actualization; greater harmony between mechanistic theories and personalistic theories within psychology; and greater harmony between research-oriented clinicians and the needs and demands of the public whose tax dollars support much of the research that clinicians do. Our purpose in this book is to show that this harmony is not only possible but that, in large part, it already exists and that it extends beyond the treatment of mental disorders to include traditional medical problems (among them, obesity and medication adherence). That is, a new science of self-actualization has been developed in the past thirty years, and it directly addresses the question of how best to engage the ‘‘self’’ of the client. This research has shown that enhancing the client’s sense of personhood within the treatment setting can greatly enhance the effectiveness of any approach or procedure, medical or psychological. In a nutshell, our goal here is to present these new ideas and results and to provide guidance to physicians, clinicians and patients regarding the everyday treatment of such problems as depression, obesity, and smoking. The ideas in this book should resonate with profes-

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sionals and lay readers alike, with medical and clinical professionals alike, and with research and applied psychologists alike. We begin by briefly tracing the rise and fall of the humanistic theoretical perspective (and related perspectives) within academic psychology. This theoretical tradition, founded by Carl Rogers, Abraham Maslow, Rollo May, and many others, is most similar to the kind of thinking that is widely found in selfhelp books. In particular, this tradition suggests a distinctive model of the optimal provider-client relationship, one that is very different from, and potentially much more effective than, the traditional authority-supplicant rolerelationship that still dominates within many helping contexts. The nature of this interpersonal model is a central topic of this book. Unfortunately, the humanistic perspective that grounds this model was largely discarded by research psychologists in the 1970s in favor of a more narrow cognitive perspective. We believe that considering why mainstream psychology rejected humanistic psychology will shed substantial light on the current divide between the ‘‘softer,’’ growth-oriented clinicians, and the ‘‘harder,’’ empirically oriented clinicians. Specifically, we hope to demonstrate that the divide is more a historical accident than a necessary barrier. Although the early humanists tended to marginalize themselves by rejecting empiricism, they didn’t have to; as we shall see, there is no necessary conflict between humanistic theory and quantitative methodology, and indeed, they can be quite complementary (Rychlak 1977). Following this brief historical introduction, in Chapter 2 we chart the thirty-year rise within scientific psychology of a comprehensive theory of motivation called ‘‘self-determination theory’’ (SDT), which carries the best of the humanistic ideas forward while finally supplying them with the research grounding that any new set of ideas requires to be taken seriously (Deci and Ryan 1985b, 2000). This theory is consistent with former notions of selfactualization as well as with the most advanced thinking of contemporary philosophers, evolutionary biologists, and dynamic systems theorists. Further, SDT is giving rigorous meaning to such concepts as ‘‘free will,’’ ‘‘healthy values,’’ and ‘‘true self’’ by focusing on individuals’ quest for phenomenal ownership of their behavior as a central cause of positive adaptation and development. In particular we examine SDT’s findings concerning social contexts and the enhancing or inhibiting effect that styles of authority communication can have on the development of optimal, self-regulated functioning. After this introduction to SDT and the research that supports it, we show concretely how clinical practitioners may apply these ideas in both the psychological and medical fields to enhance the effectiveness of treatment with their

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clients. Specifically, we discuss SDT’s concept of autonomy support. As we show in Chapter 3, autonomy support (in brief, the practice of acknowledging the client’s perspective, giving the client as much choice as possible, and providing meaningful rationales when choice provision is impossible) may be the most crucial ingredient that clinicians can supply as they attempt to enact therapeutic programs with patients or clients. That is, for the purpose of maximally engaging clients’ motivational and organizational resources, how a treatment program is conducted may matter at least as much as, if not more than, what the program consists of. In Parts II and III, we discuss the concrete application of the foregoing ideas, within a variety of medical (Part II) and psychotherapeutic (Part III) domains. Here we wish to show that the approaches presented really work, as numerous high-quality studies demonstrate. We hope that by the time the reader has finished the book, he or she will not only have picked up some important tips but will understand why self-help remains a perennial topic of interest. In our view, it is primarily because the self-help authors actually convey some truths —chiefly in their implicit assumption that humans are self-organizing systems who may need little more than an acknowledgement of their autonomy and growth potential to enact tremendous changes in their lives. SDT clearly articulates what such acknowledgment consists of and how it works. In this way SDT helps to clarify how to assist the inherently active individual to improve him or herself.

The Historical Background The dark ages in psychology. The late 1950s and early 1960s formed a watershed in scientific psychology, as the field emerged from the ‘‘dark ages’’ of radical behaviorism. Cast under the spell of B. F. Skinner and his colleagues, most research psychologists of the 1930s, 1940s, and 1950s eschewed mentalistic theories and would not tolerate the inclusion of subjective or experiential factors within their scientific explanations. Of course, it was during this era that the dominant cultural image of research psychologists was established —namely, that they are clueless individuals in white lab coats, running rats through mazes and people through reinforcement trials while ignoring what is most important to, and about, humans. Because of the pioneering research of Richard Tolman, Jerome Bruner, Jean Piaget, and many others, however, the behavioristic stranglehold was broken in the early 1960s. Psychologists increasingly found that many important phenomena could not be explained from within the operant behavioral worldview. Such phenomena include how rapidly children absorb the grammar of

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their native languages, how easily people learn new behaviors via mere observation, the fact that people persist at great length in behaviors that yield no external reward, and how creatively people solve never-before-encountered problems. Hastening the rise of mentalism was the emergence of electronic computing and its suggestion of a ‘‘rule-based software’’ metaphor for understanding the human mind (Baars 1986). In short, during the 1960s research psychologists finally came to agree that mental and experiential processes must be considered after all. Two candidate successors for behavioristic psychology. Two movements stepped into the gap: cognitive psychology, which rectified the failure of behavioristic researchers to consider the signal processing that goes on within the minds of individuals, and humanistic psychology, which addressed the failure of behavioristic researchers to consider the selves and personhood of individuals. During the 1960s, these two visions of subjectivity helped overthrow the behavioristic worldview (Schultz and Schultz 1987). Although the two perspectives agreed in their focus on the mental activity occurring within the individual, they disagreed on many other things. For example, cognitive psychology maintained a strong focus on nonconscious and nonaccessible mental processes. In this, the cognitive approach has important shared roots with Freudian psychodynamic psychology. In contrast, the humanists emphasized conscious mental processes and the power of human choice, taking strong exception to Freudian psychology’s emphasis on humans as creatures driven by bestial urges and ruled by unconscious mental processes. Humanistic psychology was also in many ways the academic representative of the countercultural zeitgeist that emerged within the 1960s (Schultz and Schultz 1987); this was of course a time when many conformist assumptions and norms were cast off in favor of radical new ideologies, personal explorations, and modes of interpersonal encounter. In contrast, the cognitive perspective was not aligned with these cultural forces; in fact, cognitive scientists had little concern, at first, for understanding higher-level personality or social-cognitive processes. Yet another difference was that humanists worked mostly in applied areas of psychology, as clinicians, counselors, or social workers, whereas most cognitivists worked in academic research settings. Yet the most important source of the rift that grew between humanistic theorists and the mainstream research community was probably their disagreement on the role of quantitative methodology in acquiring knowledge. Was it more important to conduct statistical analyses of numerical data collected from large representative samples or to conduct qualitative analyses of narrative data collected from individual lives? Humanistic writers tended to extol the narrative case-by-case approach, denouncing large sample studies, empirical

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quantification, and statistical-significance testing as politically loaded practices that hide and even violate the unique subjectivity of people (Jourard 1974). Human beings, it was argued, are radically different from the ‘‘objects’’ studied in the other natural sciences, for humans are potentially self-aware and self-transcending. From this point of view, experience is the great mystery; the human psyche can be properly explored only on its own terms, and it must thus be viewed ‘‘from the inside.’’ In short, the humanists argued that psychology must reconstitute itself as a very different science, abandoning the pretense of objectivity inherited from the natural sciences in favor of a new, more ‘‘human’’ science. Unfortunately, the products of humanistic research were often unimpressive, sometimes presenting laborious descriptive analyses of trivial personal experiences, and other times seeming to make hopelessly naive assumptions about the inherent ‘‘goodness’’ of human nature (Funder 1997; Smith 1982). There was also a general shying away from causal analysis, as if scientific explanation itself were taboo (Wertz 1998). Humanism began to acquire a reputation for self-indulgence and self-absorption: the human potential movement, for example, which was originally directed toward bringing about an Aquarian age of increased tolerance and self-actualization (Ferguson 1980), soon became known instead for its hedonism. That is, many people used the movement as an excuse for seeking individualistic pleasure in the absence of any restraining authority. In addition, the experiential encounter group, perhaps the most important innovation of the human potential movement, soon acquired a reputation as a place where group leaders exerted strong and sometimes dehumanizing power over participants in their quest to expose every emotion and eliminate every hang-up. Such practices were even ridiculed as the pitiful antics of hopelessly infantile individuals (Koch 1971). Of course, most academic humanists did not fall prey to such traps and continued to promote socially responsible forms of personal fulfillment and growth. Further, they continued to write passionately and well; even today, more real insight can be gleaned from the pages of the Journal of Humanistic Psychology than can be gained from most academic psychology journals. And yet, since the 1970s the academic humanists have become increasingly marginalized within the field as a whole. Again, this seems due largely to their refusal to employ conventional empirical methods and, perhaps even more, because of their outright hostility toward those methods (Child 1973; Giorgi 1970; Wertz 1998). The weaknesses of humanistic and cognitive psychologies. By seeking to reform both theoretical and methodological psychology simultaneously, the humanists overextended themselves and diluted their message. Further, their

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attack on empirical methodology was wrong, and it undermined their credibility. Research methods, after all, are only tools, not ideologies, and like all tools, they can be applied more or less thoughtfully. Psychological methods are continually developing, just as in other disciplines, and the best, most reliable knowledge can be procured only by applying the best, most illuminating, and unbiased techniques. Doubtless, the qualitative case-based analyses that the humanists championed as an alternative model of science can be very interesting and informative. But they can never supply the confidence concerning causal relations that is critical for attacking large-scale psychological and public health issues. Because of this, funding for humanistically oriented researchers began to dry up, as did the interest and patience of academic psychology as a whole. This was unfortunate, because humanism did not have to estrange itself from mainstream science (Rychlak 1977). As we concretely demonstrate in Chapter 2, humanistic theories and quantitative methodologies can be quite complementary after all. In contrast to the humanists, the early cognitivists positioned themselves squarely within the empirical mainstream, adopting the same experimental standards and statistical methodologies that the behaviorists had employed and developing many new methods besides. Importantly, proponents of the new cognitive models thereby also positioned themselves squarely within the stream of federal-grant funding and thus assumed the ordained mantle of psychological science. Because of this funding, and because of the very powerful conceptual tools they can offer, cognitive or information-processing approaches now dominate almost every discipline of academic psychology. Interestingly, this influence has also extended into the domains most concerned with personhood—namely, clinical and social psychology. For example, many forms of psychopathology are now viewed in primarily cognitive terms, as maladaptive attributional styles, unrealistic future expectancies, or perseverating self-regulatory failures (Abramson, Metalsky, and Alloy 1989). Similarly, many personality traits are profitably viewed as habitual patterns of construing or interpreting the world (Cervone, Shadel, and Jencius 2001). The list of successes could go on and on. In spite of its many accomplishments, the cognitive approach has made mistakes. Specifically, in many ways cognitive psychology has tended to slide back into the behaviorists’ reductionistic, mechanistic, and potentially dehumanizing assumptions that humans are mere ‘‘automated machines.’’ For example, some contemporary cognitively oriented social psychologists deny that the phenomenal self can have agency or causal impact, arguing that it should be reduced or eliminated entirely from consideration as an explanatory construct (Bargh and Chartrand 1999; Wegner and Wheatley 1999). These

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workers suggest, just as the behaviorists did, that human feelings of choice, agency, and autonomy are purely fictional. The only change from earlier is that behavior is now said to be determined by subconscious cognitive processes rather than by environmental contingencies and past reinforcements; in either case, of course, the conscious self has little control or importance. In short, the assumptions of mainstream research psychology once again appear to be at variance with common human experience. They seem to bypass the critical issues that we all face in our (real) lives: What to value, whom to be, how to choose? Because of this vacuum, people turn to self-help manuals, consuming ideas and accepting claims that are often of dubious merit.

The Self: Real, Imagined, or Both? In denying the potential importance and causal role of the human self, cognitive science may be heading toward a dead end, just as the humanists entered a dead end when they rejected conventional scientific methods. This route does not have to be taken; although hard-headed researchers are right to be wary of positing a ‘‘ghost in the machine’’ that magically interacts with the world but is somehow not of the world, increasing numbers of nondualistic and scientifically rigorous models of self and self-processes that sidestep such pitfalls are now available (Nowak et al. 2000). For example, new developments within chaos theory, dynamical systems theory, and hierarchical control theory all suggest that complex systems can manifest surprising emergent processes whose effects are irreducible to lower-level or more molecular functioning. In the brain, such processes often appear to be characterized by consciousness and subjectivity. Although they are undergirded by neuronal activity, conscious experiences involving a sense of self have unique characteristics that can strongly influence the functioning of the neural systems in which they emerge (Damasio 1999). More specifically, brain events possessing the property of experienced self-awareness may have substantial consequences for future (nonconscious) brain events, consequences that are not deducible simply from knowledge of the underlying neuronal states that supported the original events (see Sperry 1988 for an in-depth discussion of this top-down, or monist interactionist, position). In short, consciousnessness matters. Importantly, from our point of view the self is indeed a ‘‘fiction,’’ at least in the sense that it has no existence independent of brain function and in the sense that specific self-experiences can be concocted somewhat arbitrarily. That is, we would agree that self-experiences are constructed within the human mind and that the self perhaps has no more intrinsic reality than the characters that

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haunt a novel or film. Objectively speaking, then, there is no ‘‘little person’’ inside the head. This said, the fact that people believe that they have a self has important consequences (Smith 1982): we would be hard-pressed to get by without a sense of self! Thus, although the self is a fiction, it is a fiction with a function, in fact, with a variety of important functions. These functions include helping the human organism to constitute itself as a stable and coherent entity within an interacting social network of selves (Reis 2001), helping the organism to feel and know what is ‘‘right’’ for itself (Rogers 1956), and helping the organism to generate and select long-term goals and plans for itself (Sheldon 2001). Perhaps most important for this book, a major self-function is that of motivating behavior over long periods of time, particularly adaptive behavior that may not necessarily be pleasurable for its own sake (Markus and Nurius 1987). This is not easy to do, as any maker of New Year’s resolutions can attest. Nevertheless, by aligning its sense of self with a chosen course of action, the human organism can gain important motivational resources.

The Society of Selves and the Role of the Clinician A notable insight to emerge from cognitively oriented social psychology within the 1980s and 1990s was the recognition of the multiplicity of selves within the human mind (Nowak et al. 2000). In other words, it seems that each of us is populated by a veritable society of selves with different goals and self-perceptions. These different mental self-models and patterns of executive functioning typically alternate over time in the amount of control they exert over momentary behavior. In an important sense, then, we are not necessarily the same person today as we were yesterday! Further, these different versions of self can conflict with one another, and in extreme cases, these conflicts can lead to fragmentation within the psyche (Donahue et al. 1993; Emmons and King 1988). From this perspective, the health- or growth-seeking self that desires medical or psychological treatment is likely to be only one of many partially autonomous selves, grappling for ascendancy within the psyche. Although it may dominate at some times, at other times the health-seeking self may be far from view. This is consistent with the observation of many clinicians—namely, that clients often manifest extreme ambivalence and changeability regarding their participation in treatment. Operating from an (optimistic) humanistic point of view, we believe that the health-seeking self has an inherent advantage, in that it is most closely aligned with the integrative tendency that is at work within all living things. In other words, consistent with the new positive psy-

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chology movement emerging in the United States (Seligman and Csikszentmihalyi 2000), we believe that ‘‘health has a head start.’’ But the advantage is small, and the movement toward health can be easily disrupted. The clinician, we assert, thus has the important task of fanning the flame of the growth-seeking self by recognizing and nurturing the client’s impulses toward health. Rather than simply applying techniques designed to solve problems, the clinician’s real job may be to connect with and motivate the self of the client. To explore these issues in depth, we turn now to a detailed consideration of self-determination theory.

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Self-Determination Theory and Its Supporting Research Base

An important tenet of operant behaviorism, the model that dominated within academic psychology for several decades, is that behavior is repeated because it is reinforced and terminated because it is not reinforced or because it is punished. Behaviorists of the first half of the twentieth century insisted also that reinforcements needed to be defined independently of behavior, as distinct external commodities or consequences that follow on termination of the particular behavior. From this perspective, we should not expect to find organisms persisting in behavior that does not lead to tangible external rewards or that leads instead to punishments. And yet, as early as the 1920s, scientists observed exceptions to this rule: for example, rats would cross electrified grids in order to explore novel spaces, and monkeys would persist for long periods in trying to solve a puzzle even though no external reward came once they had solved it. Although behavioristically oriented theorists attempted by various means to explain such findings away, ultimately, their efforts were not persuasive (Deci and Ryan 1985b). In 1959, Robert White broke new theoretical ground by proposing an innate need for mastery or ‘‘effectance,’’ which pushes individuals to explore the environment and to master new challenges, even in the absence of external rewards. White argued that such an inborn motive would yield important survival advantages: it would automatically lead organisms to enhance and

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diversify their skills and enable them to better learn their surrounding territory. He argued further that the reward for such behavior comes in the activity itself—that is, in the enjoyment the individual experiences while doing the activity. Thus was born the concept of intrinsic motivation. White’s ideas and the related proposals of other theorists of the time helped break the behavioristic stranglehold. In the late 1960s and early 1970s researchers began in earnest to address the phenomenon of intrinsic motivation, attempting to understand what brings it about, what sustains it, and what undermines it. At a time when many people were rebelling against authority and against conventional value and reward systems, it seemed especially important to understand the conditions that lead people to be self-motivated (or not). For example, how might students be prompted to study because of interest more than grades, and how might employees be prompted to work because of the challenge more than the money? These questions are important for enhancing not only the quantity but the quality of motivation. As we now know, people perform best and most creatively when they are intrinsically engaged in what they are doing—that is, when they experience ‘‘flow’’ in their activities (Csikszentmihalyi 1997). Edward Deci conducted one of the pioneering studies in this area in 1972, showing that when people are paid to solve puzzles, they are much less likely to pick up the puzzles spontaneously afterward. As observed through a hidden window, paid subjects much preferred to do something else during a waiting period following the initial phase of the experiment. In contrast, those who were not paid continued to play with the puzzles, seeking progressively harder challenges. Subsequent research replicated and extended this intrinsic motivation ‘‘undermining effect,’’ showing that it also occurred when people engaged in activity in order to receive others’ approval, to meet experimenter-supplied deadlines, to get food or snack rewards, or to boost their own (experimentally manipulated) threatened self-esteem. Other researchers (such as Kruglanski 1975, Lepper, Green, and Nisbett 1973, and Amabile 1996), reported similar findings. It is hard to overemphasize how surprising the undermining effects were, at least, as seen from a behavioristic (rather than a humanistic) perspective. Again, the operant behaviorism model said that people persist in behavior because it has been reinforced, via the receipt of some tangible reward or consequence. In contrast, the new research suggested that people may actually desist in behavior precisely because it has been rewarded. The implications for the question of how to motivate students, workers, athletes, and others were profound; it seemed that, in an important sense, people may be ‘‘punished by rewards’’ rather than reinforced by them (Kohn 1993). Thus, if we are at-

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tempting to induce spontaneous liking for an activity, perhaps the last thing we should do is give out gold stars and bonuses to those who participate in it! Building on his pioneering studies of the early 1970s, Deci began to develop a comprehensive theory of human motivation (Deci 1975) in order to explain these effects. Deci was joined by Richard Ryan in 1980, thus establishing one of the most sustained and fruitful collaborations in modern psychology. Below, we present the major ideas and findings of the theory that has evolved, starting with consideration of the philosophical perspective that underlies it.

The Organismic Perspective Self-determination theory is an organismic theory of motivation. The organismic philosophical perspective has venerable roots in history, traceable through Plato, William James, Jean Piaget, John Dewey, and, of course, the humanistic psychologists of the 1960s. Organismic perspectives share certain basic assumptions (Overton 1976). First, humans are active more than they are reactive. That is, rather than being pushed and pulled by environmental influences and reinforcers, people are proactive, selecting incentives to strive for. Of course, we all live under basic biological needs and situational constraints, but within these limits, we are creative problem-finders and problemsolvers. We are self-movers, whether or not we experience ourselves that way. Robert White’s concept of a natural effectance or mastery motive is a good example of this organismic assumption, and it helps to explain where the ‘‘selfmovement’’ comes from; it arises in part because humans are naturally curious, challenge-seeking creatures. Deci and Ryan’s SDT acknowledges and echoes White’s concept by proposing a fundamental need for competence within the human organism, which motivates much exploratory and growthrelevant behavior. Simply put, people want to find things to do, and they want to do them well. A second tenet of the organismic perspective is that a natural integrative tendency operates within all living things and thus that humans have an ongoing potential to reach new levels of expression and functioning. This tendency springs from the very nature of life: living beings are negentropic, which means that they are highly ordered systems, existing far from thermodynamic equilibrium, that maintain their structural integrity by increasing the complexity of their structure in response to challenges. In this humans are dissipative (entropyreducing) systems—in other words, a class of complex vortexlike phenomena in nature that neutralize potentially destabilizing influences by using them as a spur to new and even greater levels of order (Glansdorff and Prigogine 1971). An important feature of dissipative systems is that they can enter

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long periods of stasis during which the system’s structure and functioning does not change. In other words, people can ‘‘get stuck,’’ finding it hard to accommodate their way of being to new circumstances. In Chapter 3 we will see how easily various controlling authorities can trigger defensive reactions that can ‘‘stick’’ people in undesirable but hard-to-escape modes of functioning. Third, organismic philosophy is generally dialectical; in this perspective, life is an ongoing struggle characterized by cyclical movement between impeding challenges, coping responses, creative resolutions, and new challenges. As implied above, some challenges may prove too much for people. When impeding forces exceed a person’s coping abilities, defensive functioning may ensue, which can impede the growth process. Further, when disturbances radically exceed capacities, then regression or even cessation of functioning may occur. Of course, difficult challenges can also spur good things—that is, new levels of order. This potential illustrates the synthetic element of the dialectical process, according to which movement over time consists of theses (challenges) followed by antitheses (responses), followed, ideally, by syntheses (new order). Interestingly, the dialectical perspective also suggests another reason why people sometimes cease to grow: stasis can occur not only when the ‘‘theses’’ are too challenging but also when they are not challenging enough. This is rarely the case, however, for health-related behavior, which typically occurs in response to difficult health challenges. For this reason, our focus here is primarily on responses to difficulties. From the organismic perspective, life is most fully actualizing itself when behavioral functioning is increasing in complexity over time. In other words, if we are negentropic systems that can exist only because of our profound ordercreating capabilities, it seems logical that the more order we create, the better. One can also make an aesthetic argument for this perspective, valuing the creation of new beauty or meaning as a supreme good. Some organismic theorists have used such ideas to propose a moral imperative—namely, that the growth potential of life must be served, no matter what. Thus, when we consider both evolutionary and aesthetic criteria, we find that there may be only three true imperatives for human beings to maximize their potential: to survive, to reproduce, and to continue to develop in complexity over their life span via active engagement in the ‘‘dialects’’ of life. We ourselves subscribe to this view.

The Integrative Process at the Internal Boundary For Deci and Ryan, one important dialectical process is the struggle of the conscious self to master and regulate its internal environment, its drives and impulses. In other words, the self-function labors to increase the size and

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efficiency of the ‘‘interface’’ between itself and unmastered feelings and reactions. More concretely, we are all attempting to prevent the recurrence of the undesirable outcomes that resulted in the past, when we allowed our impulses and emotions to have free play. Assuming all goes well, people will move toward greater and greater degrees of conscious awareness, over time, in their decisions regarding which impulses to follow and which ‘‘selves’’ to give voice to. That is, on average, people should tend to function more autonomously as they get older, feeling greater power of choice and ownership over their behavior (Sheldon and Kasser 2001). Because felt autonomy is typically associated with more successful functioning (Sheldon and Elliot 1998), this will also tend to lead, over time, to greater skillfulness and higher levels of adaptation, in other words, to personal growth. As implied above, however, the movement toward greater selfregulation is far from certain; people may readily get ‘‘stuck’’ in maladaptive functional patterns if their capabilities are overwhelmed by circumstances or if they are insufficiently challenged by life.

The Integrative Process at the External Boundary But what if others get in the way of our quest to master our emotions and impulses? Should we withdraw from those who arouse difficult or unpleasant feelings in us, or should we respond with unmitigated hostility? In broader terms, does SDT’s focus on the self’s ‘‘relationship with itself’’ encourage the narcissism for which the humanists were (often unjustly) criticized? The answer is no, and it brings us to a fourth tenet of organismic philosophy: holism, in which the relation of the individual to the larger totalities of which he or she is a part is also important. In other words, the integrative tendency works not only within the individual but also in the space and relations between individuals. As negentropic (order-creating) systems, not only do we have an innate desire to increase our personal order, but we also wish to enhance social order: we want to bring about more coherent functioning in the social relations and systems in which we are embedded. The holistic assumption of organicism finds expression within SDT via Deci and Ryan’s postulation of a second dialectical process with which people struggle—namely, the interface of self with social environment. More concretely, we are trying to fit our sense of self in with others. But this task, too, is difficult, for we must learn how to properly characterize and appreciate others, just as we must learn this for ourselves. And we must learn to differentiate ourselves from others and from the social environment, especially when these external systems are insufficiently sensitive to our needs or when they try to manipulate us. There are thus many potential pitfalls in our relations with

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others, and we may become stuck in maladaptive or static patterns of interpersonal or group interaction that are hard to escape. To summarize so far, Deci and Ryan propose that there is a ‘‘phenomenal self,’’ an evolving character within the neural architecture that is struggling for greater integration and self-ownership. This struggle takes place on two fronts: in the self’s relations with internal emotions and impulses, and in the self’s relations with other selves. Both struggles are motivated by an inherent need for autonomy. Notably, then, this brings to two the number of fundamental needs that Deci and Ryan say are evolved into the human psyche (namely, competence and autonomy). Although autonomy is sometimes confused with independence (aloof resistance to others) or competence (successful functioning), Deci and Ryan define it differently: as regulation of the self by the self rather than by non-assented-to internal and external forces. Ideally, whatever people do, they should be able to align their sense of self with that action—if they cannot, something is amiss (either in the person or in the situation). But does the postulation of a need for autonomy lead us back toward narcissistic individualism, to a ‘‘self gone wild?’’ Again, no. Taking into account the holistic urge of humans to integrate themselves into the larger social structures in which they are embedded, Deci and Ryan postulate a third and final basic psychological need: for relatedness. We want to achieve a sense of communion with other selves. In fact, of all the potential psychological needs that are debated in the contemporary literature, relatedness or belongingness is probably the least controversial: almost all attachment, evolutionary, psychosocial, interpersonal, and personality theorists would agree that humans have a deep and inherent motive to feel connections with others (Baumeister and Leary 1995). In one sense, this need for relatedness acts as a sort of a check on the need for autonomy, keeping the unbridled self from raging out of control. In another sense, however, the need for relatedness is simply a natural expression of a higher-order growth principle, in which people attempt to enhance order and integration at every level of functioning, both intrapersonal and interpersonal. That such a tendency could exist in humans is well supported by findings concerning the adaptive and perhaps evolutionary advantages of altruism and cohesive group functioning. This research demonstrates that groupishness is often self-serving (even if not by intent), in that cooperators typically secure greater individual resources via this behavior than they could have obtained by competing (Sober and Wilson 1998; Sheldon and McGregor 2000). Is there any necessary conflict between autonomy and relatedness? In most cases, no. In fact, much research shows that autonomy and relatedness experi-

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ences are actually complementary, not conflictual: people who report strong feelings of autonomy in a social setting typically also report strong feelings of relatedness (Hodgins, Koestner, and Duncan 1996; Sheldon and Bettencourt 2002). By communing with the other, the self expands itself (Aron and Aron 1997), simultaneously fulfilling both its desire to express itself and its desire to be included in something larger. Thus, in total, SDT proposes three basic needs psychological needs or motives: competence, autonomy, and relatedness. People naturally seek incentives of these types, and they tend to thrive and grow when they get them (Sheldon et al. 2001). Notably, however, autonomy is in a sense the ‘‘master’’ need, because it most directly represents the organismic movement toward greater integration and self-regulation over time. It is time for us, then, to explore the nature of the human need for autonomy.

The Need for Autonomy: Origin or Pawn? The most direct indicator of integrated, self-regulated, autonomous functioning, according to Deci and Ryan, is the internal perceived locus of causality. Simply put, people can feel themselves to be either origins or pawns (DeCharms 1968). Origins feel that they choose what to do and that they are in creative control over themselves and their behavior. Because the sense of self is fully engaged within the behavioral sequence, there is self-responsibility for behavior. And origins’ behavior tends to be skillfully and creatively executed because all of their integrative capacities are engaged. Pawns, in contrast, feel that they are being regulated by the environment (this may be true or merely imagined, an issue we take up later), and their sense of self is not engaged within the behavior. Pawns are unlikely to feel full responsibility for what they do, and they are unlikely to function as successfully as they otherwise might. Contemporary SDT proposes that all ‘‘intrinsic motivation underminers’’ work by giving people an external perceived locus of causality for their behavior. That is, when people come to believe that they are behaving in order, for example, to get money, to avoid criticism, or to meet deadlines, then they are more likely to feel like a pawn. Thus, the activity may not meet their need for autonomy or self-regulation. As a result, the activity may not be as satisfying and the person’s intrinsic motivation for the activity may be diminished. As some readers may have noticed, this perspective is akin to Marxism’s concern for the potentially alienating and dehumanizing characteristics of work and social environments. In fact, these assumptions have even older roots, finding expression within Hegelian idealism, Rousseauian romanticism,

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and before. The perspective’s lineage through humanistic psychology, with its concern for protecting and enhancing the integrity of the self, should be obvious. Although this subject remains controversial within academic psychology, the assumption that people want a sense of self is not really surprising: it is a natural consequence of the organismic assumption that humans are inherently active creatures who move themselves within the limits imposed by circumstances. Given the plain fact that we are the origins of our behavior, an important task for the developing self is to learn to experience itself this way— that is, to learn to experience the truth. Fortunately, we have an innate need and motivation to do so. Self-determination theory is particularly interested in what humanistically and existentially oriented theorists might call ‘‘authenticity.’’ The theory proposes that sometimes people act out of their deepest, most wholehearted and growth-oriented motives and needs, while at other times they act out of feelings of pressure, coercion, or bad faith. As we noted above, early versions of SDT simply contrasted intrinsic (that is, authentic) motivation with extrinsic motivation (behavior undertaken to obtain anticipated rewards or avoid punishment). But this dichotomy proved to be too simple; obviously, people can still feel authentic even while engaging in nonintrinsically motivated behavior. For example, a man might feel considerable autonomy and sense of choice even as he changes his baby’s (disgusting) diaper! Thus, more recently, the theory has subdivided extrinsic or nonintrinsic motivation into three types: external (acting to get rewards or avoid punishment), introjected (acting to avoid self-imposed guilt or anxiety), and identified (acting in accordance with felt personal values; Ryan and Connell 1989). Although all three types of extrinsic motivation can give rise to behavior that is not intrinsically pleasurable, the three extrinsic motives vary in the degree of self-integration or authenticity they represent. For example, the man might change his baby’s diaper mostly because he knows the mother will scold if he doesn’t (external motivation), mostly because he’ll feel bad about himself if he doesn’t (introjected motivation), or mostly because he cares about the baby and endorses hygiene as a value (identified motivation). In the last case, the behavior has been fully internalized into the self and thus is considered to be authentic and self-regulated even if not enjoyable for its own sake. In self-determination theory, external, introjected, identified, and intrinsic motivation represent a continuum of ‘‘perceived locus of causality’’ (PLOC) for behavior that ranges from completely external to completely internal. In principle, any motivated behavior can be located at some point along this continuum. Interestingly, the four dimensions of the PLOC continuum exemplify the

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essence of important past theories of human motivation. Intrinsic motivation corresponds well to the innate curiosity that cognitive-developmental psychologists have insisted is vital to human functioning and development. Of the three extrinsic motivations, external motivation corresponds to tenets of operant behaviorism, in which disliked behavior takes place only in anticipation of concrete rewards. Introjected motivation corresponds to ideas discussed by Fritz Perls, Carl Rogers, and various psychodynamic theorists, in which a person acts out of an internal sense of pressure or guilt, as one part of the self (the superego?) attempts to force the compliance of another part. Identified motivation corresponds to tenets of existentialist theory, in which maturity involves finding meaning and feeling a sense of choice even in the face of disliked necessities. A final important feature of the PLOC continuum is that it can represent a crucial issue within psychosocial developmental theory (Erikson 1963), to wit, whether people have internalized the doing of socially valued tasks (such as voting, serving on juries, or changing diapers) that may have little intrinsic appeal. From SDT’s perspective, mature people have learned to fully own their extrinsically motivated behavior, whereas less mature people have not. As we show in later chapters, there is also much benefit when patients or clients in treatment or therapy learn to take ownership of their health practices and behaviors. From the behavioristic perspective, of course, SDT’s proposals concerning the nature of internalization and of personal growth represent nothing less than a flight from reality. Again, behaviorism says that the causal efficacy of the self is an illusion; people’s behavior is completely determined by their reinforcement histories, by physiological processes, and by current environmental constraints. From this point of view, instead of attempting to increase the feeling that our sense of self is causally involved in our behavior, we should be trying to decrease that feeling—in B. F. Skinner’s (1971) words, we should move ‘‘beyond freedom and dignity,’’ giving up all belief that our choices and character have influence. Ironically enough, from the viewpoint of SDT, these behavioristic assumptions can indeed become true, but only if the person believes them. In other words, although people really are self-movers and really do have choice, environmental forces can obscure this fact, causing individuals to feel ‘‘controlled.’’ Once people feel controlled, then they may stop thinking and may simply allow environmental forces to regulate their behavior. A person in this situation is likely to have a strong external perceived locus of causality, in other words, to feel like a pawn. Which of these two radically different views of humanity, in which we either possess or lack the potential for choice, is up to the reader to choose. The strictly determinist perspective of the radical behaviorists is hard to defeat,

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Table 1. Important features of self-determination theory Self-determination theory (SDT): ≤ Has a humanistic orientation supported by rigorous quantitative and experimental research ≤ Makes positive assumptions about human nature and propensities while explaining how negative outcomes can accrue instead ≤ Assumes that people, in order to thrive, must meet three psychological needs: autonomy, competence, and relatedness ≤ Focuses on people’s struggle to feel greater self-ownership of motivated behavior, including health- and treatment-relevant behavior ≤ Explains how authorities and practitioners can best motivate subordinates and clients so that they internalize suggested behaviors and self-regulate them

although there are more elaborate ways to counter it that go beyond the scope of this book. But again we point out that the two perspectives are not necessarily in opposition. In other words, although the mental self may not be real in an ultimate sense, and even though its momentary constitution may be strongly influenced by prior environmental and brain events, some studies suggest that self-experiences do have causal influence, by virtue of the feedback relations between brain events characterized by self-awareness and later brain activity that can follow from such events (Sperry 1990). For example: when a person who in a moment of insecurity imagines, mistakenly, that another dislikes him or her and fails to interrogate and perhaps arrest this (potentially mistaken) thought, then a cascade of negative neuronal, (stress) hormonal, cognitive, and interpersonal events may be triggered, combining to bring about the very circumstance the person feared. If the person instead pauses to test the perception and chooses to put it aside for the time being, then things may turn out quite differently. As we show in Chapter 8, contemporary cognitive-behavioral therapy is designed to bring about this very outcome by enlisting the self in the process of breaking its own bad habits. As another example, consider a person who suddenly perceives an unexploited niche in the Internet world, recognizing that he or she has the potential to fill it. At that moment the person’s sense of owning and endorsing that potential (or not)—that is, of aligning self with idea—can be an important determinant of whether the possibility is eventually made real. We assert that such ownership or endorsement is largely a matter of momentary conscious choice. The willful self, though fictional, has much real power because of its substantial potential influence on subsequent experience and thus brain activity.

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In table 1 we provide an overview of important features and assumptions of self-determination theory in one convenient location. As we demonstrate in the next section, these assumptions have been well supported in the empirical literature (although many difficult issues and controversies of course remain).

A Review of the Research The propositions of self-determination theory are well supported by much high-quality experimental and longitudinal data. To avoid overwhelming the casual reader, here we review only evidence published in the field’s most prestigious empirical publication: the Journal of Personality and Social Psychology ( JPSP). Articles published in this American Psychological Association journal must meet the most rigorous criteria of psychological science and must be judged to make the most outstanding contributions to the field. By constraining this discussion to research published in JPSP we hope to showcase the theory’s most important findings and the rigor with which these findings have been derived. Much other excellent research, of course, has also been published in many other high-quality publications. Edward Deci’s early research on the undermining effect led the way. In a 1971 JPSP article he introduced his important ‘‘free choice’’ measure of intrinsic motivation, in which participants are left alone following the experimental manipulation (either being rewarded or not for doing the assigned activity) to occupy themselves as they please. Further puzzle problems, as well as other potential pastimes such as magazines and books, are left in the room. Intrinsic motivation is defined as the total number of seconds, out of three hundred, that the participants play with the puzzles (as timed by the experimenter, who observes through a hidden window). Again, this early work showed that people were less likely to play after having been rewarded. Deci replicated and extended these findings in 1972, proposing the beginnings of a theory to explain the findings based on participants’ perceptions of the coercive nature of the reward. Deci, John Nezlek, and Louise Sheinman (1981) explored this latter idea within elementary school classrooms, showing that teachers who use rewards controllingly (to get rewardees to ‘‘knuckle under’’) induce lower intrinsic motivation and self-esteem in their pupils, whereas teachers who use rewards informationally (to convey a sense of competence to the rewardees) tended to bring about increased motivation and enhanced personal responsibility in their pupils. Richard Ryan, Valerie Mims, and Richard Koestner (1983) replicated and extended this finding, showing that a key feature of the undermining phenomenon is the sense of pressure and tension that accompanies controlling

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rewards. They further argued that the interpersonal context in which rewards are administered is a crucial determinant of later motivation. Ryan’s dissertation work (1982) extended the theory in an important way, showing that people can feel coerced and controlled by themselves as well as by others. In this set of experiments, for good performance on a cognitive task participants were either given the means to reward themselves or were rewarded by an authority. Those in the self-reward condition felt controlled and later manifested reduced intrinsic motivation, especially in a second condition in which ego-involvement (that is, a sense of having to prove one’s intelligence) was experimentally manipulated. This research demonstrated that people may lack a sense of autonomy even when they are in charge of events. It appears, then, that self-determination is a state of mind as well as a feature of social environments and that it is more than simply feeling a sense of control (or not) over the outcomes that once receives. To use some examples, a slave may be competent and in control of his or her daily life but may not feel selfdetermined, just as a highly successful person may be driven by inner demons and compulsions. In contrast, a person may feel very incompetent and unable to properly control his or her behavior while still feeling very self-determined (for example, while learning a difficult but fascinating new sport). Much of the research of the 1980s focused on the important setting of primary education, where overbearing interpersonal control can have adverse consequences. After all, elementary students are in a natural low-power position, being much younger and less knowledgeable than their teachers. Further, students have little or no choice about attending (versus not attending) school, not to mention what or how they study. And because students are urged to focus on grades and please their teachers, the school environment contains many potentially undermining rewards. Small wonder that so many people emerge from primary education with their innate curiosity ‘‘stamped out of them’’! In 1987, Wendy Grolnick and Richard Ryan published the results of an important experimental study that explored these dynamics. Fifth-grade children were brought to the laboratory to read passages from stories. They were given either a controlling task-set (‘‘We’ll be testing you on this later, to make sure you worked hard enough!’’) or a nondirective task-set (‘‘After you finish, I’ll simply ask you questions about what you read’’). The nondirected students reported far more interest in the passage and less pressure and tension. They also demonstrated the best conceptual understanding of the material, in terms of complex propositions recalled. In contrast, the controlled students showed less conceptual understanding. Interestingly, however, they evidenced greater rote recall of the simple facts of the passage; in other words, they had suc-

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cessfully ‘‘crammed’’ for the test. On being retested one week later, however, controlled students had lost their advantage in rote recall and still had poorer conceptual understanding. In short, although people treated in controlling ways may evidence some performance advantages, these advantages are of a less desirable and less sophisticated nature and are unlikely to persist in the long run. During the 1990s, SDT was expanded in many ways and was applied in new domains. One expansion was based on the introduction of the PLOC continuum, discussed earlier, in which extrinsic motivation was differentiated into several types that vary in their degree of internalization into the self. Richard Ryan and Jim Connell (1989) published the first studies in this area, showing that where on this continuum a person’s motivation is located has important implications for that person, in terms of both academic performance and prosocial behavior. Later related studies, all published in JPSP, showed that internal perceived locus of causality leads to better outcomes in the domains of: marital relationship satisfaction and longevity (does the person have selfdetermined reasons for being in the relationship? Blais et al. 1990); religious activity (is the person’s religious behavior based on guilt or a sense of choice? Ryan, Rigby, and King 1993); adherence to a radical weight-loss regimen (does the person begin participating in the program for autonomous or for controlled reasons? Williams, Grow, et al. 1996); political activism (does the person follow and participate in the political process for introjected or identified reasons? Koestner et al. 1996); and personal goal pursuit (does the person identify and pursue personal goals because of a sense of choice or a sense of compulsion? Sheldon and Kasser 1995). In short, when people do things for the wrong reasons (that is, for controlled rather than autonomous reasons), their persistence, performance, and well-being may all suffer. Self-determination theory also expanded during the 1990s in its consideration of the nature of healthy human values. It turns out that what people do matters at least as much as why they do it. For example, there appears to be a ‘‘dark side’’ to the American dream of attaining wealth and fame, in that people who strongly value such extrinsic goals are lower in many indices of adjustment and well-being (Kasser and Ryan 1993). Other research published in JPSP has demonstrated that those with strong extrinsic values are less likely to help or think about others, and more likely to engage in mindless ‘‘timewasting’’ behavior, in their daily lives (Sheldon and Kasser 1995). Although we make little mention of the healthy values issue in this book, it is implicit in much of what we say. Another expansion of the theory considered why people behave very differently in varied role-domains, to the point of fragmentation in extreme cases.

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Specifically, Kennon Sheldon, Richard Ryan, Laird Rawsthorne, and Barbara Ilardi (1997) showed that people who are ‘‘chameleons,’’ manifesting very different traits in diverse roles, are susceptible to a host of physical and psychological pathologies. Although some such participants were able to ‘‘own’’ their widely varying behavioral styles between roles, most of these participants instead felt inauthentic and highly conflicted across different areas of their lives. These findings on the negative effects brought about by extrinsic values and those brought about by fragmented role-behavior were said to occur because of the failure of psychological need-satisfaction that accompanies such modes of behaving. Yet there was little longitudinal evidence to support this proposed process, in which need satisfaction (or the lack of it) strongly influences later health. This changed in 1999, when Sheldon and Andrew Elliot assessed the amount of psychological need-satisfaction that occurred in time-consuming daily activities over the course of an academic semester and showed that the accumulation of many small positive experiences predicted enhanced wellbeing from the beginning to the end of the semester, whereas the lack of such experiences predicted decreases in participants’ overall well-being. Further, each of Deci and Ryan’s posited needs (autonomy, competence, and relatedness) were found to have unique effects on changes in well-being, indicating that these needs must be considered as three distinct psychological requirements for thriving. Again, SDT’s organismic perspective posits that when people obtain such experiences, their innate growth potentials and integrative tendencies are maximized. Unfortunately, when they do not obtain such experiences they may wither in the same way that a plant will droop if deprived of sun, soil, and water. To recapitulate the argument, self-determination theory begins with the concept of intrinsic motivation, viewing it as the prototypically self-organized state, in which the individual is striving to master environmental challenges purely for the satisfaction of doing so. Such behavior is assumed to be automatically self-integrated, and thus the individual has full access to cognitive and creative resources. Intrinsic motivation is thought to express and represent the individual’s inherent growth process, in that such states are most likely to occur in areas of life in which the individual has long-term, expanding interests and commitments. Thus, one important growth effort is that of finding and following intrinsic motivations. This effort tends to be enhanced to the extent that the individual’s psychological needs are fulfilled and to the extent that the self can master emotions and impulses ‘‘at the internal boundary,’’ which may otherwise disrupt the process.

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But not every behavior can be intrinsically motivated. Hence, another important growth effort is that of internalizing the doing of important behaviors that are not interesting and enjoyable or that may even be aversive (such as changing a diaper or voting). As this occurs the individual integrates him or herself further into society and achieves a more and more advanced state of psychosocial maturity. This process tends to be enhanced to the extent that the individual’s psychological needs are fulfilled and to the extent that he or she can master ‘‘the external boundary,’’ at which self must be related to other selves. The second growth process is especially relevant here, since we are concerned with understanding the interpersonal conditions that best enable and motivate people to change their unhealthy behavior or to adopt new, healthier behavior. Because such behavioral changes are unlikely to be enjoyable for their own sake, helping people to internalize the changed behavior—that is, to align their sense of self with their new intentions—is likely to be crucial. How is this accomplished? That is, what are the best ways to try to motivate a person to motivate him or herself? For this, we need to consider, in Chapter 3, the concept of autonomy support.

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Autonomy Support and Behavioral Internalization Promoting Ownership of Non-Enjoyable Behaviors

To summarize the story so far, in Chapter 1 we discussed the transformation of scientific psychology in the 1960s. We observed that following the overthrow of the behavioristic worldview, the cognitive approach won out over the humanistic approach as the dominant paradigm in scientific psychology, largely because it embraced (while humanism rejected) quantitative methodologies. We also observed that humanistic theory has much to recommend it and can correct the reductionistic biases that the cognitive approach inherited from the behaviorists. Specifically, humanistic theory resonates best with lived human experience, in which the search for self-integrity and selfownership is a daily issue. In short, it appears we need a science of the self that details and explains the struggle of the mental self to affirm its own reality and to consolidate its hold on the biocognitive machinery. In fact, this science already exists, as we showed in Chapter 2 by discussing the thirty-year research tradition of SDT. Self-determination theory begins with humanistic concepts and indeed is perhaps most consistent with Carl Rogers’s humanistic theory of personality (1961). Yet SDT is also rooted in developmental and organizational biological theory and has links to contemporary evolutionary and dynamical systems theory (Deci and Ryan 2000). In addition, SDT research has passed the empirical test, clearly demonstrating the importance of the theory’s humanistic assumptions and prescriptions. The

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theory thus seems worthy of careful study, particularly if we want to think of ways to reintroduce concepts of ‘‘self-actualization,’’ which so fascinate the lay public and many applied psychologists, to technique-oriented physicians and clinicians. What can these practitioners do to better engage the ‘‘evolving self’’ (Csikszentmihalyi 1993) of the client? Most physicians and many psychologists, of course, would prefer not to focus in detail on the client’s self—that is, they do not wish to conduct a timeconsuming exploration of the client’s history and mental world. Instead, they would like simply to better motivate the client to follow their professional recommendations. How can a clinician engage the client’s self fully in the technique or procedure at hand, without necessarily increasing the length or changing the focus of the meeting? This issue is particularly important given the short-course interventions and time pressures that characterize contemporary clinical and medical practice.

Characterizing Autonomy Support The answer, according to SDT, is that clinicians can provide autonomy support within the treatment context. Autonomy support is a mode of communication and persuasion, in which the person in the persuader (or provider) role fully acknowledges and respects the selfhood of the person in the persuadee (or client) role. Autonomy support is context-free, in that it can be applied in any social interaction, regardless of what type of information or persuasive communication is being exchanged. Thus it can serve as a ‘‘mode’’ for enhancing the efficacy of any treatment or procedure without necessarily lengthening that procedure (although to be performed adequately autonomysupportive treatment must sometimes be lengthier, since the provider must be prepared to fully address the client’s questions and concerns). In the discussion that follows we concentrate on educational research because this area has the greatest knowledge base. Many studies in the clinical and medical literature are presented in later chapters. We hope that the reader is willing to grant, for now, that the same interpersonal pitfalls that can befall teacher-student relationships can also befall provider-client relationships. According to Deci and Ryan, the issue of autonomy support is important in every interpersonal relationship, but it is most salient in an unequal power situation, in which one person (adult, supervisor, coach, doctor, counselor) has some degree of authority over another person (child, worker, athlete, patient, client). Although authority figures are in a one-up position with respect to their subordinates, ironically, they, too, are in a dependent position. This is because it is their job to motivate the person in the one-down position,

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and ultimately, that person may refuse to comply. For this reason, unequal power situations constitute a delicate interpersonal dance. The high-power person needs the low-power person to cooperate and has options for trying to control and force that person to do so. In contrast, the low-power person has need of what the high-power person offers but may also resist control by that person. In social dilemma terminology, the two parties must somehow find a way to overcome any missteps in order to attain a mutually cooperative solution to the dilemma, in particular avoiding the ‘‘mutual defection’’ scenario in which neither party gets what he or she wants. Deci and Ryan conceptualize autonomy support as having three distinct components. First, the authority should take and acknowledge the perspective of the subordinate. That is, as much as possible within the limits of their empathic ability, authorities should address and honor the subordinate’s worldview. How is the patient, client, or student feeling? How do things look to him or her? What seems reasonable or unreasonable from that perspective? Second, the authority should provide choice whenever he or she can. That is, as much as possible within the limits of the situation, the authority should allow the subordinate to determine what to do. For example, although students can have no choice about whether to attend school, they can be given choice about which classes to attend, which ways to study, which projects to undertake, which people to work with, and what materials to use. Third, the authority should provide a meaningful rationale when choice cannot be provided. That is, when the person in power insists on a course of action, he or she should be careful to explain why the trump card is being played in this situation. For example, a teacher demanding that students memorize the multiplication tables should take care to explain how important this skill will be in the future, opening up many new and potentially more enjoyable possibilities for the students. Some readers may feel that these recommendations are obvious and, indeed, no more than good manners. We agree. Yet these readers might be surprised at how pervasively a different approach and viewpoint, in which the authority of the authority is emphasized, persists in the helping professions (Karoly and Anderson 2000). The traditional medical model, for example, tends to emphasize the practitioner’s superior knowledge and position. In this view the practitioner should instruct the client, in no uncertain terms, what to do. That is the provider’s job, and if he or she doesn’t do it, the provider could even be held liable by professional or civic authorities! Given this state of affairs, practitioners may be tempted to try to make clients do what needs to be done, by sheer force of will and conviction. The client easily becomes a mechanical

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object, to be ‘‘repaired’’ in the same way that a tire or software bug is repaired. The self of the client may be overlooked. To illustrate what we mean, we quote at length from Paul Karoly and Cindy Anderson’s critique of contemporary clinical psychology. Although their critique is somewhat exaggerated, it rings true in many ways. They observe: The field of psychotherapy not only seems to be preoccupied with techniques of change imposition but also has succumbed to the rather pernicious mind sets of immediacy, passivity, and conceptual precision. That is, current ways of thinking have directed the efforts of professionals toward rapid results, decontextualized problem formulations, and the technical correctness of recipedriven planned interventions. The notion of the patient as a dysfunctional or would-be self-regulator in errant pursuit of personal autonomy and valued goals and in need of new or better strategies for the promotion of extended self-directedness has found little room to thrive in a ‘‘health technology’’ environment. [2000, 170–171]

Ultimately, however, as Karoly and Anderson point out, such techniquebased approaches may fail to motivate, or may even alienate, the client. Although many clients adhere dutifully to the provider’s prescriptions, trusting in the provider’s presumed superior knowledge, many others are less dutiful. In these cases the communication process may have been disrupted at the start, when clients implicitly rebelled or reacted against the provider’s brusque demeanor (Petry, Tennen, and Afflect 2000). Or the client may have regressed, feeling like an inadequate child who cannot be trusted with the facts or with choice and who then behaves accordingly (Deci et al. 1981). Or the client may have initially intended to follow the prescriptions, but these intentions and behaviors did not last once other ‘‘selves’’ became dominant. According to SDT, all of these outcomes may occur because the demeanor of the authority tends to induce an external perceived locus of causality within clients. In other words, clients may come to feel that they are not the cause of their actions— rather, the authority is. Unfortunately, once the authority is gone, action may cease. As we outlined in Chapter 2, the contrasting approach is to encourage the client to own the recommended behavior—that is, to have an internal perceived locus of causality while doing it. Again, having this attitude entails nothing more than acknowledging the truth; we are the choosers and the actors, whether or not we experience ourselves that way. By helping clients to recognize this fact we can also help them to follow through with the agentic intentions that brought them to seek treatment (Snyder et al. 2000).

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Autonomy Support and Organismic-Humanistic Theory The autonomy-supportive approach is consistent with the philosophical tenets of organismic theory and with the psychological needs postulated by self-determination theory. Again, organismic theory makes four basic assumptions: humans are proactive more than they are reactive; they have an inherent growth or integrative tendency; they are engaged in dialectical struggles to overcome the present limitations to such growth or integration; and they have an inherent desire to connect with other selves and to integrate themselves into larger social structures. An autonomy-supportive approach on the part of the clinician serves all four processes. First, this approach acknowledges that the final choice, and the decision to take action, lies with the client. It was the client’s initiative that led him or her to the encounter, and it will take further initiative on the client’s part if any good is to come of it. Second, the approach acknowledges and honors the client’s health-seeking impulse. It is assumed that all persons have the potential for positive change; this is the aspect of the person that the clinician speaks to. Third, this approach acknowledges that a struggle may be occurring inside the client. That is, the health-seeking urge may be only one of many impulses or selves that are battling for control. Although the healthseeking urge may have a slight advantage, the advantage is easily lost when more defensive or reactive parts of the client hold sway. Fourth, this approach recognizes that a key issue for people is that of connecting with the selves of significant others. This issue becomes especially important in an unequal power relationship, in which the client may invest extra meaning in the acceptance (or seeming lack of acceptance) evidenced by the authority. Stated in terms of SDT’s three postulated needs, an autonomy-supportive approach is best suited for satisfying the person’s dual needs for autonomy and relatedness, thereby enabling satisfaction of the need for competence as well. When clinicians solicit clients’ point of view, offer whatever choices are possible, and provide sensitive rationales when choices must be restricted, then clients are enabled to feel that they are the autonomous cause of their resulting actions while at the same time feeling meaningfully related to the clinician. In such a context clients are most likely to be able to invest the sustained effort and commitment needed to begin to feel a new sense of competence within their situation. In addition they will be best able to gradually internalize the doing of unpleasant behaviors—in other words, to take in extrinsic motivations and make them their own. The crucial mediating role of psychological need-satisfaction for these processes is addressed below as we consider the research on autonomy support and its effects.

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Research on Autonomy Support One challenge for SDT has been to confirm the proposition that autonomy support has at least three important facets (namely, perspective-taking, choice-provision, and rationale-provision). Deci and colleagues (1994) did precisely this in an experimental study of the internalization process. Participants came to the laboratory and engaged in a very tedious computer-tracking activity, pressing the keyboard space bar whenever a light flashed on the screen. For some participants words like ‘‘choice’’ were used, and for others, words like ‘‘must’’ and ‘‘should’’ were used. For some participants a rationale was given (‘‘Doing this activity has been shown to be useful. We have found that those subjects who have done it have learned about their own concentration. This has occurred because the activity involves focused attention, which is important in concentration. For example, this is the type of task that air traffic controllers use in order to enhance their signal detection duties.’’), whereas for other subjects no rationale was given. Last, some subjects had their perspective acknowledged by the experimenter (‘‘I know that doing this is not much fun; in fact many subjects have told me that it’s pretty boring. So I can perfectly understand and accept that you might not find it very interesting.’’), whereas other subjects received no acknowledgment. The primary outcome measure for the study was the number of seconds, on average, that subjects continued doing the activity during a free-choice period. This was construed as a measure of internalization (rather than intrinsic motivation) because the task was designed to be boring, so anyone who continued doing it must have believed that it was valuable or useful. Subjects exposed to one facilitating factor continued the task for an average of 17.6 seconds during the free-choice period, whereas those exposed to two facilitating factors continued for 66.9 seconds on average, and those exposed to all three facets of autonomy support continued for 85 seconds on average. Ratings data also supported the inference that subjects who received the most autonomy support had most strongly internalized the task. The implications of these data should be clear for anyone hoping to promote their clients’ sustained adherence to medication regimens, rehabilitation programs, cognitive retraining exercises, and so on. This experimental study focused on the positive effects of autonomy support. Many other studies have examined the negative effects of the opposite: controlling interpersonal styles. For example, Deci and colleagues (1982) conducted an experimental study in which college students were randomly assigned to play the role of teacher or student. Teachers were then randomly assigned either to a supportive condition in which they were told ‘‘to facilitate

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the student’s learning’’ or to a controlling condition in which they were told to ‘‘make sure the student performs up to standards.’’ Coders who were blind to the conditions analyzed the session audiotapes, and it was found that teachers in the controlling condition talked more, were more critical, gave more commands, and allowed less choice and autonomy. Their students enjoyed the lesson less and solved fewer puzzles on their own. Cheryl Flink, Ann Boggiano, and Marty Barrett (1990) found similar results in an experimental study of actual fourth-grade teachers who had been instructed to either facilitate students’ learning during a lesson or ensure that children perform well at the end of the lesson. The children in the ‘‘controlling’’ condition learned less, consistent with the study cited in Chapter 2 (Grolnick and Ryan 1987) concerning the greater conceptual understanding evidenced by children who were allowed to engage the material on their own terms. Thane Pittman, Jolee Emery, and Ann Boggiano (1982) supplied a reason for this, finding that students treated in a controlling manner during a lesson only did the bare minimum, choosing the easiest and least challenging tasks. Together, these studies show how easily a strong ‘‘results orientation’’ on the part of the physician or clinician may backfire, producing less rather than more of the desired behavior. At this point, some readers may be thinking, ‘‘This is all fine and good, but what if someone needs a firm hand? And this business of allowing choices and taking perspectives—what if it leads to permissiveness and chaos?’’ In fact, SDT has always emphasized the importance of both limits and structure. That is, autonomy-supportive authorities need to demonstrate expertise and convey information, just as any mentor does. Furthermore, they need to communicate expectations and sometimes punish transgressions (Ryan and Stiller 1991). Although structure is important, it is not the same thing as autonomy support, and it may not be as important as autonomy support. For example, Grolnick and Ryan (1989) found that parental autonomy supportiveness (as determined through interviews) predicted a child’s competence and adjustment (as rated by teachers), as well as the child’s academic performance (grade point average). Autonomy support and parental structure were uncorrelated, meaning that autonomy-supportive parents gave their children the same amount of structure as did controlling parents. Parental structure had some positive effects (mainly in influencing children’s sense of being able to control outcomes) but was not the main determinant of positive outcomes. Again, from the perspective of SDT, what matters is not what information or structure the authority conveys but how he or she conveys it. Regarding permissiveness: at some point, the authority must simply trust the client to decide for him or herself what to do, just as parents must, at some

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point, let their children make their own choices about dress, food, friends, college, and even careers. Of course a doctor or clinician whose client refuses to take treatment seriously may become frustrated and even decide to terminate the helping relationship. From the perspective of SDT, this is probably a better outcome than would occur if the provider instead tried to strong-arm the client. From the organismic viewpoint, the growth impulse and the person’s choices must be trusted, because these are the only things that can effect real change. It is important to point out that autonomy support is much easier said than done! One reason autonomy support is difficult is that many patients, clients, and students pull controlling behaviors from authorities, even seeming to prefer them. Grolnick and Ryan (1989) have shown that some students naturally elicit more controlling behaviors from teachers, presumably because this is what they have learned from their authoritarian parents. Ellen Skinner and Michael Belmont (1993) showed that a recursive or self-sustaining cycle can be established in which children elicit controlling behavior from teachers, which then affects the children’s motivation and behavior, which in turn elicits further efforts at control from teachers, and so on. These findings illustrate the ease with which ‘‘vicious cycles’’ can be started, when even one of the two interaction partners expects to be controlled or demands control. They also illustrate how careful authorities need to be if they are to avoid such negative dynamics. Again, the three facets of autonomy support provide a useful heuristic to keep in mind: in one sense, all the authority figure has to do is remember to keep taking perspectives, providing choices, and supplying meaningful rationales. The observation that some clients seem to demand controlling behavior leads into the important issue of personality style. Self-determination theory specifies three important personality traits or styles: autonomy orientation, in which people habitually attend to inner needs and feelings and orient toward situations that allow self-regulation; control orientation, in which people habitually seek rewards and constraints in the environment with which to align their behavior; and impersonal orientation, in which people habitually feel helpless and easily lose motivation (Deci and Ryan 1985b, 2000). As we illustrate below, these habitual styles figure prominently into SDT’s causal models as important personality factors that influence outcomes independently of the influence of contextual factors. For present purposes, the most important thing to note about personality style is that it does not moderate the effects of contextual factors on outcomes. In other words, there is no empirical support for a ‘‘matching’’ hypothesis in which control-oriented people do best when treated controllingly and

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Work climate (autonomy supportive versus controlling)

Job satisfaction outcomes

≤

∞

Employee need-satisfaction (autonomy, competence, relatedness)

∞ Individual differences (autonomy-oriented versus control-oriented)

≤ Job performance outcomes

Figure 1. An integrated model of the relations between employee and context characteristics, employee need-satisfaction, and employee well-being and performance

autonomy-oriented persons do best when granted autonomy. Both types do better when granted autonomy support, although controlled types may feel somewhat more uncomfortable about it, at least at first. What this means is that there may never be a justification for controlling behavior on the part of authorities, not, at least, if they want to maximize clients’ later motivation. The reason for this, once again, is SDT’s assumption of the universal need for autonomy, competence, and relatedness. In other words, all people, regardless of their ethnicity, culture, or personality style, need these three feelings to remain motivated. In particular, peoples’ needs for relatedness and autonomy tend to suffer when authorities ignore their perspective, deny them choice, and fail to offer reasons for their demands. When this happens people may fail to thrive. Indeed, much of the SDT research of the 1990s has been dedicated to showing the mediational role of need-satisfaction. This research places need-satisfaction squarely at the center of the model, between contextual and personality variables on one hand and performance and wellbeing outcomes on the other. We turn to such models in the next section. One integrated path-model, reported by Baard, Deci, and Ryan (2001), is depicted in figure 1. These investigators collected data on 698 associates at a major investment banking firm, attempting to predict two outcome factors: objective job performance (taken from personnel files), and satisfaction on the job. As causal factors the model focused on the autonomy supportiveness of

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each worker’s immediate supervisor (as perceived by the worker) and the degree of autonomy orientation of the worker. As mediational factors, the model focused on the worker’s experience of autonomy, competence, and relatedness on the job. These were in turn examined as predictors of the outcomes. Good support was found for this model, in that the worker’s personality style and worker’s perception of the supportiveness of the supervisor both influenced the worker’s need-satisfaction, which in turn influenced objective job performance and subjective well-being. Importantly, there was no moderating effect of personality style on the effect of supervisor autonomy support on need-satisfaction, nor did personality style moderate the effect of needsatisfaction on the outcomes. Thus, again, there was no evidence to support a matching hypothesis according to which some people thrive under controlling conditions. Instead, there was much evidence to support Deci and Ryan’s universalist assumptions about the ‘‘experiential nutrients’’ necessary to bring about maximal performance and well-being.

Suggestions for Service Providers The theory and data discussed above suggest a number of general recommendations for those hoping to motivate another person. We will present these below, phrased as a set of recommendations. Of course, we support readers’ autonomy to decide for themselves whether to follow these recommendations! We hope that the evidence we’ve presented has been persuasive enough to indicate that it is worth a try. 1. We recommend that providers practice the three facets of autonomy support. In other words, take the client’s perspective, give them choices, and provide a meaningful rationale when there is no choice. Although this may sound simple, it is not. Autonomy support is a skill that takes work, and perhaps a lifetime, to develop. In part this is because, in order to fully acknowledge the self of another person, the provider must fully acknowledge his or her own self. Thus, in trying to be autonomy supportive to their clients, providers may encounter issues and emotions that are not yet resolved and integrated within themselves. Another source of difficulty is that the objective situation is often conducive to controlling tactics. Time is short, pressure is high, and the provider may feel sure that he or she knows what the client should do. In addition, some clients may seem to want or even demand that the provider take control. Why not give them what they want? But this leads us to our second recommendation: 2. We recommend that providers be autonomy supportive with everyone,

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not just those who seem to prefer it. As we have discussed, there is no empirical support for a ‘‘matching’’ hypothesis, according to which control-oriented persons do better when treated in a controlling fashion. Even strongly controloriented persons do better in the long run if their self-agency is acknowledged. Again, in all except the most extreme situations, we are all of us in fact the choosers, and the sooner we realize it, the better. From the perspective of SDT, control-oriented persons may be in an arrested state of development. In fact, this state of arrest may even be a root cause of the problem for which the client seeks help. For such persons, a prerequisite for truly effective therapy may be some beginning movement toward a more autonomous personality style. An additional benefit of supporting the autonomy of every client is that this approach will better fulfill their psychological needs, providing the ‘‘nutrients’’ necessary to fuel difficult movement. Autonomy support is likely also to boost the quality of interpersonal relatedness between provider and client. Clients who feel more related to the self of the provider are more likely to internalize the behaviors the providers recommend. Indeed, it is increasingly demonstrated in clinical literature that the quality of the therapeutic relationship is a major predictor of positive change in the client, regardless of the particular technique being practiced by the clinician (Teyber and McClure 2000). Given the potential short-term impersonality of many contemporary helping relationships, compared to past times when friends, pastors, and trusted family doctors brought long-term stability to such relationships, it is extremely important to attend to any factors that can improve feelings of relatedness. Again, SDT research has shown that the autonomy supportiveness of the provider is a strong determinant of the client’s feelings of relatedness with the provider. 3. We recommend that providers not emphasize the monetary aspect of the relationship. Another tradition in SDT, not yet discussed in this book, concerns what happens when a subordinate or client perceives the authority or provider as motivated primarily by extrinsic concerns. Cameron Wild, at the University of Alberta, has spearheaded most of this research. One study showed that pupils given a piano lesson by a teacher whom they were led to believe was motivated primarily by money later rated the teacher as less supportive, perceived the lesson as less interesting, and did not wish to sign up for future lessons. This occurred even though the teacher (who was blind to the subjects’ assigned condition) behaved identically in this condition as in a separate condition in which pupils thought the teacher was a volunteer (Wild, Enzle, and Hawkins 1992). In another study, participants expected the least amount of positive change in an entrant to an alcohol rehabilitation program

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when the counselor was portrayed as money-oriented (Wild et al. 1997). A variety of studies have further demonstrated the negative effects that can occur when authorities or providers are perceived as being extrinsically motivated (reviewed in Wild and Enzle 2002). Of course, clients know that physicians and clinicians are not volunteers. Yet the research just described indicates that things will go best if clients perceive the provider as intrinsically motivated—that is, if they perceive genuine interest and involvement in the provider’s demeanor. In these cases the fact that this is how the provider makes a living will be forgiven, since everyone must make a living!

Can Autonomy Support Be Taught? One important question for our argument is whether people can change their interpersonal style. Can a person with a controlling style learn to be more autonomy supportive? There is good reason for optimism on this count. First, the experimental studies described above indicate that participants randomly assigned to either a controlling or a supportive teaching role can enact the role sufficiently well to elicit effects on ‘‘pupils.’’ Apparently, most people are flexible enough to adopt the style suggested by the experimenter, regardless of their habitual style. More important, emerging research suggests that autonomy-supportive styles can be passed on as part of the educational process. This research, spearheaded by Johnmarshall Reeve of the University of Iowa, is described below. A study described in Contemporary Educational Psychology in 1998 examined the effects of both personality style and training in controlling, neutral, or autonomy-supportive instructional strategies on later teacher behavior. Participants were 159 students in a teacher certification program who came to a session and received one of three six-page training booklets that presented an educational strategy, including a rationale for the strategy, case study examples, and relevant research support. The autonomy-supportive booklet emphasized the three facets of autonomy support described above, and it encouraged teachers to promote students’ interest in learning, valuing of education, and confidence in abilities. The controlling booklet focused on common behavioral-management practices, including communicating that there is a right and a wrong way to do things, providing attractive consequences following desirable behavior and unattractive consequences following undesirable behavior, and using verbal feedback as an opportunity for differential reinforcement (that is, comparing children to one another). The neutral book-

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let simply featured instructional strategies to help students build organized and well-articulated cognitive schemas. The booklets contained application exercises and took about forty-five minutes to complete. Afterward, teachers’ motivating style was measured via their responses to a ‘‘Problems in School’’ questionnaire, which consisted of a series of vignettes or problems to be handled. As expected, those exposed to the autonomysupportive booklet manifested the most autonomy support in their responses to the vignettes, whereas those exposed to the neutral booklet were less supportive, and those exposed to the controlling booklet were least supportive. Importantly, the effects were shown to persist one month later, when teachers were given a follow-up series of vignettes to complete. In other words, the training lasted. In addition there were parallel effects of teachers’ preexisting personality style: autonomy-oriented teachers were in general most autonomy supportive in their solutions to the problems, whereas control-oriented teachers were least autonomy supportive. This outcome was expectable, given prior findings on the influence of personality style on similar outcomes. Interestingly, the control-oriented teachers, for whom the information in the autonomy-supportive booklet was most unfamiliar, tended to put the new strategies to work only if they agreed that the material made sense. In other words, because learning to be autonomy supportive was a larger stretch for them, they were more likely to experience conflict between the information and their prior beliefs. For change to occur in this case, the new information had to be perceived as intelligible, credible, and useful. In an encouraging result, most of them did perceive the information this way and showed at least beginning movement in the direction suggested. The conclusion: autonomy support is teachable. For change to occur, however, an intelligible rationale must be provided. It thus appears that SDT’s account of how positive motivational change occurs can be applied at a ‘‘meta’’ level to demonstrate how positive change in teachers’ motivation to support students’ autonomy occurs! We would expect no less. This concludes our theoretical introduction to the concepts and findings of SDT. We hope that readers now have a clear understanding of the argument and the evidence that supports it. In Parts II and III we illustrate how to apply these ideas in the domain of physical and psychological health, respectively. We continue to present supporting evidence throughout the book, in the belief that dialectical movement between relevant research findings on one hand and concrete recommendations on the other can best convey the material. Then the readers can decide, for themselves (of course), what might be useful.

P A R T

Self-Determination Theory Applied to Medical Practice

II

4

Self-Determination Theory and Physical Health

Diseases are of two types: those we develop inadvertently, and those we bring on ourselves by failure to practice preventive measures. Preventable illness makes up approximately 70% of the burden of illness and associated costs.—C. Everett Koop, ‘‘A Personal Role in Health Care Reform,’’ 1995 Each year in the United States, more than 40 percent of deaths are premature, and they are attributable to tobacco use, diet and activity patterns, alcohol abuse, and infections such as HIV (McGinnis and Foege 1993). Tobacco alone is considered responsible for more than four hundred thousand deaths each year (roughly one in five deaths). Prospective studies have shown that 82 percent of all cardiovascular events occurring in middle-aged women (Stampfer et al. 2000) are caused by smoking, unhealthy diet, and lack of exercise and that most cancers are largely attributable to lifestyle factors rather than genetic factors (Lichtenstein et al. 2000). These recent studies confirm the crucial role that motivated behaviors, such as exercising regularly, following a healthy diet, and quitting smoking, can play in the maintenance of health. In short, many chronically ill people have the means readily at hand to improve their condition, assuming that they are willing to act. Medication adherence. Consider how (and whether) people take prescribed

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Medical Practice

medications. Evidence suggests that patients take only about 50 percent of the medication that is prescribed (Haynes, McKibbon, and Kanani 1996; Sackett and Snow 1979) and that fully half of all patients who are prescribed medications for two weeks or longer take a level of medication that is below what is necessary to be effective (Roter et al. 1998). For example, the regular use of beta-blockers, aspirin, angiotensin-converting enzyme inhibitors, and warfarin can reduce mortality rates by 21 percent to 33 percent for patients who have indication for treatment (Woolf 1999). As another example, randomized controlled trials of a class of cholesterol-lowering medications called statins have been shown to reduce the risk of major coronary artery events (31 percent) and of mortality from all causes (21 percent) in patients with and without known cardiovascular disease (LaRossa, He, and Vupputuri 1999). Yet estimates are that less than 30 percent of the people who would benefit from these medications are taking them (Pearson and Peters 1997). These are huge numbers, given that nearly nine hundred thousand Americans die from heart disease and stroke every year (Peters, Kockanek, and Murphy 1998). Improving patient adherence to these and other medications could yield large improvements in public health. The reasons why people fail to adhere to their medication regimes are complex, but as we have argued, one undoubtedly important factor is their motivation to use the medications. Smoking cessation. To illustrate further, consider smoking cessation (Woolf 1999; Fiore et al. 2000). Again, smoking kills 400,000 Americans every year and is the single most prominent risk factor for many varieties of ill health. Quitting smoking has clearly documented excellent benefits; for example, stopping smoking lowers a smoker’s risk for having a heart attack by 50 percent in twelve months (U.S. Department of Health and Human Services 1990). Furthermore, although the risk for lung cancer for an active two-packa-day smoker is thirty-two times higher than for a nonsmoker, it falls to only two times that of nonsmokers over ten years of abstinence. In spite of such information, which has been widely disseminated to physicians and the general public since 1990 (U.S. Department of Health and Human Services 1990), surveys indicate that fewer than half of heavy smokers even believe they have increased risk for heart disease or cancer (Ayanian and Cleary 1999), much less that quitting is in their power. This demonstrates a failure to inform the public of important health risks in a manner that they can internalize (Weinstein 1999). Physician counseling. The problem does not stop at the patient. Stephen Woolf (1999) points out that the potential health benefits derived by stopping smoking, lowering cholesterol, controlling blood pressure, and increasing exercise are so large that they dwarf the positive effects of all the established treatments for cardiovascular disease. In this light, he argues that policy mak-

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ers and clinicians should consider substantially redistributing the resources that go to the treatment of diseases (for example, cardiovascular disease and cancer) and their late-stage complications, instead devoting more resources to primary prevention and health promotion. In particular, research resources should be focused on understanding the nature of practitioner-patient relationships, in order to determine which personal and interpersonal characteristics can motivate preventative behavior. For example, the evidence suggests that if physicians regularly and systematically counseled their patients who smoke to stop, it would double the quit rates and prevent one to two million premature deaths each year (Fiore et al. 2000). Unfortunately, however, less than 30 percent of physicians report counseling their patients to quit and only 3 percent provide them medications known to help them stop smoking (Thorndike et al. 1998). It appears that physicians, too, are falling short in an important motivated behavior that would certainly improve their patients’ health. Taken together, the failure of Americans to adhere to scientifically proven health behaviors (such as healthy diet, regular exercise, alcohol in moderation, not smoking), a failure that occurs at every level from the policy maker to the provider to the patient, represents a huge treatment gap. Certainly, this treatment gap has many causes, but a considerable part is motivational in nature. We argue that this largely unexploited niche in the field of health care represents a large window of opportunity for practitioners and patients alike. Before this gap can be narrowed, however, health care practitioners and policy makers will need to have a clearer understanding of what motivation is and how to facilitate it.

Motivation Defined Motivation refers to the psychological forces or energies that impel a person toward a specific goal. One way to think of this is retrospectively, defining motivation as having existed only when the goal is reached (otherwise, the motivation was insufficient or wanting and perhaps was never serious). But this definition is too stringent, and it overlooks long effortful strivings that do not result in success. Thus, we define motivation as the psychological forces that impel continued effort toward a goal, regardless of the (immediate) success of that effort. This process-based definition nicely handles the case with many health behaviors—namely, that they involve maintaining some practice or habit (for example, regular exercise, healthy diet, yearly mammograms) even when there is no ‘‘terminal’’ goal in sight. In these cases, no end state can be reached; instead, a positive state is maintained, even at the cost of sometimes tedious or aversive effort.

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Note that this definition of motivation has two features: it refers both to a goal and to the impetus to reach that goal. These represent the directive and energization components of motivation, respectively, within classical motivation theory (Deci and Ryan 1985b; McClelland 1985). Logically, improving one’s health involves attending to both dimensions. That is, ideally, one selects important treatment goals and musters the energy needed to reach the selected goals. The first of these two dimensions, the specific content of what the patient can do to maintain his or her health, is defined largely by advancing medical knowledge. Of course, medical knowledge changes over time with advances in pharmacotherapy, genetics, screening techniques, operative techniques, and understanding of risk behaviors. Recent important changes in the content of medical knowledge include the findings that hormone replacement therapy does not reduce risk for cardiovascular events in women with known coronary disease (Hulley et al. 1998), whereas cholesterol reduction does (LaRossa, He, and Vupputuri 1999). In this book, we do not attempt to canvass the current state of medical knowledge. Instead, we address the second dimension: how to help patients gain access to the energy and resolve to implement knowledge of any type—new and improved or tried and true. We assert that this energy-based dimension of motivation is largely under the patient’s control. Although skeptics might argue that some people have little ability to control themselves, even they must agree that people have much more potential control over their own unhealthy behaviors than they do over such other health risks as genetics, accidents, and exposure to viruses. Indeed, as we described in Chapter 2, SDT assumes that people are naturally inclined to take such control—that is, they are naturally oriented toward growth, health, and enhanced self-regulation. This fact has particular importance for health care practitioners, because it means that they don’t have to make their patients want to be healthy. The practitioner and patient almost always share the general goal of maintaining or improving health from the start. The energy is already there. As we discussed in Chapter 2, however, SDT postulates that this energy can be ‘‘fragile’’ and easily eroded. In other words, although people have a natural impetus or bias toward health, this bias is not large enough to win out all the time. In part, this is because many health-impairing behaviors are relatively comfortable or even gratifying in the short term. In contrast, problems resulting from such behaviors tend to accumulate over long periods of time. Contributing to these health problems may be several behaviors, or risk factors. As a result, people tend not to feel or see the negative effects of the behaviors until a major negative event occurs (for example, a stroke or heart attack).

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Table 2. Innate psychological needs, according to self-determination theory Competence: Patients need to understand how to attain health-related goals and to feel that they can be effective in carrying out the necessary actions Autonomy: Patients need to feel a sense of choice and volition with respect to their health-related goals Relatedness: Patients need to feel respected and cared for by practitioners and important others

Especially when individuals are ‘‘needy’’ or distressed, they may be particularly susceptible to such a short-term hedonic focus and prone to sacrifice health or integrity for short-term gratification. In addition, individuals’ natural motivation toward health may be subverted when they feel that others are infringing on their freedom of choice. In such cases, some clients may implicitly choose ill health, in part to spite the controller. In short, the healthseeking motivation that brings the patient to the practitioner can be subverted or thwarted in many ways. Self-determination theory acknowledges this by proposing that people have three psychological needs that must be met if their natural impetus toward health is to be tapped. These needs include those for autonomy (feeling volitional, and feeling choice and responsibility for their behavior), competence (feeling that they can accomplish the behaviors and reach the goal), and relatedness to others (feeling that they are understood and valued by significant others). People will experience more energy, or motivation, to reach a particular health goal if they feel more autonomous and more competent in their health behavior, as well as more related to their health care practitioner and to important others in their lives via that behavior (see table 2). The implication of these assumptions for the health care practitioner is that health-related information should be presented in a context that facilitates the patient’s motivation for health—specifically, a context that supports the patient’s needs for autonomy, competence, and relatedness. Given the enormous health consequences of voluntary behavior outlined above, maximizing the natural motivation that patients have for health should be the focus of every health care system and each health care practitioner.

Quantity Versus Quality of Motivation Unfortunately, practitioners, policy makers, and program designers have in the past tended to think of motivation in a one-dimensional way, as varying only in amount or quantity (Bandura 1997; Janz and Becker 1984). In

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contrast, little or no attention has been given to the quality of motivation. In other words, in addition to distinguishing between amotivation and motivation, as does classical motivation theory, SDT also distinguishes between highquality and lower-quality motivation. To illustrate: Many health care researchers have assumed that any apparent motivation is ‘‘good’’ motivation, and using behavioral techniques, they have sought to use rewards and punishments to manipulate patients’ behavior. In the process, practitioners have sometimes used coercive or underhanded techniques, sacrificing quality in the interests of immediate results. All too typically, for example, health care practitioners try to influence their patients’ motivation by scaring them or by relying on their authority to try to force patients to do what the practitioners want. And practitioners are not the only ones who are controlling. Modern health care plans manipulate physicians and patients alike via the imposition of monetary incentives and punishments (such as co-payments and risk sharing). In such systems, physicians are often deprived of the right to exercise their best judgment in the patient’s interests and instead are forced to act in the financial interests of the health care plan. As we discussed in Chapter 2, such external incentives can undermine any intrinsic motivation that may exist in both the patient and the practitioner. In the health care domain, the clearest examples of the undermining effects of rewards and punishments are the long-term negative effects of co-payments on patients’ use of preventive services (for example, mammograms and pap smears). For example, when patients are made to pay for smoking cessation treatments (Curry et al. 1998) or to provide co-payments for mammograms, pap smears, or preventive counseling services (Solanki and Schauffler 1999), they are significantly less likely to avail themselves of the treatments or screenings. By not taking advantage of these treatments or screenings, their health worsens, the disease burden in the population increases, and the health care costs for the system rises in the long term (Lightwood, Phibbs, and Glantz 1999; Pronk et al. 1999). As another example, getting people to quit smoking within a smoking cessation program by using rewards compared to supporting patients’ own motivation to quit has been demonstrated to result in fewer long-term quitters (5 percent versus 10 percent), precisely because it undermines peoples’ autonomous motivation to quit (Curry, Wagner, and Grothaus 1991). Thus, relying on models of health motivation that manipulate external factors alone can lead to poorer health and higher costs for the patient, insurer, and employer by undermining the very motivation the interventions were intended to increase! Of course, many behavioral health interventions do go beyond coercive

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rewards to focus on internal factors, such as patients’ sense of confidence (also called self-efficacy or competence) regarding their ability to carry out positive health behaviors. These programs have proven their worth (Hillsdon and Thorogood 1996; Jeffery et al. 1998; Tang et al. 1998). And yet, we contend that even these programs are not as effective as they could be because they focus on a single dimension of motivation—in SDT’s terminology, they focus only on the need for felt competence, or, stated differently, they also tend to focus on quantity while ignoring quality. Unfortunately, if the patient lacks more enduring internal resources, the initial program-induced confidence may fade when the going gets tough. Therefore, we now take up the broader model of SDT and its claim that practitioners, in addition to supporting their patients’ sense of competence, also need to support their patients’ sense of autonomy regarding their health choices and behaviors, as well as their sense of relatedness regarding the authority figure who counsels them. This will open a window on the quality that may be missing in many conventional motivation-enhancement programs.

SDT and the Nature of Quality Motivation Again, in addition to distinguishing between amotivation and motivation, SDT differentiates between higher- and lower-quality motivation, specifically by distinguishing between autonomous and controlled motivation. Motivation is autonomous to the extent that people feel a true sense of volition and choice and act because of the personal importance of their goal. Motivation is controlled to the extent that people act because they feel pressured or compelled, either by others or by themselves. Stated differently, controlled motivation typically involves having an external perceived locus of causality for one’s behavior, and autonomous motivation involves having an internal perceived locus of causality. According to the theory, only autonomously motivated behaviors result in meaningful, long-lasting changes. Conversely, behaviors that are controlled by rewards and punishments are predicted to last only as long as the contingencies remain in place (see table 3). As we noted in Part I, self-determination theory (Deci and Ryan 1985b; Williams, Deci, and Ryan 1998) also posits that there is a natural human tendency called internalization through which people accept responsibility for the regulation of their behavior. That is, formerly controlled motivation can be ‘‘transmuted’’ into internalized motivation, given supportive conditions. When patients have fully internalized a health goal, they have accepted the goal as their own, and their motivation has then become self-determined or autonomous.

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Table 3. Types of motivation for health-related behavior change Amotivation: Patients report no intention to change; they feel unable to change and are unwilling to try Motivation: Patients report the intention to change and will likely make an attempt to change. Their motivation can be of two types: Controlled: Patients try to change either because they feel pressure from an external source such as a doctor or spouse or because they are pressuring themselves with threats of guilt and shame Self-determined or autonomous: Patients try to change because the change is important to them personally and they feel willing to take on the challenge

The importance of the internalization process becomes clear when we consider that patients often experience a new diagnosis or new risk information as unwelcome and foreign. They may feel resentment toward the news bearer and may attempt to deny or resist recognizing the problem. Even when they do take action, they may feel that they are doing so only because the disease and their provider are forcing them to (external motivation). That is, they may perceive the locus of causality for such behaviors as being external to the self. Internalization occurs as the new information and behavioral necessities are incorporated into the patient’s self- and world-schemas. Again, this is a natural process, but it is also one that can readily be undermined. When internalization is only partial—called introjected motivation—then the person’s self is only partially aligned with the motivation. In this case, internal conflicts are common as one part of the self battles with another part for consistent control over the behavioral system. Patients who are pressuring themselves to achieve a partially internalized goal typically report experiences that are very similar to the feeling of being externally pressured by others. Often, introjected patients feel ambivalent about changing, and they report feeling guilty or ashamed of themselves. For these reasons, SDT labels both of these types of motivation (external and introjected) as controlled motivation, because the predominant experiences of the patient are resistance and a lack of wholehearted volition. Again, SDT specifies that autonomy support (see Chapter 3) is one of the best facilitators of the internalization process. That is, research shows that when important others (such as health care practitioners, coaches, or teachers) elicit and support people’s self-initiatives while minimizing control, then those people tend to develop more autonomous motivation over time. The nature of

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such support will be considered in greater detail in a moment. First, however, it is necessary to pause to consider what autonomy is not.

Autonomy Versus Independence The term autonomous is often confused with the term independent. It is important to recognize that to be autonomous or self-determined does not mean to be isolated or independent of others. Autonomy refers to behaving with a sense of volition and internal assent, whereas independence refers to not relying on others. People can be autonomous while depending on others; in fact, autonomy and relatedness are actually complementary, not conflictual, needs (Sheldon and Bettencourt 2002). For example, Ryan and Lynch (1989) found that people who had strong attachments with others (that is, strong interdependence) were more likely to display autonomy—a sense of volition regarding their physical health—then people who were detached or isolated. In contrast, from the perspective of SDT, those who make a point of asserting their independence are often being controlled by unresolved interpersonal issues and are not really being autonomous at all. Practitioners need to understand the difference between autonomy and independence because supporting a client’s independence rather than his or her autonomy can lead that client to a state of isolation, with insufficient social support. In other words, we assert that it is not patients’ independence that should be supported but, rather, their sense of volition. Numerous studies have supported this distinction, studies that also demonstrate the superiority of autonomous compared to independence-oriented motivation for promoting adaptive motivated behavior. Below, we outline specifically those behaviors that best support the natural internalization process and thus help to increase patients’ autonomous motivation.

Autonomy Support in the Physician-Patient Relationship Supporting autonomy starts with listening carefully to patients, hearing and acknowledging their perspectives and emotions. As patients relate their stories, practitioners need to remain supportive and nonjudgmental. Patients feel more willing to change if they feel that they have truly been heard. Once patients have described their perceptions, autonomy-supportive practitioners provide information and available treatment options while encouraging patients to take the initiative and responsibility to make a choice that best fits their lifestyle. Much of medical practice involves making specific

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Table 4. Health care practitioner behaviors that support patients’ feelings of competence, autonomy, and relatedness ≤ Listening to patients ≤ Eliciting patients’ perspective ≤ Acknowledging patients’ feelings and ideas ≤ Supporting patients’ choice and providing a menu of options ≤ Encouraging patients’ initiative and responsibility ≤ Minimizing control ≤ Giving patients information and/or a rationale for change ≤ Being nonjudgmental

recommendations for patients from among the known effective treatment options. Practitioners need to provide a clear and meaningful rationale for their recommendations and then elicit their patients’ understanding and feelings regarding the proposed treatment plans. Once the recommendations have been made, practitioners need to ask their patients how they feel about the recommendations and remain nonjudgmental with respect to the patients’ opinions. The intelligence of patients should always be respected, and every effort should be made to explain treatments in a way that patients can understand. If more than one effective treatment option exists, giving patients a choice can increase their feelings of autonomy. When patients indicate that they wish to initiate a treatment that differs from what practitioners have recommended, their autonomy is supported if practitioners minimize control and encourage them to try the approach and then report back their success after a reasonable trial period. Of course, if patients choose a treatment that is known to be harmful, practitioners need to clearly explain why they can’t support that treatment option. In short, giving patients a respectful but clear rationale for change helps them to begin to internalize that new goal. The qualities of an autonomy-supportive health care climate are summarized in table 4. Just as autonomy is frequently misunderstood as independence, autonomy support is frequently misunderstood as indifference on the part of the practitioner. Supporting autonomy does not mean being distant, withholding, vague, or leaving patients to fend for themselves with difficult decisions about their care. Instead, it requires that practitioners hold meaningful discussions with their patients, to listen as well as to advise, and to suspend judgment while eliciting patients’ opinions. Autonomy-supportive practitioners use evidencedbased standards, set limits, make recommendations, and give accurate feed-

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back just as controlling practitioners do, but autonomy-supportive practitioners do so in an understanding, encouraging, nonjudgmental style rather than an imperious, dismissive, or condescending style.

The Nature of Controlling Behavior To facilitate the patients’ internalization, practitioners need to minimize controlling behaviors. Many of these are subtle, such as looking at a watch or asking closed-ended questions while obtaining patient histories (Beckman and Frankel 1984; Marvel et al. 1999). More overtly controlling behaviors include interrupting or talking over patients, redirecting interviews before patients have completed their initial complaint, and imposing a perspective before the patients have stated theirs. In particular, providing judgmental responses or telling patients that they will have to change, without letting the patients establish their own goals or offer their own solutions to their problems, tends to discourage patients from taking responsibility for their behavior. The downside of these practices is that patients treated in this way tend to provide less information regarding their symptoms and behaviors, leading practitioners to less accurate diagnoses. And high practitioner control may make patients feel less like they are changing for themselves and may leave them feeling passive or resentful instead. Patients who feel more controlled demonstrate less flexibility in using the information provided and have less motivational energy to draw on. In sum, the goal of autonomy-supportive counseling is to leave patients with the feeling that they are the ones who have made the decision to undertake a new behavior or treatment. As we stated in Part I, this is in fact the truth: we are all the deciders and actors within our lives, whether or not we realize it. Autonomy-supportive caretaking best helps people to recognize this while providing a caring and positive relationship.

Self-Determination Theory’s Empirical Model of Health Motivation The general empirical model that has emerged from many studies guided by SDT suggests that (1) the degree of autonomy supportiveness of health care practitioners and (2) the patient’s general or trait orientation toward autonomy both predict patient autonomous motivation for participating in medical treatments (see figure 2). In addition, the model demonstrates that patients’ sense of competence (or confidence) is also predicted both by providers’

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Health care climate (autonomy supportive versus controlling)

Mental health outcomes

≤

∞ Patient need-satisfaction (autonomy, competence, relatedness)

∞ Individual differences (autonomy-oriented versus control-oriented)

≤ Physical health outcomes

Figure 2. An integrated model of the relations between patient and context characteristics, patient need-satisfaction, and patient health outcomes

autonomy supportiveness and by patients’ trait levels of autonomy. In turn, patients’ sense of autonomy and their confidence regarding their behavioral change goals predict their ability both to maintain those new behaviors and to experience positive physical and mental health outcomes. Importantly, this model captures our assertion that both the quality and the quantity of motivation matter. In other words, people not only need to feel that they can do something (confidence); they also need to feel that they are responsible for initiating and maintaining that behavior (autonomy). The empirical evidence base supporting the self-determination model of physical health is reviewed next. Although here we focus on the end point of physical health, readers should understand that physical health, mental health, and functional status are inextricably woven together within the fabric of peoples’ lives. Thus the same motivational predictors of physical health are also predictive of mental health and are isolated here only for purposes of clarity. In later chapters we reintegrate these important determinants of human experience at a higher level. Readers should note also that we focus first on the central part of the model presented in figure 2—namely, the effects on health outcomes of autonomous motivation for engaging in a particular type of health behavior. We then focus on the two predictors of this positive state: individual differences (trait autonomy) and providers’ autonomy support (health care climate).

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Autonomous Motivation and Health Behavior Change A variety of studies have tested the hypothesis that when patients are autonomously motivated (in contrast to feeling controlled) they will be more likely to sustain their healthy behaviors over the long-term, which in turn leads to positive health consequences. These studies have all used the Treatment Self-Regulation Questionnaire, or TSRQ (Ryan and Connell 1989) to measure patients’ autonomous and controlled motivations for engaging in the targeted health behavior (for example, dieting and exercising to lose weight, trying to quit smoking). In an observational study of one hundred patients entering an outpatient alcohol treatment program (Ryan, Plant, and O’Malley 1995), the two primary outcomes were the number of weeks attended and the clinicians’ ratings of patients’ involvement in the program. As predicted, patients who had more autonomous motivation for participating at the outset attended more regularly, were more likely to complete the program, and had higher clinician ratings regarding their involvement in the program. Thus, in this study, the patients’ sense of autonomy predicted both the quantity of motivation (attendance) and the quality of the motivation (involvement). Another observational study focused on morbidly obese patients participating in a medically supervised very low calorie, liquid-diet weight-loss program (Williams, Grow, et al. 1996). In this study, 128 patients followed the diet and met weekly for twenty-six weeks with a study physician or nurse. Each week they also attended a group session focusing on mutual support and consulted with nutritionists and exercise physiologists. The goals for these sessions were to help the patients relearn their eating and exercise patterns. A few weeks into the program, patients completed the TSRQ. Autonomous motivation was found to predict weekly attendance, as well as six-month reduction in body mass index. Participants were again contacted two years after starting the program to assess their long-term weight loss exercise pattern after leaving the program and. The long-term results indicated that autonomous motivation was positively predictive of both their maintained reduction in body mass index and the amount they exercised at that point in time. In short, those who felt pressured or compelled within the treatment program did not succeed; those who participated with a sense of free choice did. A third study focused on patients with narcotics addictions, attempting to predict their attendance at a methadone maintenance program (Zeldman, Ryan, and Friscella 2001). Again, autonomous motivation for participation in the program significantly predicted regular attendance, and also predicted objective indexes of success (that is, clean urine testing). We would like to

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emphasize this relation between autonomy and attendance, because attendance is considered to be perhaps the most important determinant of treatment outcome to adherence researchers (Stephenson et al. 1993) and is also the indicator most easily available to clinicians. In a recent effort to link motivational predictors to physiologic outcomes, we (Williams, Freedman, and Deci 1998) assessed diabetes patients’ autonomous motivation for adhering to diet and exercise regiments. For the 136 patients in this study, autonomous motivation was moderately strongly correlated with healthier (lower) glycosylated hemoglobin, an indicator of glucose control and long-term health for patients with diabetes. Smoking cessation and its maintenance have also been predicted by autonomous motivation to quit smoking (Williams, Gagne, et al., in press). In this study, more than 240 smokers were asked about their autonomous and controlled motivations for stopping smoking. Even after controlling for level of addiction, past quit attempts, and demographic variables, autonomous motivation predicted carbon monoxide–validated cessation at six, twelve, and thirty months and continuous cessation at all three times. In another study of smoking, high school students were followed for four months as part of a study to test two styles of presenting information to teens (Williams, Cox, Kouides, and Deci 1999). The teens’ smoking behaviors and their autonomous motivation for not smoking were assessed at baseline and four months later. Increase in autonomous motivation predicted a reduction in smoking over the four months of the study. Similarly, in a study of 242 patients undergoing noninvasive diagnostic testing for coronary artery disease (CAD), autonomous motivation for a healthier lifestyle (for example, exercise and diet) was measured at the time of testing and three years later (Williams, Mushlin, et al. 2001). Change in autonomous motivation predicted an increase in exercise behavior and efforts to improve diet three years later. This study provides further evidence that change in autonomous motivation (that is, internalization) is associated with maintaining healthy behaviors known to reduce heart disease. In a particularly revealing study, 126 patients who had been prescribed long-term medications for a variety of medical conditions (two months’ minimum) were asked about their autonomous and controlled reasons for taking their medication, and their adherence was assessed both by objective pill counts and by self-report (Williams, Rodin, et al. 1998). Autonomous motivation (and not controlled motivation) was strongly correlated with both adherence outcomes. Several other constructs from other models of healthrelated behavior (for example, the health belief model [ Janz and Becker 1984] and its construct of ‘‘perceived barriers to behavior’’ [Glasgow, McCaul, and

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Schafer 1986]), as well as health locus of control (Wallston and Wallston 1978), were also assessed. Only one other construct besides felt autonomy predicted adherence; specifically, a weak negative correlation emerged between patients’ perceiving barriers to adherence and their actual adherence. Physicians participating in the long-term medication study were asked to rate the degree they felt that each of their patients was actually adhering to the medication regimen (Williams, Rodin, et al. 1998). Importantly, their ratings were found to be uncorrelated with any of the adherence outcomes. This finding is significant because it suggests that patients with autonomous motivation and patients with controlled motivation tend to look alike to physicians. In other words, providers may not be able to tell the difference between strong motivation that is controlled in nature and motivation that is autonomous in nature. Perhaps explaining this, Sheldon and Elliot (1998) showed that people with strong controlled motivation tend to have strong initial effort intentions. However, these intentions fade as time goes by. Taken together, these findings suggest that physicians may readily be misled by controlled patients’ vocalized effort intentions, even as these patients also mislead themselves. To detect the difference between autonomous and controlled motivation, practitioners would need to elicit more of their patients’ reasons for taking their medications and listen for whether the patients are taking the medications with a sense that they are important to them personally rather than because someone or something is pressuring them. By taking the time to elicit such information, providers can better tell which patients need extra support or help in internalizing their health behaviors. The studies summarized above make it clear that we need to understand the factors that promote autonomous motivation. Self-determination theory, like most of contemporary psychology, has tended to look in two primary areas for such understanding: individual differences in personality and differences in the social-contextual environment in which people find themselves. Again, the model presented in figure 2 encompasses both of these factors. However, we consider the practitioner’s interpersonal style (that is, autonomy-supportive versus controlling) to be the more important determinant of health behavior. In large part, this is because this style can be taught to practitioners (Williams and Deci 1996). In contrast, participants’ trait levels of autonomy are less easily changed. As we discussed in Chapter 3, however, even personality dispositions can change over time, perhaps via new psychological development on the patient’s part brought about by the encounter with the disease (Tedeschi and Calhoun 1995). It is useful for providers to become familiar with these styles and to learn to recognize them when they see them. Thus, in

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the following section we describe the role of individual differences in the SDT model of health behavior.

Motivation-Relevant Personality Traits: Causality Orientations Thus far we have been discussing autonomous versus controlled motivation to engage in a particular behavior, such as stopping smoking or adhering to an exercise regimen. The concept of general causality orientations (Deci and Ryan 1985a) addresses the autonomy-control distinction at a much broader level of personality (defined as the consistent and stable patterns of thinking and behaving that characterize particular individuals across situations). Specifically, the concept of causality orientations refers to broad individual differences in the way people relate to the environment with respect to initiating and regulating their own behavior. The autonomy orientation involves a general tendency to be self-initiating and to orient toward contextual factors that promote choice. Autonomyoriented people consult their experience as an important source of information about what to do, and they tend to take responsibility for whatever choices they make. In contrast, control-oriented people seek out the contingencies and ‘‘rules’’ in the situation, attempting to conform their behavior to the controls they perceive in the environment. They tend to take less personal responsibility for their behavior, and they more readily abandon that behavior when the situational contingencies supporting the behavior are removed. These different orientations can be charted on the General Causality Orientation Scale, or GCOS (Deci and Ryan 1985a). In one use of the GCOS, people are asked to read twelve brief vignettes and to indicate how likely they would be to respond to the situation in the manner indicated below the vignettes. A sample vignette and its autonomous and controlled responses are presented below: You have been offered a new position in a company where you have worked for some time. The first question that is likely to come to mind is: Autonomous response: I wonder if the new work will be interesting? Controlled response: Will I make more money in this position?

As illustrated in figure 2, the empirical model predicts, none too surprisingly, that people who are high in general autonomy orientation also have greater autonomous motivation (as measured by the TSRQ) for regulating specific health-related behaviors. Consistently with this prediction, general autonomy orientation has been found to be associated with more autonomous

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motivation for each of the following specific health behaviors: stopping smoking (Williams, Gagne, et al. 2001), regulating diabetes (Williams, Freedman, and Deci 1998), weight loss by morbidly obese patients (Williams, Grow, et al. 1996), and healthy lifestyle changes by patients with chest pain (Williams, Mushlin, et al. 2001). In addition to having effects mediated by behaviorspecific autonomy, general autonomy orientation has been shown to account directly for weight loss maintained over two years in morbidly obese patients (Williams, Grow, et al. 1996), as well as for weight loss over three years for patients with chest pain (Williams, Mushlin, et al. 2001). In contrast, control orientation has not been found to correlate with any healthy behaviors and in fact has instead been found to correlate with the Type-A or coronary-prone behavior pattern (Deci and Ryan 1985a). Taken together, these studies support the hypothesis that personality contributes to patients’ ability to internalize and follow through with new healthrelated behaviors. Importantly, as we discussed in Chapter 3, no personality research has provided support for a ‘‘matching’’ hypothesis in which those with a controlled orientation benefit most from being treated in controlling ways. In other words, no conditions have yet been uncovered in which control-oriented persons even equal (much less exceed) autonomy-oriented persons in the ability to make necessary lifestyle changes. We now turn to the second factor predicting internalized motivation for treatment—namely, the autonomy-supportiveness of providers (the health care climate; see figure 2). Again, we view this as the more important factor because it can more easily be targeted by interventions.

Empirical Effects of Autonomy-Supportive Treatment by Providers (Health Care Climate) Practitioners create the interpersonal conditions in which patients receive new recommendations for maintaining or improving their health. Such recommendations include but are not limited to: lifestyle changes, such as diet, exercise, using seat belts, not smoking, and moderating alcohol use; preventative medical recommendations, such as screening for disease via mammograms, blood pressure and cholesterol checks, pap smears, and immunizations; and medical treatments, such as drug or physical therapy regimens. Much research has focused directly on how health care practitioners can promote patients’ autonomous motivation for implementing such recommendations, although promoting patients’ sense of confidence or competence is also typically addressed (see below). Autonomy support is often measured by self-report, specifically via the

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Health Care Climate Questionnaire (HCCQ), which asks patients how much their practitioner listens to them, answers their questions, and provides choices. Importantly, this methodology relies on the patients’ own experiences. Autonomy support has also been measured more objectively; for example, trained independent judges have rated practitioners based on audio- or videotapes of the practitioners’ interactions with patients and have reached a high level of agreement regarding these issues. However it is measured, autonomy support is later used to predict the degree to which patients internalize the regulation of their health behaviors. For example, in the study of morbidly obese patients (Williams, Grow, et al. 1996), the degree of autonomy support the patients experienced predicted their autonomous motivation to lose weight even after controlling for trait levels of autonomy orientation, attendance, and weight loss at six months. As mentioned earlier, autonomous motivation in turn resulted in better maintenance of weight loss and exercise. The study of adherence to long-term medications (Williams, Rodin, et al. 1998) gave complementary results. Patients who reported that their physician was more autonomy supportive also reported more autonomous motivation for taking the medication, and they were thus more likely to adhere to the medication. The diabetes study described above (Williams, Freedman, and Deci 1998) yielded similar findings. That is, patients’ reports of their physician’s autonomy supportiveness predicted an increase in their autonomous motivation for regulating diabetes-related behaviors, and in addition, autonomy support directly predicted significantly improved glycosylated hemoglobin scores over twelve months. In the study of patients who complained of chest pain (Williams, Mushlin, et al. 2001), the autonomy supportiveness patients reported predicted later increases in their autonomous motivation for a healthier lifestyle. Similarly, when high school students reported that the physicians presenting them with information on smoking were more autonomy supportive, they reported increases in their autonomous motivation for not smoking (Williams, Cox, et al. 1999). In an intervention study of smoking cessation (Williams, Gagne, et al., in press), physicians were taught to counsel the patients to quit smoking using the National Cancer Institute guidelines (NCI) for smoking cessation (Glynn, Manley, and Pechacek 1990). The patients who perceived their physicians as more autonomy supportive were more autonomously motivated to quit and had greater six-month quit rates (biochemically validated) than patients who experienced their physicians as more controlling. The initial patient-physician interactions in the smoking study were tape-

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recorded, and observers also rated the physicians’ autonomy support (Williams, Gagne, et al., in press). These independent (observer-based) ratings of autonomy support were also significantly related to patients’ autonomous motivation for stopping. Thus, the relation of patient ratings of autonomy support and the patients’ subsequent autonomy is not just the result of autonomous patients’ perceiving their doctor as autonomy supportive. Another level of this study involved training physicians to counsel patients in both an autonomy-supportive style and a somewhat more controlling style (both types of counseling provided the same content). Patients were randomly assigned to a physician so that some patients received the autonomysupportive style, others the more controlling style. Results indicated that in the autonomy-supportive condition patients developed more self-determined motivation for quitting smoking. Taken together, these results support our contention that autonomy support within the health care environment (either as perceived by the patient or as rated by observers) predicts greater autonomous motivation by the patient for specific health-relevant behavior as assessed with the TSRQ. Evidence thus far indicates that this relation is significant even when controlling for patient autonomy at the personality level measured on the GCOS. In addition, several of these studies found direct relations between autonomy support and longterm behavior independent of patients’ reported motivation. Thus, it seems that health care practitioners who can provide their counseling to patients in a more autonomy-supportive manner will facilitate behavioral change in a manner that will lead to sustained change and health improvement. Next, we consider typical results of practitioners’ adoption of a more controlling style.

Empirical Effects of Controlling Treatment by Practitioners Studies by several researchers have found that many physicians naturally rely on an authoritarian style. For example, two studies published fifteen years apart identified that the mean time it took physicians to interrupt their patients was sixteen seconds in 1984 (Beckman and Frankel 1984) and twenty-three seconds in 1999 (Marvel et al. 1999). Once interrupted, the patients rarely were able to return to their original concern; the physicians controlled the remainder of the interview, making the interaction much more of a physician-centered, and much less of a patient-centered, process. In a set of four studies of patients with peptic ulcer disease, hypertension, diabetes, or breast cancer (Kaplan, Greenfield, and Ware 1989), observers’ ratings of patient-physician interactions indicated that the typical style physicians used was very controlling and that increased control was associated both

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with greater patient passivity and with poorer health outcomes. In these studies, however, some patients were coached to be more active in getting answers to their questions and to participate more actively in their care. These patients demonstrated better physiologic and functional status outcomes than patients who were not trained to overcome their physicians’ brusqueness. In a large study of informed decision-making involving 1,057 medical encounters and 3,552 clinical decisions among 59 primary care physicians and 65 surgeons, it was found that only 9 percent of all patient decisions were fully informed (Braddock et al. 1999). The more complex the decision to be made, the less fully patients were informed. This study is directly relevant to the issue of autonomy support and SDT, since one of the criteria of autonomy support is the willingness to provide relevant information to patients so that they can consider their options fully. When physicians do not fully inform patients, they are not supporting patients’ autonomy. We conclude from these studies, conducted by researchers outside the SDT tradition, that physicians are typically fairly controlling in their clinical encounters and that they therefore miss opportunities to gather relevant information and to motivate their patients.

Comparisons with Self-Efficacy Interventions Again, self-determination theory posits a need for competence along with needs for autonomy and relatedness. The bulk of the research we have conducted thus far has focused on the need for autonomy because this area is the least well represented in the literature. The need for competence relates to people’s feelings that they can achieve the health-relevant outcome, and as we noted above, it has been well represented in health psychology by the concept of self-efficacy (Bandura 1997; Glasgow, McCaul, and Schafer 1987; Howorka et al. 2000). Again, programs that support peoples’ sense of competence have demonstrated positive effects, certainly more than programs that try to control patients with rewards and punishments. Rather than reviewing the entire efficacy literature, however, we confine ourselves to research that we have conducted, in which we measured both competence and autonomy. The adherence to medication study (Williams, Rodin, et al. 1998) described above measured anticipations of competence at sticking to the regimen. But anticipated competence failed to predict the variance in adherence to medications, whereas autonomy was strongly related to adherence. We also assessed competence in the diabetes study (Williams, Freedman, and Deci 1998) and found that both autonomy and competence were moderately correlated with lower patient glycosylated hemoglobin over the twelve months of the study.

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Further analyses showed that changes in felt autonomy predicted changes in perceived competence, which in turn predicted change in glycosylated hemoglobin. Last, in the study on adult smoking (Williams, Gagne, in press), both perceived competence and autonomy significantly predicted cessation at six, twelve, and thirty months, but competence fell to insignificance once the model accounted for perceived autonomy. Thus, initial perceived competence has been found to predict physical health outcomes independently of autonomy in some but not all studies. Although initial felt competence (or confidence) may be a weaker factor supporting long-term health change than initial felt autonomy, it does appear to be important and so is retained in the model presented in figure 2. As we noted early in this chapter, many epidemiological studies show physical health can be dramatically improved through motivated behaviors such as quitting smoking, exercising more, eating a healthy diet, and adhering to prescribed medications. We have argued that understanding the motivational basis of adherence to healthy behaviors and the long-term cessation of unhealthy behaviors requires adopting a more general model of motivation than that offered by the behaviorist tradition, which focuses on controlling patients behavior with rewards and punishments. It also requires adopting a model more general than that offered by the social-cognitive tradition, which focuses on enhancing patients’ sense of confidence or self-efficacy (quantity of motivation) but does not focus on autonomy (quality of motivation). Selfdetermination theory provides such a model. We have reviewed a variety of studies indicating that patients will be more likely to adopt and maintain healthy behavior if their motivation is more autonomous in nature—that is, when they have successfully integrated the regulation of the relevant behaviors into their sense of self. The idea of promoting patients’ autonomous regulation of their health behavior requires a rethinking of health care delivery. Indeed, it suggests that it will be necessary to conceptualize and talk about fundamental issues in a very different manner. For example, the term compliance is used regularly to represent whether patients take their medication as prescribed. However, compliance itself implies control rather than autonomy or volitional use of the treatment. That is, one complies with a control—with the demands of an authority. Unfortunately, as we have shown, complying with a demand is quite different from making a choice to take a medication or stop smoking. Accordingly, we use the term autonomy support to refer to the process by which patients can be helped to make a personal choice regarding their health behavior. Considerable research now indicates that patients tend to be more

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autonomous, and in turn behave in healthier ways, when practitioners are more autonomy supportive during the initial encounter. It is hard to maintain healthy behaviors and change unhealthy patterns, no matter what one’s motivation. The studies we have reviewed have consistently shown that this task is easier when patients feel understood and cared for by their practitioners and when the practitioner respects them, gives them full information, and solicits their active involvement in the decisions to be made.

5

Facilitating Health Behavior Change The Case of Tobacco Dependence

Health care practitioners face the daunting challenge of encouraging patients to take their medications, to refrain from unhealthy behaviors such as smoking, to engage in healthy behaviors such as exercising, and to undergo unpleasant preventive procedures such as screening mammography. To illustrate how difficult these challenges are, consider that many practitioners have trouble simply getting their patients to show up for scheduled appointments! Clarifying how practitioners can facilitate healthy patient behaviors is thus an extremely important matter, which, if accomplished, would likely improve patients’ health and satisfaction, increase practitioners’ feelings of competence, and decrease health care costs, all in one fell swoop. In this and the next chapter, we focus on the ‘‘how to’’ aspects of motivating healthier patient behaviors. First we focus on generalities of behavior change, discuss the natural history of change, and apply these concepts to consider the relationship between ‘‘Dr. P.’’ and ‘‘K. M.’’ as they discuss K. M.’s attempts to quit smoking. In Chapter 6, we focus on the difficult circumstance of facilitating effective diabetes self-management. Given the growing public health problem associated with diabetes (Harris et al. 1998), this is obviously an important arena in which to apply our theoretical perspective. A great deal has been learned about facilitating healthy behavior change over the past forty years. Unfortunately, this knowledge has traditionally been given little attention in medical school. In effect, physicians have been left to 65

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prescribe treatments while assuming that their authority and good intentions are enough to assure their patients’ compliance (Phillips and Jones 1991). In the ensuing discussion of how to motivate healthy behavior, we draw from convergent aspects of several well-validated psychological theories of behavior change. Interested readers are encouraged to explore the theories themselves through the following references: the health belief model (Janz and Becker 1984), motivational interviewing (Miller and Rollnick 1991), stages of change (Prochaska, DiClementi, and Norcross 1992), social learning theory (Bandura 1997), and SDT (Williams, Deci, and Ryan 1998). We acknowledge each of these models and theories for the contributions they have made to understanding health behavior. We feel that because SDT is a general and extensively validated theory of human motivation, it provides the broadest explanatory theory regarding health behavior. Our focus therefore remains on the self-determination perspective.

Facilitating Behavior Change To facilitate means ‘‘to free from difficulties or obstacles; to make easier; to aid; to assist.’’ Within a physician-patient relationship, physician facilitation means that the doctor helps the patient begin to behave in ways that lead to important health outcomes. From the SDT perspective, the aid or assistance provided by the practitioner must be something that supports (rather than undermines) the patient’s natural (but often fragile) motivation to behave in healthy ways. Thus, the important question: What do health care practitioners need to know to best promote patient motivation for healthy behavior change? Four considerations are essential to facilitate behavior change that will have a meaningful impact on the length or quality of patients’ lives. First, practitioners must know which behaviors are unequivocally linked to health, so that facilitating those behaviors is justified. Second, they must understand the typical pattern of change for health-related behaviors. Third, they must recognize that there are different types of patient motivation that are more versus less likely to be effective in producing maintained behavior change. Fourth, they should know what physician behaviors (autonomy, competence, and relationship support) are most likely to facilitate effective patient motivations. HAVING PROPER JUSTIFICATION FOR RECOMMENDED INTERVENTIONS

Health care practitioners should have clear evidence that particular behaviors are linked to improved health and/or mortality before attempting to facilitate those behaviors. There is now clear evidence, for example, that

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women over fifty who have periodic mammograms live longer than those who do not, so this is a behavior that is properly advocated by health care practitioners (U.S. Preventive Services Task Force 1996). Further, there is evidence that patients with diabetes who maintain tight glucose control are likely to have a higher-quality life free of retinopathy, nephropathy, and neuropathy, so glucose control is also appropriately facilitated by practitioners (DCCT 1993). Perhaps the clearest example of a behavior that involves a substantial percentage of patients and is directly linked to morbidity and mortality is tobacco dependence and use. As we discussed in Chapter 4, there is extensive research showing the harmful effects of smoking. There is also convincing evidence showing the beneficial effects of quitting (U.S. Department of Health and Human Services 1990; Stampfer et al. 2000). Specifically, stopping smoking leads to a 50 percent reduction in risk for heart attack within a year and reduces the risk for all causes of mortality to the same level as that of nonsmokers within ten to fifteen years. In addition, although pack-a-day smokers have seventeen times the risk for lung cancer relative to nonsmokers, within five to seven years of quitting, the risk of lung cancer falls in half, and after fifteen years the risk is only twice that of nonsmokers. Thus, substantial health benefits accrue for those who stop, but these benefits require total abstinence over months and years to achieve. Adequate justification for attempting to facilitate change of a particular behavior is typically provided by a sequence of research projects. First, epidemiological studies are performed to identify healthy and unhealthy behaviors. Then, efficacy trials are conducted that involve random assignment of atrisk patients to one of two or more conditions in order to test whether an intervention, used under ideal circumstances, will lower the patients’ risks. Last, effectiveness trials are carried out to demonstrate that the intervention can be generalized successfully into typical clinical practice. For example, given that epidemiological studies have determined that quitting smoking lowers patients’ risk of dying prematurely from smoking-related diseases, suppose an efficacy trial determined that a particular medication, when used in a certain way, is efficacious in increasing cessation. But if it then turned out that few if any of the patients who were prescribed the medication took it in the way that reduced their risk, then the intervention might not be effective, even though it is efficacious. Only effective interventions are appropriate for widespread prescriptions. An interesting example is the nicotine polycrilex gum used as a nicotine replacement treatment (Fiore et al. 2000). The gum has been shown to be efficacious, but it has not been as effective as it could have been because doctors have often not taught their patients how to use it correctly, and patients tend to under-treat themselves. To work effectively, the gum needs to be

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chewed briefly and then flattened and put against the side of the mouth. Yet many patients have not been trained to use it that way and often chew continuously, which frequently causes nausea and other side effects. In addition, patients frequently use too few pieces per day, for too few days, which results in poor relief of their withdrawal symptoms. Thus, in prescribing a treatment, it is important for doctors to teach patients how to carry it out effectively and to discuss any obstacles that might interfere with the patients’ doing so. If this is not done, prescribing the treatment may not be justified. An increasing number of behavior-related interventions have passed the tests described above and can be prescribed. For the busy clinician, this information is an important guide for which behaviors to focus on as well as for which are not worth trying to change. Clinicians who stay in touch with this knowledge are best prepared to aid in the directive aspect of healthy motivation—that is, they will be best able to help patients select appropriate treatments. Again, however, as we discussed in Chapter 4, in this book we do not canvass medical knowledge directly. Instead we focus on how to motivate or energize behavior toward any appropriate new behavior—tried and true or new and improved. An excellent resource identifying what the Centers for Disease Control recommend for clinicians to prioritize for their patients has been published in the American Journal of Preventative Medicine. Interestingly, the Centers for Disease Control recommend that practitioners use a shared decision-making approach in doing preventative counseling, an approach that is entirely consistent with SDT (Reynolds 2001). Once health care practitioners know what behavior changes can help their patients, they then need to understand how to help patients ‘‘tap into’’ their motivations toward health. Just as physicians learn the natural history of diseases such as lung cancer and hypertension so that they can advise their patients about treatment options, practitioners also need to learn the natural history of behavior change so they can facilitate their patients’ efforts to implement their advice. THE NATURAL HISTORY OF HEALTH BEHAVIOR CHANGE

Over the past four decades a great deal of research has been conducted to elucidate the processes by which human beings manage to change their long-term health-related behaviors. Many researchers (among them, Prochaska, DiClementi, and Norcross 1992; Miller and Rollnick 1991; and Williams, Deci, and Ryan 1998) have found striking similarities in how people successfully change long-term health-related behaviors. This research has revealed that making changes that are maintained over the long term typically takes two to three years, during which time individuals may make three or

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Table 5. Features of the natural history of behavior change ≤ ≤ ≤ ≤

Expect a time frame of two to three years Three to four serious change attempts, with relapse, is frequently required Each failed attempt increases the likelihood that the next attempt will succeed This process has been observed for many health behaviors

four serious but unsuccessful change attempts. In other words, lasting change often takes considerable time and effort to accomplish. Fortunately, this time frame for lasting behavior change fits well with the ongoing nature of the practitioner-patient relationship. Thus, health care practitioners can be important facilitators of change for any patients with whom they have a long-term relationship (as we illustrate later in the chapter). The behavior change research has also shown that each time a person makes a failed change attempt, it increases the likelihood that the next attempt will be successful. This pattern of change has been identified and generalized to at least twelve health behaviors, including smoking cessation, reduced alcohol consumption, condom use, and regular use of sun screen to prevent skin cancer. Even physicians have been shown to take two to three years, with several unsuccessful attempts at change, before they are regularly able to implement their intention to regularly counsel their tobacco dependent patients. Given the nature of this pattern, it is crucial that a person’s unsuccessful change attempts not be portrayed as failures but rather as indications of the person’s growing motivation to change (see table 5). This syndrome, in which patients have frequent relapses and may take years to accomplish successful long-term change, causes understandable frustration in practitioners. After all, most practitioners have been trained to take decisive action and to expect immediate results. However, when practitioners understand the typical pattern or natural history of change, they may be less discouraged when relapses occur, may better maintain their own motivation to counsel patients sensitively to change, and may give off fewer signs that they view the patients as failures. The following encounter with a smoking patient helps to illustrate the all-too-typical pattern in which a doctor feels frustrated and discouraged, loses his motivation, and then avoids the issue of smoking altogether. K. M. is a healthy thirty-year-old white female with a five-year-old daughter with asthma and a two-year-old son. She has smoked one pack of cigarettes per day for the past fourteen years. She visited her doctor’s office for treatment of an acute cough productive of greenish sputum and a low-grade fever. After

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assessing her for bronchitis and prescribing an antibiotic and cough syrup, Dr. P. also wanted her to stop smoking. The discussion went as follows. doctor: ‘‘Smoking causes bronchitis and prolongs the symptoms, and makes your daughter’s asthma worse. There are also many other health risks to smoking. You really have to quit smoking.’’ patient: ‘‘I only smoke outside, never around my daughter. I did stop for a few days, once, and I should probably make myself do it again, at least until the cough eases. After that, I’ll see what happens.’’ doctor: ‘‘You should go to a smoking cessation class at the American Lung Association. You can find their phone number in the yellow pages. Come back to see me in 3–4 months so I can see how you’re doing with your bronchitis and your cigarettes.’’ (The patient made the appointment with the secretary on the way out but failed to come in for it.)

About nine months later, the patient returned with elbow pain that the doctor felt was tendonitis. He noticed that she had missed her last appointment. While examining her elbow, Dr. P. also noticed the odor of cigarettes. Quite understandably, he was frustrated about the missed appointment and felt uncomfortable about raising the topic of smoking again. The appointment ended without any mention of the missed appointment or the smoking. Given the typical pattern of change, it is not surprising that K. M.’s first attempt to quit smoking was unsuccessful. Persistence is called for on the part of the physician, and knowing more about motivation could help him plan the next step. UNDERSTANDING THE MOTIVATION FOR CHANGE

Understanding motivation begins with a consideration of goals. In the example, the patient and doctor seemed to have a shared goal related to her health, but in fact their specific goals were quite different. The doctor was operating with the goal of permanent cessation to improve and maintain the patient’s long-term health, but the patient was operating with the goal of temporary cessation to get over her bronchitis. Because there was no mutually agreed-upon goal, the situation produced tension and difficulty for the relationship. The patient missed an appointment because she was not motivated to take on her addiction, and during her later appointment prompted by the elbow pain, she did not feel comfortable talking to the doctor about either the missed appointment or the addiction. The doctor felt frustrated that his attempt had been unsuccessful, possibly feeling both unsure of his own competence and angry with the patient for not following through. However, afraid to jeopardize his otherwise good relationship with the patient, he, too, avoided discussing the skipped appointment and the addiction.

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Table 6. The Public Health Service guidelines for doctors’ behaviors to treat nicotine dependence (the ‘‘5 A’s’’) ≤ Ask patients at each visit whether they smoke ≤ Advise each smoker to stop smoking ≤ Assess patient willingness to make a quit attempt ≤ Assist patients in their quit attempts if they are willing to try ≤ Arrange a follow-up visit if they are willing to try

Four months after K. M.’s tendonitis appointment, Dr. P. attended a tobacco dependence course as part of his continuing medical education. At the workshop, participants reviewed information about the health effects of smoking and the benefits of quitting, learned about the basics of human motivation, and were introduced to the Public Health Service’s brief intervention for patients dependent on tobacco, the ‘‘5 A’s’’ model (Fiore et al. 2000). This model is consistent with our theoretical perspective and is thus worthy of brief discussion (see table 6). The ‘‘5 A’s’’ model involves health care practitioners’ Asking, Advising, Assessing, Assisting, and Arranging. Specifically, it encourages doctors to ask patients about tobacco use at every visit. Practitioners then advise each tobacco user to stop, discussing the benefits and consequences of quitting versus continuing and assessing whether the patient is willing to make a quit attempt. If a patient is willing to try quitting in the next two to four weeks, the practitioner assists in various ways such as encouraging the patient to set a specific quit date, making referrals to support groups, helping the patient ask for support from family, friends, and coworkers, and discussing how to cope with difficult situations that are likely to arise when the patient stops using tobacco. Finally, the practitioner arranges a follow-up appointment to promote maintenance, prevent relapse, and, if the relapse has already occurred, encourage another try. For the busy health care practitioner, the crucial step is assessing the patient’s willingness to stop. About 70 percent of smokers want to stop, but only 20 to 40 percent are willing to make a serious quit attempt at any one office visit. If a patient has no current intention to stop, then the physician may be wasting valuable time trying to convince him or her to stop beyond providing a straightforward statement of advice to stop. Pressuring patients to stop or to go to programs before they are ready to quit, as Dr. P. tried to do, may even alienate the patient. If the patient is unwilling or unmotivated to stop, health care practitioners can either move on or, if time allows, spend a few minutes trying to uncover and facilitate any autonomous motivation for changing.

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Self-determination theory specifies that the best way to increase someone’s motivation to change a behavior is by being autonomy supportive. Autonomy support in terms of smoking cessation starts by eliciting patients’ perspectives concerning their smoking and its role in their lives, while remaining nonjudgmental. Only in this case is there a chance to affect the motivational process in a positive way. Notably, in the brief exchange between Dr. P and K. M. outlined above, Dr. P made no attempt to elicit his patient’s perspective on smoking or quitting smoking. He simply advised her to stop and told her how to do it. Of course, making a statement of advice is important to promoting quitting. However, by ignoring his patient’s perspective, Dr. P. missed an opportunity to support his patient’s natural motivation to become healthier. As we discussed in Chapter 4, people initially tend to experience a behavior change goal given to them by their health care practitioner as foreign, as external to themselves. In this case, their reason for attempting to reach such a goal is that ‘‘the doctor told me to.’’ However, according to SDT (Deci and Ryan 1985b; Williams, Deci, and Ryan 1998), underlying healthy behavior change and its maintenance is the natural human tendency of internalization. Through internalization people take in and accept responsibility for regulating their behavior. As people gradually internalize a goal and thus accept personal responsibility for it, they develop different reasons for trying to achieve the goal. In other words, they make the goal a part of their self-experience. In practice, patients can either be unmotivated or can have one of two types of motivation. This is important for doctors to understand because these motivation states are good predictors of how likely it is that patients will be able to change their behavior. As he sat in the seminar, it made sense to Dr. P., in reflecting on his past experiences, that patients can be amotivated, can have controlled (noninternalized) motivation, or can have self-determined (internalized) motivation. Those who are amotivated with respect to a particular behavior change are the ones who are not sure if they want to change or are unwilling to commit to a change date in the near future (for example, in the next two to four weeks). They are not ready to change. When doctors try to get amotivated patients to change, patients are likely to feel controlled. Again, this not only is an ineffective use of time, but it may also leave the patients feeling resentful. In cases of amotivation for smoking cessation, we recommend making a simple, informational statement advising the patient to quit and then moving on to other health issues. Even such simple statements, if made in a concerned but nonjudgmental way, can facilitate later motivation and are associated with increased rates of quitting. This is because the internalization takes place largely outside the office, as patients reflect on what they have learned. If patients

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seem at all receptive to the information, then the provider can attempt to elicit their perspective on the issue, as we have described above. Patients who are willing to commit to a goal of behavior change in the next two to four weeks can be thought of as being motivated to change and would thus be expected to at least attempt to change, unless of course they are just not being honest with the health care practitioner. Recall, however, that SDT says there are two different types of motivation—controlled motivation and self-determined motivation. In the case of controlled motivation, patients are either trying to change because someone else, such as the doctor or a spouse, says they should and is pressuring them to change or because they themselves think they should and are pressuring themselves internally with negative emotions such as guilt or shame. Contained within these controlled reasons is their sense that they have not really accepted the goal as their own. In contrast, if the motivation is autonomous or self-determined, then the reasons will sound quite different. Patients will report that they want to lower their risk and improve their long-term health, and they will convey that they are ready to deal with the roadblocks involved in achieving that. A more positive and more realistic attitude of what is involved in changing and sustaining the desired behavior is associated with this self-determined type of motivation. The practical importance of distinguishing between these two types of motivation is that the likelihood of successful change is quite different for people with these two different types of reasons. Those for whom the motivation is controlled may try to change because they feel pressured to do so, and although they may have short-term success, they are much more likely to relapse. They have not really accepted the goal as their own, and they are not ready to deal with the discomfort that accompanies a change such as giving up smoking. They will easily go back to their former ways when things get tough. For example, a woman who smokes but feels ashamed for doing so may try to quit by using her negative feelings as impetus. But she is likely to find that this does not offer a sufficient foundation for lasting change. In contrast, self-determined motivation for change entails people wanting to change because it is important to them personally, because changing the behavior is consistent with their deeply felt values. A woman who has just found out that she is pregnant and wants to quit smoking because it is important to her to be healthy and even more important to her to protect the fetus would be self-determined in her motivation to change. She has decided to change for reasons that are truly her own, reasons that reflect important values for her such as having a healthy baby and being healthy herself so she can enjoy her baby as he or she grows up. The defining issue for self-determined motivation is whether people value the goal, not because their doctor says they should,

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not because a family member told them to, but because the goal is personally meaningful to them. As we reviewed in the last chapter, there is considerable research indicating that patients whose motivation for change is selfdetermined are more likely to maintain their behavior change over time. It is important to remember that decreasing or stopping unhealthy habitual behaviors such as smoking, overeating, or abuse of alcohol and instead adopting healthy behaviors such as exercising regularly or taking medication as needed is very hard. The change may interrupt people’s typical life patterns— for example, requiring them to stop having the snack they always have before going to bed because the medicine that has been prescribed for bedtime is not effective if taken within an hour of having eaten. Changing unhealthy behavior may also prompt anxiety and lead to substitute behaviors that are also unhealthy and have to be curbed or monitored. For example, because smoking helps some patients ‘‘calm their nerves,’’ it is not at all unusual that when they give up smoking they gain considerable weight within the first six months. Changing a behavior that reduced their anxiety can leave patients without an easy or familiar way of dealing with their stress. A person who is ready to change, whose motivation for smoking cessation, for example, is self-determined, will be better prepared to encounter these problems and find solutions. A woman who grabs a cigarette whenever she feels nervous may use nicotine replacement during a transition period and may join a support group to have a place to express her anxiety. A man who has a compelling urge to eat when he stops smoking may keep his refrigerator full of celery and may begin doing aerobic exercise two or three times a week as a way of managing the urge and feeling better. Theories of change also emphasize how important a patient’s social environment is for maintaining the change of difficult behaviors. A woman who is trying to lose weight may find it much harder to cut down if her husband and children keep the house filled with potato chips, sticky buns, and jellybeans. Having the support of family and friends is crucial for making a difficult change. In fact, studies have shown that helping smokers arrange social support from others who are attempting to quit increases the chances that patients will be able to quit smoking by about 50 percent (Fiore et al. 2000). Sustained change requires persistence, determination, and the expenditure of considerable energy. Constant temptation and the inner conflict it provokes use up energy and work against sustained change. With the encouragement of others, however, individuals are more likely to be able to maintain the needed energy. As Dr. P. thought about his interactions with K. M., he realized that the two of them had been working with different goals—he with the goal of long-term cessation, she with the goal of stopping for a few days. In addition, as he

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thought about her reasons for trying to quit, it seemed to him that they were ‘‘controlled’’ reasons. She had said she should make herself stop until the cough eases, rather than deciding to stop for good because she believed it would be important for her own long-term health and well-being. Her starting point for pursuing the goal did not bode well for her success at it. FACILITATING POSITIVE MOTIVATION FOR CHANGE

During Dr. P.’s continuing medical education course on behavior change and tobacco dependence, the instructor explained how to best facilitate behavior change. The instructor began by saying that humans have a natural or inherent tendency toward growth and health; they are innately motivated to take on responsibility for their own healthy behavior. Yet individuals also have three intrinsic needs—to feel competent, autonomous, and related to others— and their natural tendency to assume responsibility for their health and behavior depends on the satisfaction of these needs. In social situations that allow people to feel competent, autonomous, and related, they will be more likely to have self-determined motivation. When doctors relate to patients in a way that allows patients to feel competent, autonomous, and related with respect to a behavior-change goal, the patients will internalize the goal more fully and will be more self-determined in their reasons for pursuing that goal. Competence, the instructor said, refers to understanding how to attain desired outcomes and to feeling effective in carrying out those necessary actions. As Dr. P. thought about K. M., it occurred to him that she might have felt incompetent to change because he remembered her saying that she had tried once and obviously had failed. The patient probably did not realize that most smokers who are able to quit will have had two or more failed attempts before they are successful. Each failed quit attempt increases the likelihood that they will succeed the next time if they are able to remain abstinent for more than six days, refrain from smoking for thirty minutes after getting up, or smoke fewer than fifteen cigarettes a day (Farkas et al. 1996; Dale et al. 2001). The instructor went on to say that autonomy refers to being self-initiating and feeling volitional in one’s behaviors. It has to do with engaging in an action with a sense of willingness rather than a sense of obligation and pressure. Autonomy, the instructor said, is often confused with independence. To be autonomous does not mean to be independent of others; it means to feel willing and able to choose with respect to a behavior. Patients can feel willing and able to choose while relying on their doctor for advice and on their family for support. Change is hard, and patients are more likely to succeed if they feel supported by their health care practitioner and others rather than independent of them.

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The instructor explained that relatedness refers to feeling respected and cared for by important others as well as to respecting and caring for others oneself. Patients who feel that their health care practitioners are relating to them as individuals, who are really talking to them rather than to just another body passing through the office, will be more inclined to accept their practitioner’s advice and transform it into their own goal. As Dr. P. recalled his brief discussion with K. M. about her smoking, he recognized that, because he was in a hurry, he had probably been abrupt with her, and she may well have felt that he was not really relating to her. He also realized that he had not discussed the issue of how her family and friends could either help or hinder her attempt to quit smoking.

Putting It All Together What does this mean for facilitating change of hard-to-change, healthrelated behaviors such as smoking, poor glucose control (for patients with diabetes), or overeating (for morbidly obese patients)? As Dr. P. began to put it all together, he could see that there were probably ways he could relate differently to his patients that would help them achieve better health. He wondered whether he had always given his patients the information they needed to make informed decisions and carry out important goals. And then he remembered a time when one of his patients, in exasperation, said to him, ‘‘You always use medical words that I don’t understand.’’ That resonated with something the instructor had said, and he could see that patients need to understand their illness and the treatment options if they are to feel competent in managing the illness. He resolved to make sure that he spoke to patients in a way that they would really understand what he meant. He knew that it would be different to try to relate to them from their perspective, so they would really understand what he was saying, but he felt ready to put in that effort. Remembering the statistics about how many quit attempts people typically make and how important it is for them to feel competent, Dr. P. decided that he would be careful to acknowledge his patients’ efforts and reframe a failed attempt in positive terms. After all, they had tried, which is an important indicator of future success. He might also think out loud with them about what went wrong and what they might do differently next time. As he considered all this, he thought that he himself might feel more competent as he related to his patients in these new ways! Doctor P. also pondered the importance of giving patients more choice and allowing them to take greater initiative so they would have increased sense of autonomy. This, he had learned, involved encouraging patients to talk about

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their own motivation for change and their feelings about trying to change. The instructor had emphasized the importance of not pressuring patients to accept their doctors’ goals, instead letting them make their own decisions. That did not mean abandoning his patients or leaving them to fend for themselves. Clearly, they would do better if they accepted his help. But it was important that he try not to be controlling and demanding even at times when he was sure he knew what was best for them. The doctor recalled an article he had once read about negotiating goals with one’s patients—an idea that suddenly seemed to fall into place. Negotiating a health-related goal would allow the patients to feel a sense of ownership of the goal, that is, to feel autonomous with respect to it. After this insight, Dr. P. himself felt more motivated to discuss smoking with his patients. No longer would he avoid the issue—he would simply deal with it differently than he had in the past. Much had been said during the seminar about relationships and how essential they are for sustaining long-term change, and Dr. P. was beginning to see how this fit in, too. Accepting patients’ failures without judgment or criticism not only would help them feel more competent but could also leave them feeling that the relationship was more positive and caring. And if he listened carefully to how his patients wished to deal with a problem, it could help them feel both autonomous and cared for. He could maintain his own ideals about health behavior while learning how his patients see smoking, and stopping smoking, as fitting into their lives.

K. M. Returns for a Visit During the first week back in his office, Dr. P. did his best to remember what he had learned in the seminar. It was not always easy, especially when he felt hurried and stressed, but he was determined to keep trying. During the second week K. M. made an appointment, with a complaint about chest pain. During the interview, Dr. P. determined that it was a noncardiac type of pain that had begun recently, soon after K. M.’s mother, who was fifty-eight, was diagnosed with a myocardial infarction. K. M. was concerned that she herself was having a heart attack as well, and because of all the stress, she was now smoking a pack and a half a day. This time, Dr. P. did not shrink from the topic, and the conversation went as follows. doctor: ‘‘I’d like to discuss your smoking, is that okay?’’ patient: ‘‘Yes, but it scares me.’’ doctor: ‘‘What scares you?’’

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patient: ‘‘Well, I think I’ll try the patch.’’ doctor: ‘‘Okay, but it is important that you quit completely before starting the patch. If you don’t, you can become even more addicted to the nicotine. Also, you need to know that some people get a rash, so be sure to put it in a new place each morning. And if you do develop a rash, let me know. Now I want to ask you when you will quit?’’ patient: ‘‘This Sunday is my mother’s birthday, so I’ll choose that day to quit. What can I do about the weight gain?’’ doctor: ‘‘Quitting would be a nice present for your mother. The weight gain can be troublesome, but most people gain five to ten pounds and lose it within a year of quitting. Do you have any ideas about how to avoid it?’’ patient: ‘‘I’d like to start walking more, but I really don’t like running very much.’’ doctor: ‘‘Walking is a great exercise, particularly if you do it when you get the urge to smoke or eat. It will help change the daily routine you have associated with smoking. Just walking regularly can be very helpful. You might also try to have low-calorie snacks on hand, to eat if you feel hungry and can’t resist eating something. Also, try to avoid alcohol, it’s full of empty calories and is highly associated with restarting smoking. If you gain some weight, try not to pressure yourself too much—it’s hard to change too much at once. ‘‘I have brochure here from the Public Health Service with some tips on how to quit. It’s called ‘You Can Quit Smoking.’ Try to read this over before your quit day this weekend, as it could prove helpful.’’ patient: ‘‘I’ll be embarrassed if I fail again.’’ doctor: ‘‘I want you to know that the average smoker has to try two to three times before being able to quit long-term. You have already tried twice and had some success. From those experiences, you’ve learned a lot about quitting, and you’re more likely to be able to quit long-term this time. By asking others to help you quit, like your friends or family, or by going to a support group, you might have an easier time getting through the difficult patches. I suggest you consider those options, too. I’d also like to see you or hear from you during the week after you quit, to see if I could be of any help.’’ patient: ‘‘Okay, I’ll call you.’’ doctor: ‘‘Quitting is a hard thing to do, and you are the one who has to make the change, but I think you have the experience to make it work, if you use your resources.’’

During this interview Dr. P. was able to hear K. M. fully, acknowledge her fears, present options for change, and tie his advice to her immediate situation, all without being overly controlling. She openly shared her concerns about failing, and he was able to be empathic and reassuring. This is an important point, because when patients do not feel very competent they need support,

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accurate information about the possibilities for succeeding, and the opportunity to brainstorm about how to deal with obstacles. About ten days later, Dr. P. got a message that K. M. had quit and had been off cigarettes for six days. He returned the call and learned that although she had strong urges to smoke, she was still smoke-free. She was relying on her family and they had been very supportive, but she didn’t have time to go to a support group. She agreed to the doctor’s request to come in to see him in a month. At the end of the month, K. M. phoned again and said that she was still smoke-free and did not need the office visit. They had a brief but satisfying discussion, and Dr. P. was encouraged that she had not relapsed. The fact that she had made the phone call was evidence of her motivation to maintain the change. Seven months went by, and K. M. returned with another episode of bronchitis. Part way through the interview she told the doctor that she had started smoking again about four weeks earlier. She appeared ashamed and said she felt terribly guilty every time she lit up. Her mother had remained abstinent from smoking and was doing well in her cardiac rehabilitation program. At that point, Dr. P. had several decisions to make. From a health perspective, strongly advising her to quit again would have been the best thing to do. But that may not have been the best way to approach her from a motivational perspective. He had heard her criticize herself for relapsing, and he had noted how sheepish she was when she talked about it. So it was clear to him that she knew she would be better off if she quit. He was also encouraged by that she had brought the subject up voluntarily, without his having asked. It seemed to him that the best thing to do would be to act supportive and simply ask her what her thoughts and plans were with regard to her smoking. doctor: ‘‘Sounds like you’re pretty frustrated with having started smoking again.’’ patient: ‘‘I feel like I’ve let everyone down.’’ doctor: ‘‘Remember, most people who smoke have to try several times before they really quit for good. It sounds to me like you’re on the road to quitting. You were able to remain off the cigarettes for six months, which is a very good sign of future success! So, you tried but didn’t quite make it this time. What got you started smoking again?’’ patient: ‘‘I went out with some friends who smoke and had a couple of drinks, and the next thing I knew, I was smoking.’’ doctor: ‘‘Alcohol is strongly associated with smoking for you, and for most smokers. You might want to keep that in mind and avoid alcohol, or at

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least prepare yourself, before you drink. Do you have an interest in trying to quit again?’’ patient: ‘‘I’d like to, but not right now. The stress at work is very high and sometimes I feel like I really need a cigarette.’’ doctor: ‘‘Can I ask you again next time?’’ patient: ‘‘Yes.’’

For Dr. P. this was disappointing, because he had been encouraged by K. M.’s second quit attempt. But he also realized that it was her choice. She had the relevant information, and she knew she would be better off stopping. She was also talking openly and honestly with him. The groundwork had been laid, and it was a matter of the patient making the decision. If the doctor had put pressure on her, it could have backfired, working against her taking responsibility for behaving in a healthier way. When she returned six months later, the doctor raised the issue again, as he said he would. She said she was still smoking but that she was getting ready to try quitting again. In fact, two months after that K. M. did try again, on her own. She used the over-the-counter patch again, but now she also made time to go to a behavioral support group. The doctor learned of her success when she came in for a routine pap smear, by which time she had been seven months smoke-free. Three years have since passed and she has not had a cigarette. She had internalized the motivation for quitting to a point where she initiated the process on her own terms, and she had succeeded. As is so often the case when counseling patients about smoking cessation, the first couple of years with K. M. were difficult for Dr. P., because his efforts seemed to be for naught. The first year was the hardest, because he did not understand much about motivation and the natural process of change, and therefore he was uncomfortable addressing the issue. Even the second year was tough, but at least he understood then that the pattern was typical, and he felt good that he had been able to establish an open, supportive relationship that he believed would be help K. M. in the long run. The fact that she eventually quit on her own satisfied him in an odd sort of way, because he knew that this would help her feel a sense of responsibility for stopping, which would help her maintain the motivation to abstain. In fact, patients most commonly quit smoking on their own, and this may take months or even years to accomplish after they have first broached the issue with a health care practitioner. But by providing health-related information in a supportive, nonjudgmental manner, the practitioner can increase the chances that patients will quit on their own in the future. This occurs because the information and support help patients internalize the motivation to make

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health-related choices that they will maintain over the long-term. So the practitioner will have accomplished his or her job even though the process may not be an easy one. Risk reduction through behavior change or through adherence to medication prescriptions is likely to take months or years to accomplish. But the SDT approach presented here has been confirmed with many types of behaviors, providing solid evidence that patients can change and that health care practitioners can be of help, even though it takes time. If practitioners learn to relate to patients from the perspective of seeing them as being oriented toward health and having needs for autonomy, competence, and relatedness, then patients will be more able to change unhealthy behaviors and to keep themselves healthier. The SDT approach says that healthy behavior change is most likely to come about when health care practitioners elicit their patients’ health-related goals, respect the patients’ behavioral choices when providing advice, and support the patients’ needs in a partnership. By listening to their patients’ goals and working actively to support their patients’ needs, practitioners can help facilitate the process of internalization and bring about patients’ acceptance of important health-related goals. If instead they try to control and pressure patients to change, they can undermine the patients’ motivation, leaving them feeling resistant or even rebellious. Of course, refraining from pressuring and controlling does not mean giving up, as Dr. P. did during the first year he dealt with K. M.; doing that will only lead to many missed opportunities to promote change. Facilitating behavior change is an active process on the part of the practitioner, but it must start with the patients’ experience, and must be enhanced by an ongoing, nonpressuring relationship.

6

Supporting the Internalization of Chronic Disease Management The Case of Diabetes Mellitus

In the previous chapter, we provided a concrete illustration of how to apply SDT in a clinical setting, addressing the question of how to help motivate a patient to stop smoking. In that example, the health professional was trying to support the patient’s motivation to stop doing a particular behavior: lighting up cigarettes. Because the patient was trying not to do something that she strongly wanted to do in the immediate moment, we might say that ‘‘selfdenying’’ motivation was required to successfully enact her intention. In this chapter, we consider a case in which patients need to start doing a behavior and to keep doing it over time, despite its difficulty and even aversiveness—namely, the complex behavior of self-monitoring and managing diabetes. In this example, the health professional must try to support patient motivation to do something (such as give self-injections and check blood sugars) that they may strongly want not to do in the immediate moment. Here we might say that ‘‘self-applying’’ motivation is required to enact the intention with success. These two examples of initiatives for changing behavior may seem different on the surface—one requires patients to avoid what would be a positive experience, whereas the other requires patients to approach what is often a negative experience (at least in the short term). Yet the same motivational dynamics apply in both circumstances, in that both require effective long-term

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self-regulation to obtain a potentially important health benefit. Also, in both cases, patients must muster the will to behave in a way that some part of them may not, in that present moment, want to behave. Again, self-determination theorists assert that patient motivation is best maintained at this high level when patients have accepted that change is important for them personally and ask how this acceptance process can best be forwarded. Notably, diabetes self-management may seem in some ways more involved than reducing tobacco dependence (although in other ways, eliminating tobacco dependence is even more complex, given smokers’ chronic cravings and tendencies to relapse; Fiore et al. 2000). Specifically, diabetes self-management requires patients to master much explicit information, and patients with diabetes also need to adapt by changing their diet, exercising regularly, and taking new medications, among other things. Most important, patients must learn how to continuously monitor and cope with the symptoms of the disease, not just in the short term, but also for the rest of their lives.

Case 1: Issues at the Time of Diagnosis Consider the challenges D. S., an eight-year-old boy, and his family faced when D. S. was diagnosed with Type 1 diabetes. The boy had reported feeling fatigued for six weeks. His pediatrician told his parents that D. S. was probably suffering from a prolonged viral infection. After traveling by plane to his uncle’s wedding, D. S. fainted in his hotel room. Doctors at the local emergency room informed the family that D. S. had Type 1 diabetes and that he had passed out from dehydration related to his high blood sugar (400 mg/dl). He would need to be admitted to the hospital for rehydration with intravenous fluids and stabilization of his blood sugars with insulin. D. S. and his parents struggled with the diagnosis, trying to understand, first, what they would need to do to get D. S. safely back to their home and to their usual health care providers. Right away, the parents had to take on most of the responsibility for their son’s diabetes management. They had to learn what foods they could feed him, how to check his blood glucose, and how to give him injections of insulin. They also had to learn how to look for the danger signs of high and low blood sugar. It was a lot to take in, and many strong and conflicting emotions were aroused. Before we consider the motivational issues faced by D. S., by his family, and by the health care practitioners involved in D. S.’s care, we present considerable medical information about diabetes and its effective management. Patients just diagnosed with diabetes are faced with the seemingly impossible task of mastering this information and immediately putting it into practice.

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Readers familiar with this material may wish to skip ahead to the discussion of the motivational issues. Defining diabetes. Diabetes mellitus is a chronic disease that affects about 7 percent of the American population. The two major types of diabetes result either from the failure of an individual’s pancreas to make insulin (Type 1 diabetes, 10 percent of cases) or from an individual’s having become resistant to the insulin that his or her body does produce (Type 2 diabetes, 90 percent of cases). The overwhelming risk factor for Type 2 diabetes is obesity, and as the U.S. population becomes more obese (Expert Panel on Obesity 1998), the proportion of people with diabetes is increasing (Harris et al. 1998). Insulin is a hormone that serves several important functions in the body, including its main function of facilitating the uptake of glucose from the blood into the body’s cells, where glucose is used for energy. Insulin is also necessary for the metabolism of proteins. Without insulin people develop a rapidly fatal condition called diabetic ketoacidosis. Insulin is released from the pancreas in response to even minute increases in blood sugar (glucose). Insulin is then naturally metabolized within the bloodstream. In this homeostatic manner, insulin automatically regulates humans’ blood sugar between 70 and 110 mg/dl. Patients with Type 1 diabetes, like D. S., must take insulin to survive. The insulin has to be injected because when swallowed, insulin is destroyed by stomach acid. Patients with Type 2 diabetes do not need to take insulin, because their bodies still produce insulin. However, the insulin they produce does not work effectively to reduce their blood sugar. In all forms of diabetes, the basic failure of the body to regulate its blood glucose leads to ever-higher levels of glucose. This causes a variety of shortterm and long-term negative health consequences. D. S., for instance, suffered from dehydration in the short term, because his high level of glucose (hyperglycemia) spilled into his urine. Having a high level of glucose in the urine literally pulls water from the body. When this happens patients experience greater thirst and increased hunger, but they lose weight over time even though they eat and drink more. Once blood glucose levels reach 250–400 mg/dl or higher, hyperglycemia clouds cognitive functioning, blurs vision, and fatigues patients. At the highest levels of glucose, people can lose consciousness and may even die. The long-term health consequences of unregulated hyperglycemia include blindness, kidney failure, loss of sensation in hands and feet, and increased rates of atherosclerosis that can result in heart attacks and strokes. Patients with diabetes are also predisposed to leg amputations resulting from poor circulation and foot infections. Research studies of both Type 1 (DCCT 1993) and Type 2 (U.K. Prospective

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Diabetes Study Group 1998) diabetes have demonstrated that effective glucose regulation prevents or significantly delays these long-term consequences. Unfortunately, administration of insulin and some other oral medications can at times cause the opposite short-term condition, hypoglycemia, in which there is too little (rather than too much) glucose in the blood. Hypoglycemia results in symptoms of anxiety, sweating, shaking, and even seizures, coma, or death. Because of the potential dangers of overcorrection, the patient with diabetes faces the dilemma of balancing the short-term consequences of overcontrol against the long-term consequences of undercontrol. Resolving this physiologic and motivational dilemma requires continual care and sensitivity. Diabetes-management behaviors. The general goals of therapy for Type 1 diabetics are the normalization of blood glucose and the prevention of complications from hyper or hypoglycemia (Berger and Muhlhauser 1999). Patients with diabetes need to learn several types of behaviors to regulate their blood sugar levels effectively. First, patients have to learn to regulate their caloric intake and the timing of their meals, in conjunction with their insulin dose. Three meals a day, with snacks in midmorning, midafternoon, and before bed, are needed to provide a regular source of carbohydrates to avoid hypoglycemia in the presence of insulin. Regular physical exercise can be an important part of this regimen, because exercise helps patients use up excess blood sugar. Weight loss is also a critical self-regulatory behavior for many patients with Type 2 diabetes, because weight reduction is one of the best ways to improve glucose regulation. In addition, patients with diabetes must learn to monitor their current and long-term glucose levels. Current glucose is often monitored by pricking the fingers one to four or more times per day and placing a drop of blood on a test strip that is then inserted into a glucometer. Longer-term blood glucose monitoring is done via a periodic laboratory drawn-blood test called glycosolated hemoglobin A1c (HgbA1c), which reflects the patient’s average blood glucose over the preceding two to three months. Levels of HgbA1c greater than 7 percent indicate that patients need to alter their diet or exercise or they will likely suffer the long-term complications of diabetes. Medications are needed if diet, exercise, and weight loss fail to reasonably control patient blood sugars. Of course, to survive, all patients with Type 1 diabetes need to take insulin, which can be injected under the skin with a syringe, from one to several times per day, or delivered through a needle under the skin from an insulin pump. In addition, there are several other types of medications for diabetics. Many Type 2 patients, for example, take oral medications anywhere from once to several times a day. Such medications work by enhancing insulin release from the pancreas, reducing glucose production in the liver,

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decreasing insulin resistance in the body, or preventing glucose absorption in the intestines. Patients need to learn when to take which medication. Patients can apply two global strategies in trying to normalize blood glucose, and both apply equally to taking medication, regulating diet, and exercising. The first strategy is to adopt a rigid or set schedule—trying always to eat the same things, exercise the same amount, and take the same medications, always at the same times. Alternatively, the second strategy is to adopt a more intensive regimen, with frequent checks of blood sugar and ongoing adjustments of the medication dose according to blood glucose, meal content, and activity level. In this ‘‘intensive’’ approach, patients enjoy greater variation in their diet and daily routines. There are risks, however: in the U.S.-based DCCT (1993), patients using this approach were found to experience three times the risk of hypoglycemia compared to those receiving less intensive treatment in the usual care condition. Patients who use the intensive management strategies must therefore be much more active in managing their diabetes in order to derive the potential benefits of the approach without suffering the potential consequences. Health care practitioners can offer encouragement, recommend specific diets, and prescribe new medications, but they cannot take the place of the daily if not hourly effort that this approach to the disease requires. Ultimately, this effort must be the patient’s responsibility. Patients with diabetes who want a flexible lifestyle are thus challenged to take responsibility for a variety of behaviors. That is, they must have strong ‘‘self-applying’’ motivation. In the language of SDT, this is greatly forwarded when they internalize the doing of such behaviors, enacting them with a sense of choice and self-concordance (Senecal, Nouwen, and White 2000; Sheldon and Elliot 1999; Williams, Freedman, and Deci 1998). Patients vary in how long it takes them to internalize new behaviors, but in general, as we have discussed in the previous two chapters, this process typically unfolds over a few months to two or three years. Importantly, just as personal growth is never complete, internalization processes are never complete—they must continue anew over time, in part because diseases and treatments change over time. This brings us to perhaps the most important topic of this chapter: How can the practitioner best help patients with diabetes to internalize (that is, take full responsibility for) their diabetes-management goals and behaviors? Delivering the diagnosis. Ideally, the internalization process starts at the time of diagnosis. The diagnosis of diabetes can happen in a variety of ways and settings. Diabetes can be diagnosed in the outpatient office, after patients have felt poorly for a few weeks or months. Typically the health care practitioner will check blood sugar in the office, then tell the patient that he or she has diabetes. Sometimes, however, the diagnosis is made in the emergency

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room after patients have experienced more severe symptoms, as occurred in the case of D. S. In either situation, the moment of diagnosis usually changes patients’ lives in ways that they cannot fully comprehend right away. Most people know little about diabetes other than that it is bad news. Thus, hearing they have diabetes is likely to overwhelm them emotionally and make it hard for them to absorb much of what they are told. Many patients have a sense of disbelief, that ‘‘this can’t be happening to me,’’ when they are first told they have diabetes. They cannot take in the diagnosis and its meaning, and thus they are left feeling that the disease is something external to themselves. As this description suggests, the initial encounter with the diagnosis can be crucial in establishing a patient’s long-term motivation for self-management. Practitioners can greatly facilitate their patients’ acceptance of diabetes as a real part of themselves by supporting their patients’ psychological needs (as we discuss below). Alternatively, practitioners may inhibit the internalization process by acting in a controlling, distanced, or impatient manner at the time of diagnosis. In these cases, the patient may leave the office still feeling overwhelmed by the diagnosis and helpless about what to do. Sometimes patients develop a sense of disbelief about the diagnosis and then actively deny that they have the disease for weeks or even months. Again, self-determination theory postulates that the practitioner’s support of three specific psychological needs facilitates internalization: autonomy, competence, and relatedness. Facilitating autonomous motivation occurs when practitioners elicit and acknowledge their patients’ perspective of the disease, provide choices of effective treatment options, offer sound explanations if they disagree with how patients want to do things, and minimize control. We have discussed these dynamics extensively discussed in previous chapters and will consider them further below. Competence support encompasses teaching patients how to execute the tasks of diabetes management, including how to adopt an appropriate diet, how to interpret tests (such as finger stick glucoses and HgbA1c), and how to adjust medication dosage. Most of this competence training is provided in the American Diabetes Association guidelines for self-management of diabetes (Task Force on the National Standards for Diabetes Self-Management Education 2000). Competence support also concerns practitioners’ demonstrating confidence that patients can successfully manage their diabetes, at least most of the time. Last, relatedness support concerns giving patients unconditional positive regard and helping them get the support they need from important others, such as parents, spouses, and other family members. For example, in the context of diabetes management, this can mean developing a working alliance with a

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spouse or parent who does the cooking and making sure that they have access to the necessary dietary training. The three needs postulated by SDT are salient at the time of diagnosis. Let us now consider how the diagnosis affected D. S. and his family’s sense of autonomy, competence, and relatedness before moving on to consider how the health care practitioners dealt with these needs. The diagnosis certainly threatened D. S. and his family’s autonomy needs. At first, they experienced the diagnosis of diabetes as an alien intrusion, with a strong controlling impact on all their lives. It would force them to cope, in ways they could barely imagine, for years to come! To begin to mobilize the long-term motivation to deal with the disease, D. S. and his parents first had to begin to internalize the personal meaning of the diagnosis. More generally, patients must learn to ‘‘take the diagnosis in’’ to their sense of self, to ‘‘own’’ it, so that they can respond autonomously. Feelings of competence are also low at the time of diagnosis, and therefore health care practitioners should expect that patients and their families will need special training and confidence-boosting. As an eight-year-old, D. S. had never been in a hospital before and knew little about medical treatments of any kind, let alone diabetes. He was understandably apprehensive and anxious. His mother and father had some knowledge of diabetes, but neither parent had direct experience with the treatments. Both parents were worried that they might make a catastrophic mistake or oversight. Until they could start to feel a sense of competence about managing the disease, they felt helpless and depressed. Last, the diabetes threatened D. S.’s relationship with his family in the most fundamental way. The boy’s collapse, admission to the hospital, and need for intravenous fluids and insulin indicated his vulnerability and mortality. Perhaps they would lose him! In addition, he was away from familiar medical care. Thus, he and his family would have to consult health care practitioners they didn’t know and would have to trust in their care. At the same time, however, the closeness of his immediate family provided some comfort, and the diagnosis brought them closer together emotionally. Other aspects of relatedness need-satisfaction were also present. For example, although the context of the wedding created background stress, it also provided the presence of extended family members who could offer additional emotional and financial support. Overall, then, D. S.’s needs for relatedness were reasonably well supported. In contrast, many new diabetes patients, especially adults living on their own, may lack the immediate support of family or close friends. D. S.’s parents began trying to learn what they could about diabetes. The health care team needed to support the family’s needs for autonomy,

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competence, and relatedness during this process in order to promote acceptance of the disease and the development of knowledge and skills for managing the disease. The following paragraph describes what actually happened. The family was told that D. S. would need to be started on intravenous insulin. He had never had an IV before, and he didn’t want it. The parents asked if D. S. could use oral medications rather than insulin to avoid the IV and perhaps also to avoid the later need for injections. The doctor listened carefully to what each family member said and then inquired if D. S. was anxious about the IV and needles. ‘‘Does it feel scary to think of having an IV put in your arm?’’ D. S. nodded. ‘‘Unfortunately, D., the IV is necessary to give you back the fluids you lost because of the high blood sugar, and also to provide you with insulin. Without these, your body can’t recover. There is some pain when the needle is put in, but that goes away quickly.’’ Turning to the parents, the doctor explained, ‘‘Type 1 diabetes results from the patient not having any insulin. Because insulin is necessary for breaking down proteins and for keeping acid from building up in the blood, it’s critical for D. S., and all patients with Type 1 diabetes, to have insulin as part of his current and longterm treatment. Patients with Type 2 diabetes can take pills to manage their blood sugar because they have their own insulin. However, D. S.’s pancreas has stopped making insulin. I would like to be able to offer a pill, but unfortunately, insulin cannot be taken in pill form. Therefore, we have to use injections. Do you have questions about what I have gone over about D. S.’s diabetes?’’ D. S.’s parents said they understood, and even D. S. accepted the need for the treatment. But they had several more questions to ask. At this point, it was important for the physician to encourage D. S. and his parents to keep asking questions, because these questions reflected the family’s innate motivation for health. Attempts to dismiss their questions or to limit the process would have tended to suppress this healthy coping response. Importantly, being autonomy supportive in such a case often involves the provider’s not only answering but also proactively evoking questions from the patient. Many times patients are too stunned by the diagnosis to think of all the important issues they need to consider, and they can benefit from a provider who prompts them to bring relevant questions to mind. Addressing reservations and fears during the interview minimizes the chance that lingering concerns will undermine the patient’s motivation away from the practitioner’s office. In the conversation described above, the important initial point of agreement between the doctor and D. S.’s parents was the common goal of improving D. S.’s health. Both sides endorsed this goal; they simply had different methods in mind for achieving the goal. What ensued was a negotiation, in

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which the doctor conveyed his knowledge and opinion while simultaneously answering all questions. Ideally, he would also support the patient’s preferences as much as possible. In this case, however, it was not appropriate for the physician to support the parents in their wish to use noninsulin therapies for D. S.; the family needed to understand that this was not a viable treatment option. As such unpleasant information is given, it is very important that practitioners listen carefully, answering questions and providing a clear rationale for rejecting their patients’ desired alternatives. Once the rationale has been provided, practitioners need to check back to see if it was accepted. The rationalegiving and checking-back provisions inform patients and minimize the chance that they will be left with a perception of being controlled, blamed, or misunderstood by their practitioners. Again, such lingering feelings may undermine the initial aspect of internalization. Using reflection to enhance internalization. If D. S. or his family had not been accepting of the doctor’s rationale for the need for insulin, he could have employed the technique of reflection (Miller and Rollnick 1991; Rollnick, Mason, and Butler 1999). Reflection of people’s responses can come in several forms: simple reflections, summary reflections, amplified reflections, and double-sided reflections. All forms of reflection involve the practitioner’s repeating part or most of the person’s words back to the person. For example, a simple reflection merely restates the person’s most recent comment. If D. S.’s father had said: ‘‘I don’t feel D. S. should have insulin until you see if the pills will work first,’’ a simple reflection might be: ‘‘You feel D. S. should have a trial of pills first before he gets insulin.’’ This restatement allows the speaker to know that he or she has been heard. As its name implies, a summary reflection is intended to present what practitioners have heard over a longer period of time while also putting it into a light that may enable patients to better recognize and perhaps clarify their responses and feelings. Summary reflections start after patients have been encouraged to complete what they want to say. For example, after listening to D. S., the attending physician said: ‘‘What I have heard you say is that you are nervous about this diagnosis because you are afraid of needles and because having to inject yourself with insulin makes you think of yourself as sick. That’s natural—most people with diabetes have to live with it a while and see that they can be healthy before they get used to taking the insulin.’’ Here, in addition to acknowledging D. S.’s feelings, the physician also tried to use this ‘‘teachable moment’’ to gently let D. S. know that it is normal to have these strong feelings about having diabetes and needing to take insulin. In addition, he can expect to get used to taking the insulin and learn to see himself as

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healthy even with diabetes. This reflection likely helped forward the internalization process. Another important acknowledgment technique is a double-sided reflection. If patients report mixed feelings, such as ‘‘It is a relief to finally know why I have been feeling so sick,’’ and later, ‘‘I am afraid of the bad things that can happen with diabetes,’’ practitioners can contrast the statements with each other. The response might go like this: ‘‘So, on the one hand I hear that you have had some relief by knowing what is wrong, and on the other hand you are fearful of what might happen because of the diabetes. It’s natural for patients with diabetes to have both of these responses.’’ This technique can help patients to integrate different facets of the new information while they are becoming aware of their emotional responses to it. When people are distraught, practitioners might try an amplified reflection, wherein they reflect and exaggerate the intensity of the patient’s emotion. An example of an amplified reflection might be, ‘‘So, what I have heard you say is that injecting insulin terrifies you so much you would feel better just avoiding the insulin no matter what the result.’’ Reflecting in this exaggerated manner often helps people hear the intensity and perhaps irrationality of their emotional response, putting them in a more autonomous position to decide if they want to allow these intense emotions to dictate their behavior. This can help them gain better control of their emotions. Each of these four methods— simple reflection, summary reflection, double-sided reflection, and amplified reflection—are part of ‘‘motivational interviewing’’ (Miller and Rollnick 1991), a set of techniques that is quite consistent with SDT. These techniques help patients to feel empowered by their caretakers, thus supporting patients’ autonomy needs and promoting internalization. In addition to offering these communicative elements of autonomy support, the sensitive staff at the hospital also helped D. S. and his family by attempting to maximize their choice in other areas. For example, when D. S.’s date of discharge and return home came up, the health care team told the family that he could go home in about three days, at the soonest. However, since D. S. had relatives in the area, the staff offered him the choice of staying in the area longer, for the course of his initial diabetes teaching. Other choices were outlined for the future. Although the practitioner recommended using a fixed insulin regimen until they got home, he told D. S.’s parents that they could consider learning a flexible insulin regimen once things stabilized after they had returned home. They also discussed possible use of the insulin pump, once D. S. grew older. In this manner, discussion of future options helped D. S. and his parents accept the current limitations. Notably, none of the latter ‘‘choices’’ were crucial to the medical outcome

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for D. S.—all were viable treatment options. Yet by providing this important element of autonomy support, the health care team jump-started the internalization process, for D. S. and his family. Thus, after returning home, D. S. quickly transitioned to a flexible management regime. He and his family soon learned to follow a diabetes diet and how to count calories in a meal. It wasn’t long before D. S.’s younger sisters were identifying the number of ‘‘carbos’’ in their own food and reminding D. S. to count his, too! D. S. is seventeen now, playing football and basketball, managing his diabetes with a pump, and making plans for college, and he has traveled to Europe with his high school class, all without complications of his diabetes.

Case 2: Issues with Less Motivated Patients Consider now the case of a second patient who does not have all the need supports that D. S. and his family had. C. L. is a fifty-year-old separated African-American woman who had been a patient of Dr. W. for six years. Two years before the events described here she suffered from acute back pain, which disabled her from her job as a nurse’s aide. She also had a history of major depression, asthma, iron deficiency anemia, headaches, and nicotine dependence. Her mother has diabetes and suffered a stroke several years ago. During a routine checkup, C. L. reported having fatigue and shortness of breath going up stairs, and she complained of a mild increase in thirst. She reported that she smoked two to three packs of cigarettes per day but agreed to quit smoking. She also agreed to go for lab tests and to return for a more thorough physical exam in two weeks’ time. Later that week, the lab tests showed that C. L. had a high fasting blood sugar score of 136, a low red blood count (signifying iron deficiency anemia), and very high cholesterol. Thus, when she returned for her physical exam, Dr. W. needed to deliver three new diagnoses—diabetes, anemia, and high cholesterol. At that time C. L. admitted to Dr. W. that she was still smoking and that her asthma was acting up, too. It was apparent that C. L. was overwhelmed by all of this information. Her doctor acknowledged that she seemed anxious and went slowly over the information. He emphasized that although none of these diagnoses were medical emergencies, it was important to get them under control, because in combination, they could act to cause long-term vascular problems (such as heart attacks, strokes, and kidney failure). Because she had smoked for years, and he didn’t know how long her cholesterol had been elevated or how long she had had diabetes, he recommended starting therapy for these problems as soon as possible.

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Doctor W. first asked C. L. to go for dietary training, which would help her control her diabetes and elevated cholesterol. Until she was able to meet with the dietician, he asked her to avoid concentrated sweets, gave her a basic diabetes diet to follow, and asked her to get her blood sugars checked at the lab until she could learn to test herself. The anemia was probably caused by blood loss from her menstrual cycles, but she would need gastrointestinal tests as well. He recommended that she start on iron pills three times per day and that she see her gynecologist. In a week C. L. returned to see Dr. W. Before the visit he had received a note from the diabetes center, informing him that C. L. had been taught to check her glucose once a day. However, the note also mentioned that C. L. had stopped taking her iron tablets because she felt that they made her nauseated. During her office visit, Dr. W. asked C. L. about this, and they agreed that she would resume the iron medication at a lower dose to see if that relieved the nausea. Using mutual agenda setting. Feeling that C. L. had been overloaded by all her recent diagnoses, Dr. W. started her next appointment with an agenda setting technique, intended to increase her sense of competence as well as her autonomous motivation for self-care (Rollnick, Mason, and Butler 1999). Mutual agenda setting is particularly important in a busy primary care medical practice, in which patients like C. L. have several active issues at once. The technique can be used in all settings, however. The goal is to explicitly incorporate both the patient’s and the practitioner’s agendas into the current encounter, at the start of the session. Before entering the room, Dr. W. reviewed C. L.’s chart and identified three issues he wished to discuss (her symptoms of fatigue and thirst, her blood sugar results, and any side effects from her new medications). He then drew six circles on a blank page and wrote these topics in three of them, leaving the other circles blank. After greeting her, he showed her the paper and asked her to indicate the topics she wished to discuss. She said that she wanted to talk about her visit to her gynecologist and to know why she also had to go for gastrointestinal tests for the anemia. After writing these two topics in the circles, Dr. W reviewed all five circled topics. This process established each of their agendas at the beginning of the visit. Engaging in mutual agenda setting facilitates patients’ autonomous participation in their care. Writing down the list acknowledges patients’ perspectives and demonstrates that the practitioner is also contributing ideas. This is likely to support patient-practitioner care partnerships, enhance patient autonomy and competence, and minimize patients’ perceptions of being controlled. As will be shown below, all five items on C. L.’s and Dr. W.’s agenda were covered

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during this visit. It is often not possible to cover all the items in the allotted time. If this happens, a solution is to agree to discuss one or two of the topics in another appointment. C. L. reported that her gynecologist had identified fibroids and had recommended that she have a hysterectomy. Doctor W. asked how she felt about that, and she said that she was anxious about the operation but also relieved to know why she had been feeling so poorly. At this point, Dr. W. employed a double-sided reflection: ‘‘So, on the one hand, the operation makes you nervous, and on the other hand, you’re feeling better because your fatigue will lessen, and the operation will stop the blood loss.’’ C. L. nodded, then asked why she needed to go for a colonoscopy, if they already knew the source of her anemia? The doctor explained that she was fifty now and would need screening for colon cancer anyway; the more important reason in this case, however, was that they needed to be sure there was not a colon cancer contributing to her anemia. He asked how she felt about having the procedure. She didn’t like the idea very much, but she agreed to have the test. Now that C. L.’s agenda items had been addressed, the discussion turned to Dr. W.’s agenda. C. L. reported that she wasn’t experiencing fatigue or side effects from her medications, that her increased thirst was nearly gone, and that she was checking her blood sugars. When asked for the readings, however, she admitted that she hadn’t really been checking her glucose because she hadn’t learned how to do it well enough. Doctor W. said that learning to monitor her glucose was an important step in her being able to manage her diabetes and asked her to return to the diabetes center for a refresher course. Both parties left the encounter with a sense that it had been productive. Three weeks later (two months from her initial diagnosis of diabetes), C. L. came to Dr. W.’s office with chest pain that resolved quickly after she took nitroglycerin. She was admitted to the hospital, where a heart attack was ruled out and a cardiac angiogram revealed normal coronary arteries. In retrospect, her chest pain was most likely a combination of anxiety (panic) and gastroesophageal reflux (heartburn). Doctor W. felt that C. L.’s several new diagnoses had made her very anxious, which resulted in her chest pain. In other words, he believed that C. L.’s inability to internalize all of this negative health information in such a short time contributed to her symptoms. This was just too much to manage for a relatively unskilled person, lacking in family support. Things did improve while she was in the hospital. Her blood glucoses and HgbA1c (5.8 percent) became essentially normal on the hospital diet, her anemia improved, her heartburn resolved with treatment, and her cholesterol was now at the recommended level. After discharge, she underwent elective hysterectomy for fibroids without complication.

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Two months later, C. L. noticed that her vision was blurry. She made two visits to her optometrist, receiving changes in her prescription for her glasses. However, her vision did not improve. She came back to Dr. W.’s office after noticing increased thirst, the need for frequent urination, and continued blurred vision. Her office blood glucose was 410 mg/dl. She revealed that she had stopped checking her glucoses at home because it was hard to read the glucometer and because she had perceived her levels to be ‘‘normal so often’’ that she didn’t feel it was important. Her new glasses just weren’t helping her see the food labels, nor could she read the results of her glucose tests. Doctor W. explained the link between elevated glucose and her blurry vision, pointing out that until her sugars came down much closer to normal, her vision was unlikely to improve no matter how many times she had her glasses changed. Using patient ratings of motivation. Because C. L. had again reported not checking her blood sugars, her doctor decided to talk to her explicitly about her motivation for diabetes self-regulation. In addition to perhaps identifying conflicts or blockages, he felt that this approach might facilitate further internalization, by helping C. L. to find more autonomous reasons for managing her diabetes. To begin, Dr. W. asked C. L. to rate how motivated she was to manage her diabetes, on a scale of 1 to 10 (1 = not at all, 10 = extremely motivated). She answered, ‘‘3.’’ He then asked her, ‘‘Why didn’t you say ‘1’ or ‘2’?’’ She replied that deep down she knew she wanted to stay healthy to see her grandson grow up. In this way she had identified an autonomous reason for managing her diabetes. Reflecting this back, he said: ‘‘So, seeing your grandson grow up is very important to you.’’ Then, in order to understand what might have been undermining her motivation, he asked, ‘‘What keeps you from being an 8 or 9 in your motivation?’’ She said that she got anxious when she thought about what the disease had done to her mother. Also, she sometimes resented all the doctors telling her what to do. Because both of these responses represent nonautonomous or ‘‘controlled’’ motives, she found that she often gave in to the temptation not to think about her diabetes. Doctor W. responded: ‘‘What has happened to your mother is sad and understandably frightening for you. I am sorry to hear about your mother’s condition. But, I want you to know we have come a long way in our ability to prevent those kinds of complications from diabetes. Also, please remember that the medical staff is not trying to ‘boss’ you, but rather is just trying to help you with an understandably difficult problem.’’ C. L. thanked Dr. W. for his efforts. This numerical technique gave both C. L. and Dr. W. the chance to reflect concretely on her underlying motivations. Further, the follow-up questions

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and reflections gave her a chance to understand why she felt the way she did. It was important for the practitioner to listen nonjudgmentally throughout and reflect back her answers as much as possible. This gave the patient the opportunity to take more personal responsibility for her behaviors and for the regulation of her emotions rather than having to deny her diabetes in order to feel okay. Still, one week later C. L. missed her appointment. The doctor called her to set another appointment and to find out why she hadn’t come in. She said that she had decided she really didn’t think her diabetes was that bad compared to her other problems and that she thought it would just go away if she ignored it. At this point Dr. W. recognized that C. L. had never really internalized her diagnosis of diabetes, in spite of his efforts to facilitate her autonomy. She was afraid of what diabetes had done to her mother, and she continued to feel overwhelmed and resentful regarding her surgeries and medical problems in general. Her diabetes, with its greater long-term threat potential, was easy to overlook amid these other problems. Because she tended to come in only when there was some type of crisis, she and Dr. W. had never completely discussed her diabetes. Although Dr. W. had not ignored her, he had not taken the time to understand fully that she believed the diabetes might simply go away by itself. Before their next appointment, Dr. W. reassessed each of C. L.’s motivational needs, trying to think of additional ways he could support her internalization of self-management behaviors, enhance her sense of competence about these behaviors, and improve their relationship. It occurred to him that he really didn’t understand C. L.’s broader goals and views about her own life, nor did he understand how diabetes was affecting her day-to-day activities. He decided to spend a little time during the next visit to learn more about her values. He felt that this would give him further opportunity to support her autonomy needs and perhaps to deepen their relationship. Using values exploration. Doctor W. began by asking C. L. to identify her most important life goals. Specifically, he asked: ‘‘On a day-to-day basis, what are the things you most want in your life? What are you striving to do?’’ She reported that she wanted to stay healthy, to avoid her mother’s health difficulties, to go back to school so that she could retrain herself and return to work, and to see her grandson grow up. After she had identified this set of strivings, Dr. W. said them back to her in a summary reflection and asked if he had gotten them right. She said, ‘‘Yes.’’ He then asked how the diabetes, and the process of caring for the disease, affected her ability to reach those goals. She acknowledged that the diabetes was getting much harder to ignore and

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that her poor vision was preventing her from completing her application form for school, and she was worried that she might end up too sick to enjoy seeing her grandson. Doctor W. felt good about this conversation because he realized that understanding C. L.’s goals, and how her diabetes was affecting her, allowed him more fully to hear and acknowledge her real perspective. He could tell that C. L. was also feeling more receptive. He thus offered the following suggestion: ‘‘I have an idea that if you choose to get more involved in your diabetes care, then your vision will improve enough so you can complete your application for school. Keeping your sugars lower will also improve your long-term health, and help you avoid some of the unfortunate complications your mother experienced. We have learned a lot more about how patients like yourself can maintain their health and live very happy lives, but it takes some active involvement on your part. Do you think you are ready to give it a try?’’ C. L. agreed, saying that she was ready to learn to check her blood sugars and take her medication, even though doing so sometimes annoyed her, made her anxious, or made her think about her mother. Doctor W. acknowledged her new resolve and again emphasized that, by using this ongoing blood-sugar information as valuable feedback with which to guide her self-care efforts, she should be able to dramatically improve her condition. Providing feedback. The idea of feedback is worthy of additional consideration. The concept was created by the rocket industry in the 1940s to describe the process by which updated information is fed back to a rocket’s guidance system while in flight, so that the rocket can make midcourse adjustments to hit its target. In managing a chronic disease like diabetes, receiving accurate and appropriate feedback is similarly crucial so that the person can make the many midcourse adjustments needed to hit the target of long-term health. Even more important, perhaps, practitioners need to learn to provide this feedback in a manner that supports patients’ motivation to use the information. People, of course, are not rockets. C. L., for example, is sensitive to control and criticism by powerful peers, parental figures, and external authorities. Because her practitioner could be perceived in one or more of these ways, C. L. might easily interpret his presentation of feedback as criticism or his opinions as unquestionable dictates. When feeling controlled, she is less likely to ask questions or for clarification, or worse yet, she might simply not come for her appointments. Therefore, Dr. W. tries to present feedback in a manner that minimizes the chance that patients will hear it as criticism or control. In the case of C. L., he first had to teach her about the targets of her efforts: what the healthy levels of

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Table 7. Contrasting autonomy-supportive and controlling behaviors Autonomy supportive

Behaviorally controlling

Listening Remaining nonjudgmental Encouraging initiative and responsibility Offering a menu of options Providing a rationale for behavior

Interrupting Making value judgments Demanding change Selecting goals Applying pressure or arguing

glucose and HgbA1c are (70–110 mg/dl and up to 7 percent, respectively) and how often most patients with diabetes need to check these to stay healthy. Then he acknowledged that it is hard for many people to check their blood glucoses. He pointed out that people usually have to try several times before they can do it regularly, just as C. L. had made several aborted efforts. Again, did she now think she could do this regularly? ‘‘Yes,’’ she said, ‘‘and I’m glad to know that I’m not the only one who has problems doing this.’’ In addition, Dr. W. told C. L. that he wanted to make a habit of reviewing her recent self-test results early in every visit to allow adequate time for discussion and planning changes. In particular, giving feedback early in the interview gave Dr. W. time to elicit C. L.’s perspective on the test results, to acknowledge her emotions, and to discuss all the options for change with her. Because she had adequate time to assimilate the meaning of feedback, C. L.’s sense of being controlled by the information was likely to decrease. In short, by attending carefully to how they give patients feedback, practitioners will find many teachable moments, in which patients are ready to learn a new skill or accept a new level of responsibility. These behaviors are consistent with the concept of autonomy support as described throughout this book and are formally listed in table 7 below, as contrasted with controlling behaviors. To summarize, we have recommended a series of autonomy-supportive behaviors that help keep patients’ psychological needs at the center of clinical encounters. These practitioner behaviors include: listening carefully to patients, giving them choices of effective treatment options, and acknowledging their emotions and perspectives (perhaps by using summary reflections, doublesided reflections, or amplified reflections). Also, most patients can benefit when practitioners engage their patients in values exploration, mutual agenda setting, and/or eliciting statements of their autonomous motivation. Notably, however, these tools or techniques are especially useful with patients who miss

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Table 8. Common interviewing techniques and the needs they support Interviewing technique Reflection Simple Summary Amplified Double-sided Feedback

Values exploration Mutual agenda setting

Eliciting patient ratings of autonomous motivation

Aspect of autonomy support

Psychological need support

Listening, acknowledging, nonjudgmental, encouraging patient initiative

Autonomy Relatedness

Nonjudgmental, encouraging patient initiative, providing rationale for behavior

Competence Autonomy Relatedness Autonomy Relatedness Autonomy Competence Relatedness

Listening, acknowledging, nonjudgmental, encouraging patient initiative Listening, acknowledging, nonjudgmental, encouraging patient initiative, providing menu of options, providing rationale for behavior Listening, acknowledging, nonjudgmental, encouraging patient initiative, providing rationale for behavior

Autonomy Competence Relatedness

appointments, don’t bring their glucose records, are not checking their glucoses, or report stopping their medications. The interviewing techniques that support patients’ motivational needs are summarized in table 8. C. L. has continued to make progress. Her glucose control has improved to the point where she is not symptomatic, and her HgbA1c has moved down to 8.1 percent. Nevertheless, C. L. will always be vulnerable to states of low motivation, because in general, her personality or motivational style is more controlled or amotivated than it is autonomous. Greater fluctuation in her glucose control as well as in her appointment keeping are thus to be expected. Indeed, C. L.’s case reflects an undeniable reality—that practitioners will encounter many patients who struggle, despite their practitioner’s best efforts to help them develop autonomous motivation. Although as many as 30 percent of patients may fall into this category, the important point is that practitioners should not stop making the effort to uncover and support their patients’ autonomy and initiative (Ciechanowski et al. 2001). For C. L., the best clinical outcomes have always come when her practitioner was able to see things from her perspective and was ready to support her initiatives.

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In contrast to C. L., other patients can be highly motivated from the outset. The final case example will focus on such a highly motivated patient. In situations such as this, it is tempting for practitioners to be less involved in treatment. However, such patients also need their practitioners to be actively involved in order to maximize positive clinical outcomes.

Case 3: Issues with Highly Motivated Patients F. D. is a fifty-year-old white married male who works as an optometrist. He was unaware of any significant medical problems before the day he was diagnosed with diabetes. On that day, he developed chest pain while raking leaves in his yard. He drove himself to the emergency center. He was admitted to the hospital for tests to determine whether he had had a heart attack. The blood tests showed a rise in the proteins from his heart, which indicated that he was indeed having a heart attack. His blood sugar and cholesterol were also found to be very high. He did not smoke, but his father had had a heart attack at the age of fifty-seven. His total cholesterol had been healthy (TC = 196 mg/dl) five years earlier but had now risen to 286, and he had a low protective fraction of high-density lipoproteins (HDL = 26 mg/dl). His regular physician didn’t admit to this hospital, and so Dr. L. was assigned to be his physician. The doctor introduced himself to F. D. and his family in the intensive care unit, knowing that they had a lot of territory to cover in terms of establishing a relationship and discussing F. D.’s diagnoses and prognosis. After the introductions, Dr. L. asked how F. D. was feeling now. He indicated that he was nervous about the chest pain and whether he might be having a heart attack. The doctor acknowledged his anxiety and told him that the tests were back and confirmed that he had indeed had a heart attack. He and his wife appeared surprised, and the doctor answered their questions as well as he could about the extent of the heart attack and what would likely happen next. When the questions stopped, Dr. L. asked F. D. if he remembered having any symptoms before that day. He said that he had felt well, except for some fatigue and a mild increase in thirst over the past few weeks. Doctor L. then told F. D. that he had diabetes and that his cholesterol was also quite high. The patient and his family were astonished by all these diagnoses. They had many questions about how all of this could have happened at once, when they had perceived him as being so healthy. But after thinking back on how he had been feeling over the past few weeks (some thirst and increased urination) and on some recent weight loss, F. D. began to see the signs that he had overlooked. The doctor explained that, for many people, glucose intolerance (the

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precursor to diabetes) can be present for many years with few or no symptoms of diabetes. These years of glucose intolerance promote elevated cholesterol as well as the formation of cholesterol plaques in the coronary arteries that come with age and being male. His combination of low HDL-C (the protective type of cholesterol), high LDL-C, and diabetes had interacted to cause rather extensive vascular disease. Such blockages often do not produce any symptoms before the initial heart attack. In the next two days, cardiac catheterization revealed that F. D. had significant narrowing in two of his coronary arteries. He was placed on daily medications of aspirin, a beta-blocker (to prevent further heart attacks), and atorvastatin (a medication to lower his cholesterol). Plans were made to transfer him to another hospital for coronary angioplasty and stenting to open the blockages that would improve blood flow to his heart. However, F. D. asked to continue his outpatient care with Dr. L. In addition to agreeing to the angioplasty, F. D. also agreed to start an oral medication for his diabetes (glyburide), arranged for the family to go for diabetes education, and received information on a cholesterol-lowering diet. Ten days after his angioplasty, F. D. came to his first follow-up appointment. He had already changed his dietary and exercise patterns, he was monitoring his glucose several times a day, and he was taking his medications regularly. He was walking fifteen to twenty miles per week and had already lost six to eight pounds. Within three months of receiving the diagnosis, F. D. was twentyseven pounds lighter. His fasting home blood glucoses had essentially normalized (85–133 mg/dl). His HgbA1c had come down from 9.0 to 7.3 within the first month, and had normalized within three months of his diagnosis. His total cholesterol had come down from 282 to 127 mg/dl, and his LDL-C was now below the desired level of 100 mg/dl. Obviously, F. D. was very motivated to become as healthy as he could. Agenda setting to address the multiple issues that needed management and establishing a pattern of providing clear feedback were two aspects of autonomy support that Dr. L. employed at their first follow-up visit. In other words, he and F. D. spent considerable time reviewing their mutual concerns, at the same time considering the meaning of the test results and establishing the appropriate timing of tests. During another follow-up visit, Dr. L. learned that F. D. had had two hypoglycemic (low blood sugar) episodes since he had been discharged. It seemed to Dr. L. that F. D., in his enthusiasm to lose weight, had reduced his calorie intake so much that his diabetes medication had begun working too well. Doctor L. explained that low blood sugar should be avoided if possible be-

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cause it could cause another heart attack, and they agreed that F. D. would lower the dose of his medication. In short, Dr. L. and F. D. quickly formed a partnership, with F. D. taking the lead in day-to-day self-care but relying on Dr. L. for help in formulating a broader plan and in problem-solving when difficulties arose. During this time F. D. came to all of his outpatient appointments and called at other times. He brought all of his glucose and some blood pressure readings along. He spontaneously talked about the importance of his health in terms of his family and professional life—that is, in these discussions he essentially conducted his own values exploration. In a further illustration of F. D.’s high level of involvement, he wrote Dr. L. a letter less than two months after his diagnosis indicating that he had noticed his midmorning blood sugar was rising as high as 200 mg/dl after eating a particular cereal. He had changed to a multigrain cereal and found the readings no longer went higher than 150 mg/dl. Most physicians would love to have more patients like F. D.! In spite of all his efforts, six months after his heart attack, F. D. developed chest pain again. Fortunately, he did not have a heart attack this time, but an angiogram found 90 percent re-stenosis of the same two arteries around his heart. This occurred even though F. D.’s Hgba1c had normalized and his cholesterol was at the recommended goal range, and he was twenty-eight pounds below his weight at the time of his heart attack. Unfortunately, even patients who perfectly follow medical advice suffer setbacks. He was admitted for coronary artery bypass grafting, underwent cardiac rehabilitation over eight weeks, and returned to work soon thereafter. At one point F. D. told Dr. L. that he felt very down about needing the surgery in spite of all he his efforts. Doctor L. explored his feelings of frustration and the fear that accompanied his surgery. He assured F. D. that he had done everything he could have to improve his health. He then reframed F. D.’s concerns, indicating that easily a third of the people who have angioplasty also have recurring arterial blockages around the heart within six months. He added, however, that only a minority of people are able to maintain the kind of lifestyle changes F. D. had achieved and that those changes would pay off, providing substantial protection from further heart attacks within twelve to eighteen months after the first heart attack. They discussed depression and the importance of addressing it after someone is diagnosed with heart disease. F. D. said that he felt somewhat better and chose not to start taking antidepressants but thought that he might try them later if he stayed blue. As can be seen here, even in the case of a highly motivated patient, providing autonomy-supportive care (that is, eliciting patient perspectives, offering as

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much choice as possible, and providing a meaningful rationale when choice is not possible) is important. Offering F. D. a choice regarding antidepressants was instrumental in keeping F. D.’s motivation high, because it allowed him to autonomously endorse the idea that for now he really didn’t need to start taking them. Three years after his heart attack, F. D. has maintained his cholesterol and HgbA1c in the healthy range. He has kept all his appointments and has maintained his weight loss. His hypoglycemic episodes have largely disappeared. He and Dr. L. meet regularly, about three times per year, to review his test results. F. D. knows the meaning of the tests as well as his doctor does. Because of all he has done, he is now experiencing the protective effects of these treatments. The similarities in the medical circumstances of F. D. and C. L. are instructive. These two patients each had multiple diagnoses made at the same time that they learned they had diabetes. Both had chest pain, and both had high cholesterol. Both patients thus had a lot of new information to ‘‘take in.’’ Yet there were significant differences between them, too. For example, F. D. had a heart attack and required bypass surgery, whereas C. L. did not. This might have motivated him to manage his diabetes more vigorously than her. Another difference was that F. D. has multiple additional supports from his family, his employment, and society that C. L. lacks. Further, he has a higher socioeconomic status and is more highly educated. Perhaps in part because of these differences, F. D. has internalized the motivation for managing his diabetes far more than C. L. Whereas F. D. quickly accepted that his long-term health depended on the extent to which he took responsibility for regulating his diet, exercise, and glucose, C. L. still hoped that her diabetes might simply go away over time. These represent two extreme cases of individuals who have developed Type 2 diabetes, and they illustrate the disparity of motivation that practitioners will encounter. The basic things that practitioners need to do remain the same either way. In either kind of case, patients will have better outcomes if their practitioners try to clearly understand their values and goals and to support patients’ ideas and initiatives. It is important to invite patients to learn the meaning of their test results and to give them regular feedback so that they can join their practitioners in evaluating the success or failure of their joint attempts to manage diabetes. Practitioners, moreover, need to create a caring environment to which patients can return whether or not they succeed. Still, despite these commonalities, there are also important differences in how practitioners need to treat these two types of patients. Because C. L. has fewer resources for social and interpersonal support than does F. D., Dr. W.

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needed to be especially attentive to C. L.’s needs for relatedness. In addition, C. L.’s suppressed needs for autonomy required close attention. Unlike F. D., C. L. does not have an autonomy-oriented personality style. It thus appears that C. L. had further to go than F. D. in terms of internalizing and accepting responsibility for her behavior. Because of these factors, C. L. is clearly a ‘‘needier’’ patient than F. D. The important point, however, is that a patient’s growth process cannot be forwarded via overtly critical or controlling behaviors on the practitioner’s part, no matter how frustrated he or she may become at the patient’s progress. As we discussed in Chapter 3, there is almost no empirical support for a ‘‘matching’’ hypothesis, such that control-oriented or amotivated people benefit most from being treated in a controlling manner. In the long term, all patients do best when they are invited, rather than pressured, to take responsibility for themselves. In this chapter, we have discussed SDT-based principles regarding ways health care practitioners can interact with their patients with diabetes to facilitate healthier and more satisfying outcomes. Patients must monitor the chronic aspects of diabetes themselves (with appropriate clinical support). The important targets of the practitioner’s behavior are to facilitate patients’ autonomous motivation for their own care while refining their skills for doing so and enhancing patients’ sense of acceptance by and partnership with the practitioner. This is true regardless of the patient’s personality style, the severity of the patient’s disease, and the patient’s level of past success in managing the disease. These considerations are especially important at such sensitive periods as initial diagnosis and feedback provision, times that provide difficult but also very motivating moments.

P A R T

Self-Determination Theory Applied to Mental Health Practice

III

7

Self-Determination Theory and Mental Health

Something’s gone awry in the area of clinical psychology, and it seems to boil down to one thing: clinical scientists and clinical practitioners often fail to listen to one another. This would astound and disappoint early figures in the history of clinical psychology. In describing Morton Prince, who founded the Journal of Abnormal Psychology in 1906, for example, R. W. White states, ‘‘He began to realize that it was impossible to think of abnormal psychology as a free-standing body of knowledge. Logically, it implied an accepted base as to what was normal in human life, from which base the different disorders were departures’’ (1992, 605). In other words, Prince felt that a scientific knowledge of basic psychological facts and principles should be a prerequisite for clinicians, or else their understandings (and treatments) of their patients were likely to be flawed. Similarly, consider the words of David Shakow, one of the most important scientist-practitioners in the history of clinical psychology: ‘‘When I went up to Harvard in 1921, I was buttressed by William James’s notion (and Freud’s also, to some extent) of psychology being one’’ (1978, 149). In other words, scientific and clinical psychology must form a unified discipline, each containing and acknowledging the other. These days, thoughts of a unified clinical psychology, of ‘‘clinical psychology being one,’’ seem very distant. Clinical scientists contribute to this

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problem through arrogance and inaccessibility; for their part, clinical practitioners contribute to the problem by losing touch with their primary source of credibility, namely, psychological science. An example may illustrate the extent of the problem. In 1998, psychological scientist Bruce Rind and colleagues at Temple University published a paper in Psychological Bulletin on the relation of child sexual abuse to later problems in adulthood for victims of child sexual abuse. Their conclusion was that child abuse perpetrators are of course despicable and should be prosecuted to the full extent of the law; nonetheless, their victims do not, on average, show pervasive and sustained psychological damage. This finding provides hope because, despite the egregious behavior of perpetrators, victims are not doomed to a life of suffering. The finding takes control and power away from evil perpetrators and restores hope to unfortunate victims. Further, the finding is consistent with the new ‘‘positive psychology’’ perspective (Seligman and Csikszentmihalyi 2000) and its emphasis upon the ‘‘ordinary magic’’ of human resilience (Masten 2001). When misconstrued beyond recognition, however, the finding can be viewed as an excuse for perpetrators—if their behavior does not necessarily cause lifelong damage, then maybe it’s not so bad after all. This is a highly slanted interpretation of the data, one that Rind and colleagues do not imply or condone. Perhaps not surprisingly, however, talk-show host Dr. Laura, as well as some ultraconservative members of Congress, made this interpretation, and tried to generate controversy over it. Let’s summarize: On one hand, we have reputable psychological scientists who conducted an extremely careful analysis of an important public issue, reached a conclusion that is hopeful for victims, submitted the paper to the intense scrutiny of the peer-review process, and published the paper in the American Psychological Association’s prestigious journal Psychological Bulletin. At this level of publication, the findings can be regarded as authoritative. On the other hand, we have talk show hosts and politicians who have not even read the paper, making inflammatory misinterpretations of the results. In this dispute, which side would the American Psychological Association, composed largely of clinical practitioners, support? To the dismay of research psychologists, APA caved in to the likes of Dr. Laura and apologized for the article in Psychological Bulletin. The APA also asked the American Association for the Advancement of Science to review the affair. In a telling decision highlighting the difference between mainstream science (the AAAS) and some APA decisions, the AAAS Committee on Scientific Freedom and Responsibility refused, stating that there was no reason to ‘‘second-guess’’ the peer-review process that led to the publication of Rind and colleagues’ article. In short,

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during this incident APA administrators succumbed to political pressure, undermining the process on which psychology’s credibility rests. Other examples of the schism between empirical and applied branches of the APA could also be cited, but in the interest of moving things along, we will skip ahead. The real question is, Are these examples mere partisan squabbles among factions within APA? Does the split between psychological scientists and clinical practitioners have any real-life consequences? Unfortunately, yes. Consider this example of rebirthing therapy, an extreme treatment for reactive attachment disorder, an inability to form relationships: ‘‘Four or five adults forcibly hold down a child, sometimes swaddled in a blanket, arms pinned to his sides. He is then provoked into a rage: The therapist or parent jabs at the child’s ribs, presses a fist or elbow into his abdomen, shakes him, pours water in his face, taunts him, and shouts. Then the adult professes love. Children scream in pain, plead for mercy, and are praised for getting out all the bad feelings of childhood’’ (Horn 1997). One proponent of the therapy has said that ‘‘for kids with severe symptoms, the interventions need to be intrusive and confrontational. . . . Making the child acknowledge his rage is key to healing.’’ Another has described the therapy as ‘‘revisiting the trauma so the child can work it out a different way.’’ Clinical research scientists would view this as an unproven (and horrific) treatment for a diagnosis that has questionable validity in the first place. This example is extreme, of course, and most practicing clinicians within the APA are skilled, thoughtful, and caring. Indeed, the psychologists quoted above probably genuinely believe that their technique does (or should) work. But this is the point: belief is not enough. New therapies, especially as extreme as the one described above, should not be permitted until their efficacy has been supported by randomized research trials. Otherwise, needy citizens may be easy prey for silver-tongued advocates of alternative or New Age therapies. But this raises an important consideration. Obviously, such advocates are motivating people—to buy millions of books and to try radical therapies. If only scientifically informed clinicians were as good at getting their clients to try the more proven treatments! Indeed, we believe that self-help psychologists often effect considerable positive change in their readers and clients because they know how to speak to and inspire clients’ innate motivation for health and growth (see Chapter 2). Unfortunately, even in such positive cases the underlying causes of clients’ symptoms are often not addressed, and so the improvement is not maintained. And in the worst cases, so-called healers may abuse their clients, even to the point of death. It is important to note that clinical scientists also contribute to the lack of communication between practitioners and researchers by using impenetrable

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jargon, studying arcane questions with little relevance for real-world problems, and disdaining the difficult and messy business of validating new therapies and interventions. Further, they may overestimate the ability of harried clinicians to keep up with the ever-expanding research literature. In fact, research scientists themselves frequently complain that they can’t keep up with it all. In addition, clinical researchers who maintain clinical practices sometimes come across as detached or even arrogant, which inhibits their ability to connect and communicate with their clients. Potentially efficacious therapies may thus fail simply because scientifically informed practitioners are unable to motivate their clients properly. So far, then, we have identified several gulfs: between practicing clinicians and research psychologists within the APA, between alternative therapies and their scientific bases (and thus between clients and lasting solutions to their problems), and between some research-based clinicians and the clients whom they try to motivate. Furthermore, there seems to be a yawning gulf between two different worldviews: one in which exaggerated and even magical-seeming claims are the norm (on the self-help shelves in bookstores and in the phone book), and another in which positive claims must be regarded with skepticism until they can be validated empirically (in the clinical research literature). What a mess! Can anything be done? Self-determination theory may provide a way out of the thicket. First, SDT can help us to understand how alternative and New Age therapists motivate their clients and, indeed, attract the public’s attention in the first place. This has considerable practical import, because it may suggest ways of limiting the influence of pernicious therapists and programs. Second, SDT can suggest ways in which mainstream clinicians can draw on this motivational energy themselves in their treatment of clients. This is important because it is likely to enhance the efficacy of scientifically validated therapeutic programs. Third, SDT can bridge the conceptual gulf between New Age theories and more mainstream psychological knowledge, by showing which aspects of New Age thinking are indeed correct and useful. Self-determination theory can also help bridge the epistemological gulf between New Age ideas and mainstream theory because its humanistic theoretical postulates have been validated by the best empirical methodologies. Last, SDT can help bridge the gulf within the APA between research psychologists and clinical practitioners. Many practicing clinicians resonate to such humanistic concepts as self-actualization, genuineness, and personal growth, and SDT supplies a way for such concepts to be defined and validated to the satisfaction of hard-nosed clinical researchers. In earlier chapters we have demonstrated that not only is there a rigorous science of self-determination but its application to such physical health prob-

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lems as smoking cessation and diabetes management has great promise. In the remaining chapters we show that the application of self-determination ideas to scientifically supported treatments for mental disorders may also be beneficial (and may be a step to healing the vexing science-practice rift). In the chapters that follow, we examine treatments for substance abuse problems, anxiety and eating disorders, and mood and personality disorders, respectively, in light of SDT. The remainder of this chapter highlights some relatively straightforward and general issues that cut across different types of mental disorders and treatments for various mental disorders. A caveat before we proceed, however. Unlike some areas of physical health reviewed in earlier chapters, the research base specifically examining the role of self-determination principles in scientifically supported mental health treatments is sparse. Therefore, this and the following chapters offer rational extrapolations from the current knowledge base and highlight fruitful areas for research.

Technical Skill and Motivational Abilities: Both Are Necessary but Neither Is Sufficient By now the beneficial effects of self-determination principles, particularly the three aspects of autonomy support (acknowledgment of the patient’s perspective, choice provision, and rationale provision), should be clear. A clinician who can engage patients’ motivation for treatment and health has a key advantage over other clinicians. Imagine, however, a far-fetched situation in which you had a serious health problem and your clinician was very sophisticated in motivational techniques but little else. The situation is somewhat like that depicted in television commercials for a hotel chain. The ads show a persuasive and confident person about to engage in a complex, often life-or-death type of activity, such as surgery. The confident person is asked about credentials and experience, and says something like, ‘‘Oh, I’m not a surgeon, but I did stay in a Best Hotel last night.’’ In the real world, confidence, persuasion, and motivational abilities are very helpful, but they are not enough. A clinician like this would be extremely skilled at motivating you, but for what end? Yes, clinicians need knowledge of how to motivate, yet crucially, they also need knowledge of what to motivate. To know what to motivate, a sophisticated command of clinical techniques is required, as is knowledge of diagnosis, disorder, the course of disorders, and the implications of all this for treatment choice and provision. In other words, technical skill, without motivational abilities, is unlikely to be sufficient for

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clinical success; similarly, motivational ability, without technical skill, is unlikely to be sufficient (see Chapter 4 for a discussion of this issue in the domain of physical health). To give a less far-fetched, more real-world example, consider the following extended case example. A severely depressed man (L. T.) came in for treatment, desperate to try new approaches, because many other approaches had failed. He had tried various antidepressant medicines at varying doses, all long enough for them to work, with little success. He had tried combinations of medicines (for example, lithium augmentation of antidepressant medicines, a useful technique), again with little response. He had tried electroconvulsive therapy (ECT, a proven treatment that can be useful for people who have not experienced relief from other therapies), also without much improvement. The clinical psychologist at the outpatient treatment facility, Dr. B., conducted a detailed interview with the patient, including careful questioning about whether the man had ever experienced manic episodes (he had not) and whether bipolar disorder runs in his family (it did not). It is critical to rule out bipolar disorder in patients who present with depressive symptoms, because a person who is very depressed at one time may be severely manic at a later time and, if so, needs a different treatment. Other potential disorders were also assessed, including such anxiety disorders as post-traumatic stress disorder, but none were noted. At the end of the interview, Dr. B. diagnosed L. T. as having major depression, which needed to be treated differently than in the past. Doctor B. was aware that how a diagnosis is presented to the client can be crucial in determining the client’s later motivation to cope with the problem, as we have discussed in the previous chapters on treating physical disorders. He took care to acknowledge L. T.’s perspective, sympathizing with the effects of the disorder on his life and with the frustration he must feel in his search for an effective treatment. Doctor B. also attempted to support L. T.’s needs for relatedness by openly expressing his thinking and by inviting L. T. to work with him as a team. He said, ‘‘I think you already know this, but I want to be open about it up-front. Previous treatments, some very powerful like ECT and lithium augmentation, haven’t helped you much, so you and I have to face the tough possibility that treatments that we try together may not help much either. However, our scientific knowledge about these problems is advancing all the time. If you’re willing to work together with me on whatever treatments we choose, I’m willing, too, and we’ll see how it goes.’’ L. T. said that he, too, was willing to work hard on the treatment they agreed on. The clinician continued, ‘‘A recent research study in the New England Journal of Medicine might interest you [Keller et al. 2000, discussed in a later chapter]. Several hundred patients were studied, many of whom had similar

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experiences to yours, in the sense that they had long-lasting and severe depressions. One-third of the patients were treated with the drug Serzone [nefazodone], one-third of the patients were treated with a specific form of psychotherapy called the cognitive-behavioral analysis system of psychotherapy, and one-third were treated with both Serzone and the therapy. Around 55 percent of the patients on Serzone became symptom-free; around 55 percent of patients on the therapy became symptom-free; and almost 90 percent of patients on Serzone plus the therapy became symptom-free. That 90 percent figure is the highest response rate reported to date from a clinical trial for depression, although we’re not yet sure about the sustained benefits of the treatment. So, I recommend we try the combined treatment, but of course we could also try either one by itself first, if you prefer.’’ L. T. agreed that the combined drug and therapy route seemed best. At this point, notice that Dr. B. had shown skill in both technical and motivational domains. Technically, an accurate diagnosis was made, sciencebased recommendations for treatment were suggested, and appropriate cautions were mentioned. Motivationally, autonomy was supported, through acknowledgment of the patient’s experience and perspective, provision of an informed but understandable rationale for Dr. B.’s specific recommendation, and provision of choice in whether and how to follow that recommendation. In addition, the clinician supported relatedness needs by sympathizing with the patient, by openly expressing her thinking, and by promising to devote herself, along with the client, to resolving the problem. Finally, competence needs were supported by Dr. B.’s positive expectations that L. T. could successfully enact this treatment regimen. Doctor B. could not prescribe drugs, so the patient agreed to arrange for a consultation with a physician on his own. Dr. B. mentioned a few prescribers that the patient might want to consider. She and the patient then started the initial work for the cognitive-behavioral analysis system of psychotherapy, in which patients learn to question their potentially maladaptive thoughts and self-criticisms and replace them with more positive self- and world-construals. The next week, L. T. reported that he had experienced considerable trouble with motivation, energy, and making up his mind to do things, one consequence of which was that he had not yet arranged an appointment with a prescriber. Doctor B. responded by acknowledging the difficulty of taking action in the face of one’s depressive symptoms. She restated that psychotherapy alone produced a 55 percent success rate in the clinical trial and that adding the medication substantially increased that rate (to 90 percent). If L. T. wanted to increase his chance of success, Dr. B. recommended that he call one of the prescribers she had mentioned the previous week. Names and phone

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numbers of the prescribers were again provided, after which further attention was devoted to the principles of cognitive behavioral therapy. At the next session L. T. said that he had heard from a friend about a prescriber unknown to Dr. B. The friend was enthusiastic about the prescriber, and L. T. had put a call into the prescriber’s office, although they had not yet gotten back in touch with him. Dr. B. noted L. T.’s enthusiasm about this development, reflected it back to him, and wondered aloud how he might get in to see the prescriber sooner rather than later. L. T. responded that probably he should just call the prescriber again, just to check on where things stand. The clinician agreed that this might work. The remainder of the session was devoted to the cognitive-behavioral analysis system of psychotherapy. During the session, Dr. B. noted that L. T. was starting to learn the techniques quite well. At the next session L. T., though still quite depressed, had experienced some lessening of symptoms. He explained that he had finally connected with the prescriber’s office and that he had set an appointment for the week after next. The psychotherapy work proceeded, with continued success in terms of learning the techniques as well as noticeable symptom relief; L. T. stated that although he still had a lot of depression, the way he felt now was better than he had felt in months, and he was hopeful that still more progress could be made. Storm clouds formed, however, when L. T. met with the prescriber. Unlike the vast majority of physicians, this prescriber was technically unsophisticated. Patients liked him, though, because he had a confident and magnetic air about him. The prescriber inferred that because L. T. had not gained relief from past antidepressant therapies (except the present psychotherapy, which the prescriber overlooked), he must have bipolar disorder (even though the patient could report no past manic symptoms whatsoever). L. T. mentioned that his psychotherapist had suggested that Serzone might be a good medicine for him, based on a research study in the New England Journal of Medicine. The prescriber responded that antidepressants were a bad idea because they can make patients with bipolar disorder become manic (even though L. T. had been on several antidepressants in the past and had never become manic). The prescriber recommended Depakote, a medicine with demonstrated effectiveness for patients with bipolar disorder. Next, the prescriber asked L. T. a few questions about his early life, particularly any traumatic events. L. T. could not recall any particular events that were traumatic, but did state that he viewed his relationship with his parents as traumatic, because this relationship had been rocky for quite a while. Based on this, the prescriber arrived at the additional diagnosis of post-traumatic

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stress disorder (even though a discrete trauma is required for this diagnosis and there was none and although the symptoms of this syndrome include anxious preoccupation with a trauma, heightened startle reflexes, and disturbing dreams about the trauma, none of which L. T. endorsed). Based on the diagnosis of post-traumatic stress disorder, the prescriber recommended eye movement desensitization reprocessing therapy and recommended that the depression psychotherapy be discontinued (despite its positive effects on symptoms). Let’s explore the therapy the prescriber was recommending. In Skeptical Inquiry, Brandon Gaudaino and James Herbert (2000) have written: There has recently been a surge of putatively revolutionary treatments for various psychological problems that claim to be far superior to standard treatments in both effectiveness and efficiency. Known as ‘‘power’’ or ‘‘energy’’ therapies, these treatments are gaining widespread acceptance among mental health practitioners, despite their frankly bizarre theories and techniques, extraordinary claims, and absence of scientific support. One of the most popular of these power therapies, known as Eye Movement Desensitization and Reprocessing (EMDR), involves a therapist waving his or her fingers in front of the patient’s eyes while the client imagines various disturbing scenes that are thought to be related to the patient’s problems. . . . In fact, EMDR has been described as a prototypical case of pseudoscience.

A meta-analysis of more than thirty studies on EMDR (Davidson and Parker 2001) concluded that the only effective aspect of the treatment is that which it lifted from basic scientifically supported behavioral and cognitive therapies. The bizarre add-ons, such as finger waving, add nothing (except money to the pockets of those conducting EMDR workshops). If only L. T. had known about all this, he could have asked the prescriber if, by any chance, he had stayed in a Best Hotel the night before! Sadly, L. T. did not know, and weeks of indecision followed about which clinical course to pursue. Eventually, however, L. T. prioritized the progress he had made with the original clinician as well as the research study in the New England Journal of Medicine (suffice it to say that EMDR has not appeared in that journal), returned to the cognitive-behavioral analysis system of psychotherapy, arranged with a different prescriber to start on Serzone, and made steady progress over ensuing months of hard work in therapy. Thus the original clinician, Dr. B., together with the patient, L. T., eventually achieved good progress, through a combination of technical skill and attention to self-determination principles. Along the way they surmounted the monkey wrench that the unsophisticated prescriber had thrown into this process. To

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reiterate, and as this anecdote shows, clinical and technical skills (undergirded by systematic science) and motivational abilities (as informed by SDT) are both important for success; alone, neither is sufficient for success. Helping clients to accept the diagnosis. As we noted in the chapters on physical health, receiving a diagnosis can be stigmatizing or otherwise unsettling. Suddenly the individual is viewed as ‘‘a diabetic’’ or ‘‘a cardiac case’’ rather than as a person. Of course, this is particularly troublesome in the area of mental disorders, where public misunderstanding of the disorders is rampant. But we argue that the delivery of a diagnosis is stigmatizing and unsettling only to the extent that diagnostic procedures ignore key principles of self-determination. Diagnostic procedures that incorporate self-determination principles have the potential to enlighten, reassure, and, crucially, point the way to optimal treatment choices. Again, however, clinical and technical skills are required to know which diagnosis or diagnoses to assign, as well as to know attendant treatment options. Consider an example where diagnostic procedures misfired for various reasons, including neglect of positive motivational principles. In outpatient psychotherapy, A. M., a woman in her late twenties, was told at the end of her first session that it was quite clear that she was ‘‘a borderline’’ (in other words, she had borderline personality disorder). The therapist asked her to come back in a week to discuss treatment options. No further description of the disorder was given; no discussion of reputable resources to learn more about the disorder occurred; and no specific mention was made of scientifically supported techniques that are helpful for the disorder. In terms of the autonomy-support concept, no rationale was provided for the diagnosis, let alone any discussion of its meaning. To appreciate the problem with this scenario, we must first understand the true features of borderline personality disorder, as well as how it is often misconstrued in clinical and other settings. The disorder is characterized by a longstanding pattern of stormy interpersonal relationships, self-destructive behaviors such as self-cutting or -burning, marked emotional lability and impulsivity, and an empty or diffuse sense of identity. Unfortunately, in some clinical settings, patients with the disorder have a reputation for manipulation, including manipulating others through self-destructive behaviors (gesturing suicide), as well as for splitting ( pitting people, including clinicians, against one another); some clinicians roll their eyes about such patients, take a subtly or overtly demeaning tone when talking about them, and make disparaging comments. This is completely inappropriate. As co-author Joiner recently e-mailed the therapists-in-training at his clinic, ‘‘My tolerance for this sort of

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attitude is nil, and if I detect it, regarding patients with this or any other diagnosis, I will arrange hell to pay.’’ One reason that some clinicians adopt this cynical attitude is their belief that these patients merely gesture suicide. In other words, they engage in suicidal behaviors but do not really intend to kill themselves; instead, they intend only to provoke or manipulate others. Yet this is simply not true: fully 10 percent of patients with this diagnosis end up dying from their suicidal gestures (a rate comparable to the rate for patients with mood disorders), and a history of serious suicide attempts is more predictive of eventual death by suicide among borderline patients than among any other diagnostic group. The patient in our example, A. M., did indeed have the symptoms of borderline personality disorder—many of her relationships were marked by alternating periods of closeness and angry resentment; her anger and sadness would often ‘‘explode,’’ in her words; she cut her upper arms with knives and razor blades and engaged in other potentially self-injurious behavior (for example, driving at extreme speeds); and she complained of a sense of not knowing herself and feeling empty inside. The diagnosis of borderline personality disorder was correct. However, after the therapist told A. M. of the diagnosis without explaining or providing a rationale for the diagnosis, A. M. understandably felt a need for more information, and so she went home and searched for ‘‘borderline personality disorder’’ on the Internet. The results of her search were highly disturbing to her—she encountered chat rooms and other forums in which misguided clinicians and others were discussing the ‘‘hopeless’’ prognosis of the condition, the irritating personalities of people who have the condition, and so forth. That night, A. M. engaged in her most serious bout of self-cutting ever. It is perhaps not surprising that she would severely injure herself in response to a highly negative emotional stimulus; subjective reports of patients with borderline personality disorder indicate that self-cutting has calming and even analgesic effects (of course, a main goal of treatment is to learn less destructive ways of regulating the patient’s mood). After this A. M. developed a major depressive episode that lasted for weeks after her Internet search. This unfortunate situation could have been avoided if attention had been paid to basic issues of patient support, such as the need to help patients understand and begin accepting their diagnoses. The problem was not that the diagnosis was inaccurate; rather, the problem was the insensitive way that the therapist communicated with A. M., treating her as if she had no self and thus reinforcing and exacerbating a central symptom of her disorder. What if the therapist had said something like the following instead? ‘‘I believe I

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understand what you are struggling with—you feel out of control with your emotions, and this leads to problems like serious conflict in relationships and impulsive behaviors, including impulses to hurt yourself. You also have questions about identity—you feel empty inside and have questions about who you really are deep down. All of these experiences are part of one syndrome, which has been named borderline personality disorder. For now, I want you to know two important things about the syndrome: first, we understand a lot about it, and specific and effective treatments have been developed for it; second, as with a lot of mental health problems, people—even some mental health professionals—tend to misunderstand this condition and may say unfair, degrading things about people with the disorder, like that they are hopeless cases or irritating personalities. These things are not true. If you want more information about the condition, I’ll give you some things to read that will give you true information about the disorder. If you encounter any misunderstanding about the disorder, try and talk with me about it before acting, or consult the readings I’ll give you.’’ Although it is impossible to know for sure, our experience indicates that if the therapist had said this, A. M. may not have had the severe episode of selfcutting that night and might not have experienced a severe major depressive episode for the next several weeks. In other words, simple rationale provision could have saved this patient a lot of suffering. Another valuable aspect of explaining the disorder in terms like those described above is that patients feel understood—their experiences and perspectives are acknowledged (another principle of self-determination). It is a remarkable, common, and gratifying experience for clinicians to explain to a patient a diagnosis like borderline personality disorder, including self-cutting, stormy relationships, impulsivity, and so on, and for the patient to say, ‘‘Thank you so much. I’m so relieved. I had no idea there was a name for this; this is the first time I’ve felt understood.’’ Further evidence for the beneficial effects of full disclosure come from a study by Stephen Finn and Mary Tonsager (1992). They studied the effects of providing Minnesota Multiphasic Personality Inventory-2 (MMPI-2) test results verbally to patients who were awaiting psychotherapy (this is a standard practice). The MMPI-2 test characterizes people’s personalities on a variety of conceptual dimensions, and Finn and Tonsager believed that giving patients such information about themselves might yield substantial benefits. Indeed, compared to a control group, patients who received MMPI-2 feedback experienced decreased emotional symptoms and increased self-esteem and hope, both immediately following the feedback session and at a two-week follow-up session. The content of the feedback often involved difficult things

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to hear (for example, ‘‘Stressful situations tend to provoke strong emotional reactions from you, and you tend to react with worry and anxiety,’’ and ‘‘Impulse control can be a struggle for you, and this may have led to unfortunate situations such as relationship conflict or getting in trouble’’). Despite this, patients felt relieved to know that someone else understood them and could give them meaningful information. Their relief was manifested through decreased symptoms and increased self-esteem and hope. Encouraging clients to attend therapy. In psychotherapy in general, including in empirically supported treatments, the average number of sessions attended by patients is surprisingly low. Some studies find a modal number of one or two, though most studies find an average number of five or fewer (Mueller and Pekarik 2000). Obviously, patients cannot benefit from scientifically supported and effective treatment if they are not showing up to receive it. Engaging patients in treatment—motivating them to continue treatment— is thus a pressing problem in psychotherapy. One curious aspect of this problem is that clinicians are sometimes not as attentive to it as they should be. For example, Melinda Mueller and Gene Pekarik (2000) studied 230 psychotherapy patients. They found that patients’ expectations for the number of sessions they would attend corresponded well to the number of sessions they actually attended. By contrast, therapists’ expectations regarding the number of sessions the patient would attend were not strongly related to actual attendance. Here, as is often the case in clinical work, patients knew something that their therapists did not. This fact supplies yet another reason for therapists to engage in the autonomy-supporting activity of acknowledging and understanding their patients’ experiences and perspectives! Joiner and his colleagues have shown that a roughly similar situation pertains among suicidal patients and their clinicians (Joiner, Rudd, and Rajab 1999). They compared patient- versus clinician-rated suicide risk among 328 participants referred for suicidal ideation or behavior. Some of the participants completed follow-up assessments at six, twelve, and eighteen months. As in the finding by Mueller and Pekarik (2000), patients and clinicians often saw things quite differently. The nature of this discrepancy was such that clinicians were more likely to see patients as high in future suicide risk, whereas patients were less likely to see themselves as such. Data on predicting future symptoms indicated that patients’ self-ratings outperformed clinicians’ ratings. Once again, clinicians seemed ignorant of an important source of information. In this study, clinicians were operating from their own perspective, prioritizing such variables as history of previous attempts and personality disorder

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symptoms in making their ratings. From a technical and clinical standpoint, these are reasonable considerations. But if as an additional priority clinicians tried to understand the patients’ perspective on the issues (basic autonomy support), clinicians’ ratings may well have outperformed patients’ ratings. In practical terms, finding out that a patient is considering dropping out of therapy would likely give the clinician an important opportunity to intervene and engage the client’s motivation for health. In short, here, as before, both technical skill and attention to motivational issues seem important for the most positive outcome. How can clinicians elicit participants’ perspectives and at the same time motivate them in their change attempt? The work of Roberta Sherman and Craig Anderson (1987) provides a useful suggestion. These researchers tested a procedure for reducing psychotherapy dropout rates based on research demonstrating that explaining or imagining a hypothetical future behavior leads to increases in the likelihood of that behavior. They assigned patients to one of two groups. In one group, patients imagined and explained staying in therapy for four sessions. In the other group, patients imagined and explained an irrelevant event but received straightforward information regarding the importance of attending sessions. Notice something about these two groups. In the group that imagined and justified staying in therapy, attendance became something that was construed in the clients’ own terms—patients’ perspectives were thereby addressed and acknowledged. In doing this exercise, patients thus generated new and more personal rationales for attendance as well as parameters of choice regarding their attendance (for example, the timing and frequency of sessions and the tone of the sessions). By contrast, members of the other group received information about attendance but did not imagine therapy in their own terms. Thus, as SDT would predict, attendance was demonstrably better in patients who imagined and thought of a reason for staying in therapy as compared to those who only received information about staying in therapy. No matter how effective the intervention, patients will not benefit from it unless they show up to receive it. The emphasis on autonomy support that SDT provides points the way to straightforward but promising ways to improve therapy attendance. In brief: we recommend that practitioners listen to clients, help them to get in touch with their reasons for seeking treatment, and help them feel that they are understood and appreciated. Encouraging clients to adhere to treatment programs. Similar to the problem of attendance, the problem of treatment adherence can easily thwart even the most effective clinical intervention. Patients who don’t do the treatment are unlikely to benefit from it. The case of bipolar disorder represents a

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clear example (and illustrates the theme of the necessity of technical and clinical skills along with attention to motivational principles). Bipolar disorder, also known as manic depression, includes phases of depression, much like those L. T. experienced. In addition, the disorder includes phases of mania, which are often characterized by elevated or euphoric mood (irritable mood is also common), boundless energy, greatly reduced need for sleep, grandiose self-concept, and marked increase in goal-directed activities. For example, a woman with the disorder, C. D., reported that she had discrete and easily identifiable periods when her mood was very high (unless her activities or plans were contradicted by others, in which case she would become quite angry and irritable). During these periods, she would conceive of new business ventures and would work on them nonstop for two or three days in a row without any sleep. None of these ventures had worked out, and some of them were very costly to C. D. in terms of bad investments and strained business and personal relationships. Nonetheless, C. D. was reluctant to stay on her medications. Patients with bipolar disorder are often unimpressed with the need for medicines or the need to stay on medications. This is a well-known consequence of the symptoms of the manic phase—people who feel euphoric and grandiose may not see the need for a medicine that will make them less euphoric and grandiose. How can such patients be helped to internalize this important behavior of complying with their medication? Again, SDT asserts that providing patients with choices regarding their treatments is important. Unfortunately, there is, in one sense, no choice to be given for patients with bipolar disorder—antimanic medicines are simply required to manage this syndrome. In other words, unlike the situation with nonbipolar depression, where certain psychotherapies alone have been shown to be effective, psychotherapy by itself for the treatment of bipolar disorder is a terrible idea and has been characterized as malpractice. Despite this, there are still some choices available. Although until 1990 lithium was the only treatment option, more medicines are receiving FDA approval as antimanic agents. Many of these are anticonvulsant (antiseizure) medicines like Tegretol and Depakote. So there is now a menu of medicines, albeit relatively small, from which patients and prescribers can choose. Prescribers should be aware of these choices and should offer them to clients as part of the motivational enhancement strategy. Treatment adherence is clearly an issue regarding bipolar disorder, but it surfaces in many other contexts as well. For example, in many scientifically supported psychotherapies, between-session homework assignments are emphasized. Importantly, once patients complete the homework assignments,

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they frequently come to enjoy and value them, even if they initially resisted the idea of homework. This is not surprising from the SDT viewpoint, because a focus of most of these homework assignments is for patients to describe and construe their experiences in their own terms and to integrate their experiences with the new ideas and approaches they are learning. As a more specific example: in the cognitive-behavioral analysis system of psychotherapy touched on earlier and elaborated on in a later chapter, patients’ homework is to complete a form that summarizes their thoughts, behaviors, and desired and actual outcomes regarding a recent situation in their lives. Patients bring these forms into therapy, and they become the grist for the mill in the session; in this sense, then, patients direct the session. Moreover, choice is provided, in that they of course can choose from an array of recent situations. Similarly, in motivational interviewing, touched on in Chapter 6 and described further in the next chapter in the discussion of substance abuse disorders, patients complete a form called the change plan worksheet. The worksheet starts with the prompt ‘‘The changes I want to make are:’’ and continues with ‘‘The most important reasons why I want to make these changes are:’’ Here again, in their own terms, patients generate the impetus for change. Because their perspective and experiences are front and center, patients are more likely to feel that their autonomy is being supported. Moreover, the change plan worksheet encourages patients to provide their own rationale for change (‘‘Reasons to make these changes are:’’), quite consistent with selfdetermination principles. Unfortunately, getting clients to begin doing such homework can be a problem. Many patients react to such assignments the same way they used to react to teachers’ assignments in school: they ignore them. Or they report that they forgot about the homework in the flux of the week’s events, or lost the necessary forms to do the homework, and so forth. Here, the autonomy-supportive attitude of the clinician is crucial: it is important that clients feel that they are choosing to do the homework rather than feeling that an authority is making them do it. As we discussed in Chapter 4 concerning the failure of early attempts at smoking cessation, it is also important that the clinician not become critical or condemning at times when a client fails to complete the homework. Many efforts to change require several false starts before they are successful. The problem of the overresponsible therapist. Especially early in training (but not only then), psychotherapists tend to take a lot of responsibility for their patients’ well-being. To a point, of course, this is only as it should be— therapists are responsible to provide the best standard of care. But many therapists take this too far, believing that they are also responsible for their patients’ choices and outcomes (ironically, therapists who focus on such con-

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cepts as empathy and self-actualization do this at least as much, if not more, than other therapists!). Behavioral and other life choices are up to the patient: to think that the fifty-minute weekly psychotherapy session will be the entire fulcrum of a patient’s 168-hour week is to overestimate oneself! Therapists do this usually not out of hubris but rather out of concern and compassion. Either way it can be costly, subjecting the therapist to unnecessary personal anguish and potentially smothering and controlling the client. This problem can become acute when patients engage in self-destructive behaviors, including suicidal behaviors. Most of the pages that co-author Joiner receives on his beeper are from therapists at his training clinic who are worried that they should do more for a patient with suicidal symptoms. When he returns their call, he asks questions to see if the therapist is meeting the standard of care. Usually the standard of care is indeed being met, because of the great emphasis the therapists at the clinic give to these standards. And so he then says, ‘‘Well, you’ve done everything I would have done; I wonder, what else is it do you think you’re supposed to do?’’ Often the answer is, ‘‘I’m not sure, I just have this feeling that there’s something else I should do.’’ Then Joiner replies, ‘‘Well there’s not; but don’t lose that feeling, because it will ensure that you regularly do what’s best for patients; also, though, don’t let that feeling get out of hand, because it can burn you out, plus, ultimately these choices are not up to us, they’re up to patients.’’ The SDT perspective can help clinicians to set realistic expectations about their abilities and responsibilities. Therapists who fully endorse selfdetermination principles acknowledge the limits of their responsibilities because they fully acknowledge that ultimately people must make their own choices. Make no mistake, the standard of care is important—at times, even life-saving—but beyond that, responsibility for life choices resides with patients. Therapists who understand this are likely to enjoy their work more, to not be distracted by one patient when dealing with another, and, just as important, to enjoy their leisure time, too. In this chapter we have touched on several general ways that selfdetermination principles and technical and clinical skill with science-based treatment may mutually inform and enhance one another. In the remaining three chapters we turn to particular mental disorders and specific treatments for them, hoping to shed more light on the how of motivating clients to motivate themselves.

8

Facilitating Psychological Change The Case of Substance Abuse Disorders

Of all the scientifically supported treatments for mental disorders, motivational interviewing for substance abuse problems is most closely related to self-determination theory. Indeed, the prescriptions of this technique and of SDT are in many cases almost identical. We already discussed several aspects of motivational interviewing in Chapter 6. In this chapter we focus on this technique, review the evidence that it is effective, and point out the clear connections between it and SDT. Although the principles of motivational interviewing are meant to apply to all behaviors (just as SDT’s are), the application of motivational interviewing to alcohol problems has been the most studied and is the focus of this chapter. Let us begin with an illustrative clinical example. A patient in his thirties, T. R., sought psychotherapy for persistent problems with anxiety, particularly in social settings. Upon interview, the therapist, C. N., learned that T. R. avoided most social encounters for fear that he would not know what to do or say and would come across as unsophisticated and awkward. When he did find himself in social settings, he became extremely self-conscious, had thoughts that others saw him negatively, and experienced physical symptoms of anxiety, such as a racing heart and shortness of breath. The therapist diagnosed social phobia or social anxiety disorder. She screened for other dis-

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orders, including substance abuse disorders, and none seemed to fit—social phobia was the sole diagnosis. When asked about his substance use, T. R. reported that, every three or four days, he drank a few beers. C. N. recommended that T. R. combine a selective serotonin reuptake inhibitor antidepressant medicine with a cognitive-behavioral therapy targeting his social anxiety and associated negative thoughts and avoidance behaviors (such medications are often useful with anxiety disorders). He responded that he was not comfortable with the idea of antidepressant medicines but was interested in the cognitive-behavioral therapy. The cognitive-behavioral approach to this disorder includes, among other things, purposefully confronting one’s fears and refusing to allow oneself to indulge in avoidance behaviors. For example, someone afraid of meeting new people might be encouraged to seek out opportunities to meet new people, to tolerate the attendant anxiety, and to work against any avoidance behaviors that might interfere. This patient had been struggling with social anxiety for some time and therefore had not cultivated many opportunities for socializing —he avoided such opportunities to such an extent that few remained. He did, however, report harmonious if somewhat distant relations with coworkers, who frequently socialized together and would occasionally invite him along (he always demurred). In addition, T. R. was doing part-time graduate work at a nearby university and noticed that social opportunities were available in that setting. C. N. thoroughly explained the rationale behind the cognitive-behavioral approach, including the need to thwart avoidance tendencies and to face the anxiety by socializing, no matter how uncomfortable it felt. The basis for this is the assumption that, through repeated exposure to feared situations, the patient will simply get used to socializing and it will provoke less anxiety. Once this occurs, the patient will begin to find natural incentives and rewards in socializing that can serve to maintain the new behaviors. The therapist also elicited T. R.’s perspective about the treatment approach; he stated that it made sense and he could see how it might work but that he was also quite anxious about the whole idea. She agreed that the approach would initially provoke anxiety but also observed that, according to the research literature, this was the best-proven method available. She again broached the idea of combining the therapy with a medicine, and again T. R. declined. The therapist encouraged T. R. to draw up a list of social activities from which he could choose to start facing the social anxiety. As we will elaborate in a later chapter, giving patients many choices for how to face anxiety is very important. Because the patient is being asked to do something difficult and

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unpleasant, motivational issues should be front and center. The therapist and patient agreed that T. R. would ask his coworkers about going out after work and that he would go along on any planned activity. C. N. believed that this activity was something T. R. could do, even though it would make him quite anxious. Still, she was prepared for the possibility that he would not follow through on the plan. As we discussed in Chapter 5 concerning smoking cessation, many change attempts fail the first few times. This was the case here, as was revealed at the next visit. In response to T. R.’s contrition, C. N. acknowledged the difficulty of facing the experience of anxiety. As a way of refocusing, she suggested that he go back to his list of possible social activities and choose the item on the list that seemed the least threatening. T. R. chose to try going to the grocery store at a busy time (he generally scheduled his grocery shopping late at night to avoid encountering people). Here again, however, T. R. did not follow through. After another two or so failed plans, the therapist—who was near the beginning of her training— became concerned that she was making some technical or other error. C. N. had worked with several other patients with anxiety disorders and had made marked progress with each. She reviewed the diagnosis and the details of the treatment plan with her supervisor, who could find no glaring problem. The supervisor and therapist also discussed motivational issues, and here, too, C. N.’s approach seemed adequate—she related well to T. R. (by the patient’s report as well as the therapist’s and as documented by videotaped sessions), regularly asking for the patient’s perspective on things and displaying understanding of the patient’s experience and perspective. She also paid close attention to her patient’s right to make choices for himself and tried to provide clear rationales for any recommendations she made. Thus, on both clinical-technical and on motivational grounds, her approach seemed fine. Yet progress had not occurred, and if anything, social anxiety and especially social avoidance behaviors had worsened. The supervisor and therapist decided that some undetected issue was perhaps presenting an obstacle. If, for example, the patient’s avoidance behaviors were rewarding not only because they relieved anxiety but also because of some additional reason, that might encourage his avoidance and thwart his attempts to socialize. The supervisor noted that substance abuse can interfere with this kind of confrontative treatment because it can reduce motivation, in part by temporarily lessening anxiety. The therapist decided to gain detailed information regarding exactly what occurs when T. R. is alone and avoiding social contact.

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In response to her question, T. R. reported that he stays in his apartment and watches television. When asked to describe in more detail exactly what he was doing while watching TV, he reported that he often drank beer. The therapist responded, ‘‘Right, I remember you said when we first met that you have a few beers roughly three or four times per week.’’ T. R. said, ‘‘Well, I didn’t really know you when we started out, and I didn’t feel comfortable telling you the truth about that. Actually, I’m drinking a lot, and it may be out of hand. I drink about twelve beers every night.’’ The therapist’s first response was to appreciate that the patient had become more trusting in therapy, to the point of disclosing uncomfortable information about alcohol intake. ‘‘That took some courage,’’ C. N. said. She then stated that T. R.’s level of drinking could have consequences for physical health, as well as cause other difficulties (such as hangovers that could affect work performance and alcohol-related accidents and ensuing legal trouble). Moreover, that level of drinking would likely interfere with the cognitive-behavioral therapy for social anxiety. Then C. N. said, ‘‘I think we’re at a choice point here. I’m worried our previous plan to use the cognitive-behavioral therapy for social anxiety won’t work very well as long as you’re drinking at a high level. One option is to change our focus and work on reducing your alcohol intake. I can give you more information about this, as well as more information about the consequences of high alcohol intake, but I can’t decide for you whether you’d like to reduce drinking or not. That’s a decision for you to make.’’ The patient admitted to having real ambivalence about reduced drinking. On one hand, he could see that his drinking could be getting excessive and that it could affect his health; on the other hand, he enjoyed drinking and viewed the time he spent watching TV and drinking beer as quite pleasant. The therapist acknowledged that this could be a tough decision and suggested that they devote their next session to talking through the pros and cons of the decision. In other words, the therapist suggested the technique called motivational interviewing or motivation enhancement therapy.

The Techniques of Motivational Interviewing Motivational interviewing involves a suite of interrelated approaches geared toward building motivation for change (here, the desire to reduce alcohol intake) and also strengthening commitment to change. In brief, it attempts first to find and fan the positive health-seeking motivation within the client and then to support the client’s commitment to that interior voice. William Miller and Stephen Rollnick (2002) suggest that several specific strategies are

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useful in terms of the first phase of the therapy—building motivation for change. Some of these techniques are summarized below. Eliciting self-motivational statements. As with so many proven techniques, the approach here is clear and simple. The health care provider poses questions to the patient that are likely to elicit responses related to the motivation for the current behavior. An example concerning alcohol use is, ‘‘Tell me a little about your drinking—what do you like about it; what’s positive about drinking for you? And what’s the other side—what are your worries about drinking?’’ Patients may also be asked about the positive change they wish to make: ‘‘Tell me more about what brought you here, and your desire to change some things in your life. Why do you feel this way?’’ A patient might reply, ‘‘Because there are some things I think I was meant to do, but right now I can’t do them. I really want to fix that.’’ Such statements can have particular selfpersuasive power, as SDT would predict. During the first interview T. R. acknowledged the potential negative health consequences of his drinking but did not seem especially worried about them. On the positive side, he noted that drinking was part of a routine that was pleasurable in its own right and that it took his mind off feelings such as loneliness. The therapist noted that T. R.’s description of the positive aspects of drinking seemed more animated and heartfelt than his remarks about the negative consequences. He was disappointed to observe this but tried to be empathic anyway. Listening with empathy. The concept of empathy is often bandied about in therapeutic circles as a somewhat elusive characteristic that certain therapists develop; the characteristic has to do with intuitions about what someone is really feeling. In these circles, the notion is that empathy itself has broad curative properties for most psychological problems. The idea that empathy is curative with regard to such things as bipolar disorder, major depression, and social phobia is, at best, scientifically unsupported and, at worst, highly irresponsible. However, when defined clearly, and when combined with other motivational interviewing techniques, empathy is an important part of the treatment of substance abuse disorders. Within motivational interviewing, the concept of empathy is essentially equated with reflective listening, consistent with the early contributions of Carl Rogers (1956). Reflective listening involves the therapist’s restating the patient’s remarks while noting the emotional tone of the remarks. Obviously, this approach is quite consistent with SDT’s emphasis on soliciting and acknowledging the perspective of the one who is to be motivated. For example, when T. R. said, ‘‘I didn’t feel comfortable telling you the

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truth about that [alcohol intake]. Actually, I’m drinking a lot, and it may be out of hand,’’ the therapist might have responded: ‘‘Thanks for sharing that information—I bet it was hard. So, you’re afraid that your drinking really is getting too excessive, but you also feel some sensitivity about this, maybe a little shame. Understandably, you wanted to get to know me a bit before we discussed all this.’’ Reflective listening also has the effect of immediately reinforcing patients’ self-statements, in the sense that patients first hear themselves state their motivations and then hear the same material again in the therapist’s words. This can enhance the memorability and significance of the self-statements. Of course, not all reflective statements have their intended effect. The statement ‘‘Your feel your drinking may be getting excessive’’ could instead elicit the response ‘‘Well, I’m not an alcoholic or anything.’’ In the current situation, after C. N. said, ‘‘Perhaps we can talk about ways to get your drinking under better control,’’ T. R. responded, ‘‘It’s not like I have a drinking problem, really—it hasn’t affected my work or my grades, and plus, I really enjoy drinking.’’ The therapist then replied with a double-sided statement that tried to capture both sides of the patient’s ambivalent feelings about drinking: ‘‘I see what you mean. It’s a tough place to be—you can see that your drinking may be getting out of hand, but at the same time, you feel that it may be the best thing in your life right now.’’ Questioning. Within a motivational interviewing framework, a main task for the therapist is to ask regularly not just about patients’ motivations but also about their feelings, thoughts, worries, goals, and plans. In contrast, therapists should never find themselves in the position of instructing the patient what to do. Here again, the overall technique is quite compatible with self-determination principles, particularly the elicitation and acknowledgment of a person’s perspective and experience. In an important sense, the questioning process provides the grist for the entire therapeutic process by engaging the active core of the client. Presenting objective information. In the case of alcohol treatment it is often helpful to provide objective information regarding the gap between normative drinking rates (for example, the U.S. average of about four alcoholic drinks per week) and the number of drinks the patient has per week. The latter figure can be based on the patient’s own ratings, and the comparison is useful for several reasons. First, because the comparison is based on the patient’s own report, it implicitly acknowledges the importance of the patient’s perspective while also conveying the therapist’s respect for the patient’s word. Second, when patients see the results, they often make self-motivational statements (for example, ‘‘I’m shocked—my drinking is off the scale! This has got to

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stop!’’). Of course, in response to such statements, techniques like reflective listening (‘‘You sound alarmed that you’re that far over the norm’’) and questioning (‘‘What seems most surprising about this?’’ or ‘‘What do you make of all this?’’) can be used. Third, patients often give themselves a rationale for reducing their drinking when they see the objective results (‘‘No wonder I’m having trouble—I’ve got to do something to get my life back!’’). This is the ideal case, since self-generated rationales are likely to be more motivating than those from the therapist, according to the self-determination perspective. However, this did not occur for T. R., who announced no intention to cut back. Handling resistance. In many therapeutic settings, people with alcohol problems have a reputation for having difficult personalities or for being prone to use psychological defenses like denial and minimization (especially of their drinking). In fact, however, there is no consistent evidence that people with alcohol problems show particular personality patterns or that people with alcohol problems use more of such defense mechanisms than people without such problems. Still, substance abusers resist and deny as much as sufferers of any other disorder, which makes the general topic of resistance worthy of consideration in this context. Motivational interviewing takes an interesting view of resistance by patients —namely, that it’s the therapist’s fault. In other words, if the patient argues on and on, it must be because the therapist is trying too hard to convince him or her of something! According to the motivational interviewing approach, patients must convince themselves, or else it is no good. Thus, even in the face of difficult provocations by patients (‘‘I don’t have an alcohol problem, and if you think I do, then you’re the one with the problem!’’), the therapist should deflect the challenge (‘‘What I think doesn’t matter, it’s what you think that matters’’) and must ultimately leave the choice of what to do up to the client (including the choice that reducing drinking might currently be too hard or too unacceptable for the patient). In a sense the therapist has inherent leverage in such situations, because after all, it is the patient who has a problem and who has taken initiative to make changes, and therefore it is the patient who must decide to stop playing games and to begin finding a way to enact the intention, with the therapist’s help. The therapist should make this subtly clear while avoiding entanglement in the patient’s games. Summarizing. At the end of a motivational interviewing session, the straightforward technique of summarizing is usually used. This activity is similar to listening with empathy, but instead of the therapist’s using reflective listening regarding a statement, in summarizing the therapist reflects on what the patient has said throughout the session. One advantage of the technique is that patients

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hear their self-motivational statements for a third time (first, from themselves; second, through the therapist’s initial empathic reflection; third, from the therapist’s summary of the session). In the previous chapter, when we discussed the issue of diagnosis as stigma, we noted that technically skilled and autonomysupportive diagnosis can actually be reassuring and rewarding for patients— they often feel understood, perhaps for the first time (this issue will arise again in a later chapter’s discussion of the treatment of suicidal behavior). The technique of summarizing can be viewed similarly—patients feel that someone really gets what they are saying, supporting both their need for relatedness and their need to make sense of their situation. In addition to acknowledging the client’s perspective, summarizing can also touch on the choice- and rationaleprovision facets of autonomy support, as the therapist lists the alternatives that were considered and the motivational rationales that were stated by the patient during the session. Techniques such as summarizing, questioning, empathic listening, and the like are integral parts of the first phase of motivational interviewing—building commitment to change. A second phase of the therapy involves strengthening the commitment to change. The shift from building to strengthening commitment occurs when the patient’s attention shifts toward enacting or pursuing change rather than contemplating change and discussing its pros and cons. Admittedly, it can be hard to determine whether this shift has occurred for a given patient. Patients may shift back and forth between the contemplation of change and the enaction of change. Even in patients who are ready to act, ambivalence about drinking is common. To assess whether patients are ready for the second phase of motivational interviewing, Miller and Rollnick (2002) point to several signs: the patient’s objections and resistance seem noticeably reduced; the patient appears more resolved or at peace; the patient’s self-motivational statements are definite and change-focused (for example, ‘‘My drinking’s gotten pretty bad, and I’ve decided I need to do something about it’’); the patient begins to wonder about how life might be after change is enacted (‘‘This will give me the kick in the butt I need to meet some new people’’). It is perhaps not incidental that the idea of imagining the future has surfaced many times. Motivational interviewing sees it as a sign that change enactment can proceed; the study cited earlier (Sherman and Anderson 1987) used it—successfully—to enhance attendance in psychotherapy; and SDT views it as a sign that the client has really begun to internalize the intention to change. In addition to these positive signs of commitment to change, there are some negative indicators that may be useful to assess—things like missed appointments, ambivalence about the scheduling of future appointments, and a view

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that treatment is a hassle or a put-down as opposed to a chance for improvement. These types of indicators suggest that a self-determined commitment to change has not yet developed and that more work in phase one of motivational interviewing is needed. Scales have been developed to help assess patients’ motivation for treatment and may assist the therapist in determining whether patients are ready to shift to phase two of motivational interviewing. One scale is the treatment selfregulation questionnaire (Williams, Freedman, and Deci 1996), which assesses reasons for staying in treatment. Sample items are ‘‘I have remained in treatment because I feel that it’s the best way to help myself’’ (endorsement of which would reflect self-determined treatment motivation) and ‘‘I have remained in treatment because of the money I have invested in this program’’ (endorsement of which would reflect less self-determined treatment motivation). This scale is one of the best validated of treatment motivation scales. Another scale is the treatment motivation questionnaire (Ryan, Plant, and O’Malley 1995). A main point of this scale is to place patients along a continuum of self-determination for treatment ranging from external motivation (Sample item: ‘‘If I remain in treatment, it will probably be because I’ll get in trouble if I don’t’’) to self-identified motivation (Sample item: ‘‘If I remain in treatment, it will probably be because it’s in my best interest to complete treatment’’). This questionnaire, too, has solid validity data behind it. Although these scales can be used after several sessions to help determine whether a patient is ready to shift from phase one to phase two of motivational interviewing (in other words, from building commitment to strengthening commitment), the scales may also be useful at the beginning of treatment. For one, clinicians can get an initial sense of patients’ motivational issues from these scales. A second benefit, however, is that the scales may encourage patients to begin imagining, early on, a future in therapy that is self-determined. That is, as the first-time patient ponders how much endorsement to give the item ‘‘If I remain in treatment, it will be because I feel that it’s the best way to help myself,’’ he or she may already generate expectations and images regarding improvement. This approach is also consistent with the finding, described in the previous chapter, that skilled clinical assessment has therapeutic effects in its own right (Finn and Tonsager 1992). The treatment motivation scales were not used with T. R., the socially anxious patient described earlier, but they might have been instructive. This is because T. R.’s attendance at therapy sessions suddenly became much more sporadic after the focus of the treatment turned to alcohol use, and T. R. began to question whether therapy was the thing for him right now. In short, there was little sense of commitment and peace regarding the goal of reducing drink-

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ing. Had T. R. completed the motivation scales at that point, he may well have endorsed responses that reflected external motivations, such as ‘‘If I remain in treatment, it will probably be because I’ll get in trouble if I don’t,’’ or introjected motivations, such as ‘‘I come to my sessions because I’d feel guilty if I didn’t.’’ Discussion of his responses to these questions might have been illuminating or clarifying for him. After several sessions attempting to build commitment to change (phase one of motivational interviewing), T. R. indeed decided that he was not yet ready to stop drinking and terminated treatment. Again, the therapist in this case, C. N., was only at the beginning stages of training and was initially very distressed by this outcome. She viewed the experience as a failure and felt responsible for the patient’s continued drinking and the possible future repercussions of the drinking. On discussion with her supervisor, however, C. N. understood that the therapy had been well conducted and that ultimately patients’ life choices are not therapists’ responsibility. Again, many people seem to need to try and fail a few times before finally getting their drinking under control (an important piece of technical knowledge when working with patients with addiction-related problems). The therapist decided that her time with T. R. may well have been the first step in an evolving process that, after another try or two, might culminate in a better outcome for him. At least now he was aware of the issues. She sent a letter to T. R. briefly summarizing the work, stating respect for the fact that ultimately T. R. must make decisions for himself, and emphasizing her availability should he wish to try therapy again at some point in the future. At this stage, then, the work with the socially anxious patient did not proceed to phase two of motivational interviewing—consolidating and strengthening commitment to change. For patients who are ready for change, however, several specific techniques are recommended, and some of these are summarized next. Discussing a plan. In phase one of motivational interviewing, the focus is on patient-generated reasons for changing. To repeat, this an approach that selfdetermination theorists would commend because the patient’s perspective is highlighted and because the patient is in charge of the choice of whether and how to change. In phase two of motivational interviewing, the emphasis shifts from reasons for change to plans for change. To raise the issue of plans for change, therapists begin to ask questions like ‘‘Now that you’ve come this far, I wonder what ideas you have regarding what to do about all this?’’ Many of the same techniques from phase one are still used (such as reflective listening and summarizing) but now in the service of articulating a plan for change rather than articulating reasons for change.

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Communicating free choice. Even though the emphasis in phase two shifts from reasons to plans for change, the theme that the patient has ultimate responsibility and freedom of choice continues. Comments on the part of the therapist like ‘‘This is all up to you’’ and ‘‘No one can decide this for you; only you can do it’’ are important aspects of the motivational interviewing approach. Although this may sound scary (‘‘Only I can solve this problem!’’), it can also be tremendously empowering (‘‘I can solve this problem!’’). Approximately eight months after terminating therapy, T. R. recontacted his therapist and requested a resumption of sessions. C. N. planned to check in with him about anxiety symptoms, drinking, and any other things that may have developed and, then, if drinking levels remained high, to resume phase one of motivational interviewing. On meeting with T. R., it was clear that not much had changed (similar anxiety symptoms, similar drinking levels), except one important thing. The patient stated, ‘‘Recently I’ve been thinking a lot about my drinking and about what we talked about during the last couple of times we met together—the stuff about I’m drinking a lot more than most people and how drinking this much will affect my health eventually. Also, it’s not that fun anymore, and I feel even lonelier than before. I decided I’ve got to make some changes, and I want to start by trying to drink less.’’ It occurred to the therapist that the patient sounded as though he was ready to skip to phase two of motivational interviewing, including articulation of a plan for change—maybe the patient had done much of the work of phase one on his own during the eight-month interval when he was not in therapy. The therapist decided to be sure, however, and so she said, ‘‘I’m impressed that you’ve been doing a lot of serious thinking about all of this. You’ve been drinking at the same level for quite a while now, and drinking less will be a big change for you. Big changes can be hard on some people. I’m interested to hear more about the thoughts and feelings that have led you to want to drink less.’’ The patient responded, ‘‘I’m ready to change. I’m sick of sitting home by myself all the time; I feel like my life is just passing me by while I sit and watch TV and drink; and I’m starting to worry about my health, plus I have this big beer-belly.’’ Consequences of action and inaction. A straightforward strategy is to encourage patients to imagine the future consequences of continued drinking contrasted with lessened drinking. What are the future pros and cons of continuing drinking? Of reduced drinking? What fears might the patient harbor regarding reduced drinking? The therapist asked the socially anxious patient these questions, and he said, ‘‘I think I’ll feel better about myself if I drink less; maybe I could make more progress with anxiety and have some more friends; maybe even a girlfriend; it’ll be tough, I know, because I’ve been drinking so

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much I guess you could say I’m addicted. In fact, that’s probably my biggest worry, that I’ve been drinking so long that I wonder how my body and head will react to less alcohol.’’ Consistent with the results of Sherman and Anderson (1987) on enhancing psychotherapy attendance by imagining future attendance, the motivational interviewing technique of anticipating future consequences may enhance the chances that those consequences will occur. This would be beneficial, of course, but only if, as with the socially anxious patient, most of the imagined consequences are positive. If they are largely negative, this might be an indicator that more work in phase one of the treatment, building commitment to change, needs to occur. In keeping with phase two emphases of communicating free choice and discussing a plan, C. N. said, ‘‘I hear that you’re ready to take serious action, and wonder if you’ve been considering any particular beginning point?’’ T. R. answered, ‘‘Well, I’ve been thinking about a couple of things. One thing is that I could just stop drinking altogether. Another option is that I could try to gradually reduce it so that it’s at a more normal level; then, from there, maybe I could just cut out drinking altogether, or I could just keep drinking but at a moderate normal level. I’m not sure. What do you think I should do?’’ Information and advice. There is no outright prohibition of therapists’ giving advice from the motivational interviewing perspective. However, therapists are encouraged first to say something like the following, ‘‘I can give you my opinion if you really want it, but remember, you’re the one who has to decide in the end,’’ or ‘‘I do have my own opinions, but I wonder if it’s best for me to state them. If I did, I’d be concerned that it would seem like I was deciding for you, and remember, all of this is ultimately up to you, not me. Are you sure you want to know my opinion?’’ In these statements, the choice as to whether the patient wants to hear the therapist’s views lies with the patient and not with the therapist. In SDT terms, this minimizes the possibility that patients will perceive the therapist as controlling or insensitive and maximizes the possibility that patients will perceive themselves as the cause of whatever behaviors they choose. As we discussed in Chapter 2, this is only the truth, in that people do choose their own behaviors; but again, this can be a hard truth to learn. Emphasizing abstinence. Motivational interviewing for substance abuse does not coercively impose abstinence as an ultimate value or goal, but nevertheless, at some point during the therapy, information regarding the benefits of abstinence should be provided. The benefits of abstinence revolve around the fact that it’s the safest bet—if you don’t drink, it’s safe to assume that you won’t have alcohol-related problems. Related to this is that it is impossible to

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ensure a safe level of drinking that will cause no harm. Although moderate drinking is not ruled out by the motivational interviewing approach, in certain cases, such as pregnancy or past history of severe alcoholism, the therapist may give special warning against continuing to drink even moderately. When the socially anxious patient asked his therapist, ‘‘What do you think I should do?’’ the therapist said, ‘‘I have some ideas about what I might do if it were me, but you and I are different people. So I’m wondering if it’s best for me to share my opinions. What do you think is best, should I state my opinions or should I keep them to myself?’’ T. R. answered that he really would be interested in knowing the therapist’s opinion. She said, ‘‘All right, but first let me reiterate: only you can ultimately decide all of this. You want to reduce your drinking, and now, you are wondering exactly how to reduce drinking. Three options occur to me: One is committing to immediate total abstinence; another is committing to a trial period of abstinence, say 3 months or so; a third is tapering drinking down over time, to a lower level. Regarding abstinence, I should mention that from a strictly logical standpoint, it’s the best bet, because if you don’t drink, well then of course you won’t have problems related to drinking.’’ T. R. replied, ‘‘I’m not sure I’m ready for abstinence. Going cold turkey sounds too hard.’’ In keeping with the phase one technique of reflective listening, C. N. said, ‘‘I hear you saying that not drinking at all sounds like too big and sudden a change.’’ In keeping with the action orientation of phase two of motivational interviewing, however, the therapist continued, ‘‘So where does this leave us about what to do?’’ The patient said, ‘‘If it’s just a trial period, I suppose I could try that. Complete abstinence seems so huge—it’s forever. That’s such a big thing that it makes me unsure. But I think I could try it for a while and see.’’ He decided on a three-month trial of abstinence. The change plan worksheet. This form, mentioned in the previous chapter, summarizes actual plans for change and is a focal point of phase two. The patient and therapist use it as a touchstone, frequently referring back to it. It starts with the prompt ‘‘The changes I want to make are:’’ and ‘‘The most important reasons why I want to make these changes are:’’ Remaining prompts include ‘‘The steps I plan to take in changing are:’’ consistent with phase two’s emphasis on enacting change; ‘‘I will know that my plan is working if:’’ and ‘‘Some things that could interfere with my plan are:’’ These last two prompts construe the patient, not the therapist, as the evaluator of success. This approach is obviously consistent with SDT, and it is consistent with the problemsolving approaches we summarize in later chapters. As should be clear by now, therapy-related homework activities and related exercises like the change plan

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worksheet are more likely to be completed if they highlight patients’ perspectives and ability to make choices regarding their treatment, goals, and desires. To summarize the phases and techniques of motivational interviewing, the therapy occurs in two stages: phase one is dedicated to building motivation for change; phase two is concerned with strengthening the commitment to change. The phase one techniques of questioning, reflective listening, and summarizing are used throughout the therapy and reflect the therapy’s organismic philosophy that the instigator of change can only be the patient. The patient’s perspectives, choices, and rationales are elicited and emphasized, highly consistent with the focus of SDT on autonomy support. In phase two, techniques are added, such as the change plan worksheet, that facilitate the patient’s actual plans for change. Abstinence is mentioned as ‘‘the safest bet,’’ but all decisions regarding abstinence, reduced drinking, and even continued drinking reside with the patient.

Evidence Regarding the Effectiveness of Motivational Interviewing The most comprehensive study on the effectiveness of motivational interviewing comes from Project match (Project match Research Group 1997), sponsored by the National Institute of Alcohol Abuse and Alcoholism. In this study researchers compared three treatments for alcohol problems: a brief motivational interviewing intervention; a longer twelve-step-type approach modeled after Alcoholics Anonymous (AA) groups; and a twelvesession cognitive-behavioral intervention focused on improving patients’ coping skills. The term ‘‘match’’ (Matching Alcoholism Treatments to Client Heterogeneity) refers to an interesting aspect of the study’s design; specifically, researchers assessed patients’ pretreatment attributes and attitudes and determined whether these affected their treatment response to the three treatments (that is, whether the ‘‘matching’’ of patient to treatment was important). For example, it might be expected that someone who resents being controlled would do better with motivational interviewing than with the other two treatments, because motivational interviewing leaves more control with the patient than the other two treatments do. Another related aspect of the study is that the cognitive-behavioral treatment emphasizes teaching patients coping skills (which motivational interviewing specifically advises against); the twelve-step, AA-type treatment, too, has prescriptive aspects. In one sense, then, Project match pitted a treatment compatible with self-determination theory, motivational interviewing, against

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two other somewhat more directive treatments. Yet, we should not belabor this point because there are clear areas of compatibility between cognitivebehavioral approaches and self-determination principles, as we will show in the next two chapters. Nevertheless, relatively speaking, Project match’s motivational interviewing condition stands out from the other two treatment conditions, both of which focus on teaching specific techniques and strategies. Results indicated that patients in all three treatments experienced considerable improvement and that there were no clear and systematic differences between the three treatments. The brief, four-session motivational interviewing intervention achieved treatment gains comparable to a longer-term twelvestep approach, as well as to a twelve-session cognitive-behavioral intervention focusing on coping skills. Regarding the matching of patients to treatments, initial data suggested that matching made little overall difference (Project match Research Group 1997). A later report, however, indicated that patients with anger problems did better with motivational interviewing than with the other two treatments (Project match Research Group 1998). At a general level then, results suggested that, for most patients, treatment choice was not crucial; patients in one treatment did as well as patients in another. Given this, the shorter form of treatment (four sessions using motivational interviewing) might often be preferred. Nonscientifically oriented clinicians sometimes complain that scientifically supported treatments do not allow for the individualization of treatment. There are many problems with this view. First and foremost, the view is quite untrue and betrays a profound unfamiliarity with the way scientifically supported treatments are conducted. As can be seen in the examples above, treatments can be simultaneously programmatic and open-ended. Second, there is an element of hypocrisy in the view—the same practitioners who are dissatisfied that scientifically supported treatments do not incorporate concepts like personal growth and self-actualization are the same practitioners who believe that they (and not the patients) are responsible for tailoring treatment to the individual. This approach locates control in the therapist, not the patient, at odds with self-determination principles. Third, results from Project match suggest that the view is irrelevant, because the matching of patients’ characteristics to the type of treatment was, in most cases, not important. A clinician who endorses self-determination principles would likely reach the following conclusion about the Project match findings: Most patients have three validated choices regarding treatment—it is up to the patient to choose which is best for him or her as an individual. One of these treatments, motivational interviewing, emphasizes self-determination principles, and has

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the pragmatic advantage of brevity. For these reasons, as well as all the others summarized in this chapter, motivational interviewing is a solid choice. Even so, in a somewhat ironic twist, it would be a violation of self-determination principles for clinicians to insist on the self-determination-based treatment of motivational interviewing. True choice means that patients are free to choose from all validated treatments, even treatments with prescriptive elements. And as we show in the remaining chapters, even therapies with prescriptive elements may include and emphasize the principles of SDT. In a sense, motivational interviewing has it all—it is a scientifically supported treatment and its techniques represent direct applications of selfdetermination theory, which has also been scientifically supported (but in the experimental laboratory more than in clinical research). Techniques like reflective listening and emphasizing freedom of choice are obviously autonomysupportive approaches. More than any other scientifically supported treatment, motivational interviewing can be a point of rapprochement between scientists and nonscientific clinicians, because the common values of each group are clearly represented. This would be even more the case if motivational interviewing were tested regarding clinical problems other than substance abuse (a fruitful direction for future research). Other scientifically supported treatments are not as uniquely compatible with self-determination principles as is motivational interviewing. Even so, there are clear areas of complementarity regarding these other treatments, and these are the focus of the next two chapters.

9

Supporting Self-Determination in the Treatment of Anxiety and Eating Disorders

In this chapter we focus on anxiety disorders, but because there are important areas of overlap between techniques targeting anxiety and those targeting eating disorders, we also mention eating disorders, especially bulimia nervosa (the binge-purge syndrome). Our goal is to cover the demonstrated effective therapeutic approaches to anxiety disorders while showing that these therapies are most effective when practiced in an autonomy-supportive way. Further, although the therapies are quite structured and even prescriptive, they are quite consistent with SDT at their core. Generalized anxiety disorder is a syndrome characterized by persistent experiences of worry and physical tension. The worry and tension are often focused on one or more major life issues, such as finances or success at work or school. Data suggest that the genetic basis for the disorder overlaps considerably with that for depression (Kendler et al. 1992). Panic disorder involves the frequent experience of gripping bouts of fear that come out of the blue several times a week. Physical symptoms of anxiety (such as a racing heart and shortness of breath) are key aspects of panic attacks. During a panic attack, the sufferer may believe that he or she is having a heart attack and is about to die, and indeed, panic attacks are a major source of visits to hospital emergency rooms. People who suffer from severe panic disorder may become agoraphobic (afraid to go out of the house) because they

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worry that a panic attack may hit at any time and want to be in a safe place when it hits. Social phobia (also known as social anxiety disorder) involves fear and anxiety in social settings. The patient with alcohol abuse problems, described in the last chapter, had this diagnosis. For such individuals, social settings in general provoke anxiety; patients are often concerned that they may not know how to act or what to say and that others will form bad impressions of them. Attending parties, interacting with authority figures, asking others out for dates, eating in restaurants—all of these things can be very difficult for the person with social phobia. For some patients, a specific social situation, such as public speaking, is problematic. Some men with social phobia develop difficulty urinating in public bathrooms because of a performance-based social fear (for example, ‘‘What will everyone think if I’m standing here at the urinal but can’t urinate?’’). Obsessive-compulsive disorder is characterized by repetitive and unwanted thoughts about things like contamination and danger as well as an attendant, irresistible need to engage in some ritual related to the obsession. Common manifestations of the disorder are obsessions regarding germs and dirt, with attendant compulsive rituals of excessive washing and cleaning. The disorder can become so severe that the obsessions are overwhelming and the rituals absorb most of the patient’s time and even money (for example, showering or cleaning for hours each day or discarding major appliances, such as a washing machine or microwave, because of the belief that they have become contaminated). Post-traumatic stress disorder (PTSD) is an anxiety syndrome that develops in the wake of a discrete, rather severe life trauma, such as combat, a natural disaster (for example, earthquake, hurricane, or tornado), an accident (for example, a motor vehicle accident), or a physical assault (for example, rape). The anxiety syndrome includes such features as anxious preoccupation with the trauma, nightmares about the trauma, and a heightened startle response. PTSD was misdiagnosed in the man described in Chapter 7 who suffered from severe depression (at the same time that he was misdiagnosed with bipolar disorder). As with other anxiety disorders, there is evidence that selective serotonin reuptake inhibitor (SSRI) antidepressant medicines can provide some relief. Specifically regarding PTSD, Zoloft (sertraline) has received approval by the Food and Drug Administration as effective for PTSD, especially for women. Patients with any of these anxiety disorders tend to respond to cognitivebehavioral approaches, which emphasize behavioral confrontation with feared things (this leads to habituation to the feared things, in other words, to

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becoming less afraid of them), as well as the correction of any exaggerated anxiety-related thoughts that may be contributing to the symptoms. For example, a man with social phobia may begin to force himself to speak in public and ask women for dates, even though these things produce intense anxiety. When in a social situation, though his impulse is to flee, he endeavors to prevent this behavioral response. Throughout this process, he monitors his thoughts (cognitions) and works to make sure that his thoughts correlate with objective information. If he thinks, ‘‘Everyone is looking at me, and they think I’m ridiculous,’’ his cognitive task is to evaluate whether this is really so. He then looks carefully at the people around him to see if they actually are all scrutinizing him, and typically he finds that few are even looking at him. If anyone happens to be looking at him, he checks their facial expression and posture to see if there is any clear evidence that they think he is ridiculous. He usually cannot find any such evidence and instead finds that they are looking at him only because he is looking at them! Or consider someone with obsessive-compulsive disorder (OCD) that combines extreme fear and disgust of germs and dirt with rituals involving washing and cleaning. Behavioral confrontation (also known as exposure) would involve things like the patient and therapist sitting within a few feet of an office trash can, then sitting next to it, then touching its outside first with one finger and then with the whole hand, then putting one’s hand in the trash can, and so on, all the while resisting the intense urge to flee and go through washing rituals (response prevention). Note the incremental nature of this process— confrontation or exposure begins with a relatively mild stimulus (like sitting a few feet from a trash can) and then progresses in stepwise fashion. Note also the improvisational and collaborative nature of this approach—for one patient, a therapist might focus on trash cans (and the therapist collaboratively does the exercise along with the patient); but for the next patient, the therapist might focus on obsessions about symmetry and counting. For example, the therapist might encourage the patient to walk through a store or mall and purposefully violate rules of symmetry and counting developed by the patient (for example, ‘‘the number of steps from one place to another must be odd and divisible by seven, and if not, then the route must be retraced’’). For an OCD patient of this type, exposure would involve violating the rule, and response prevention would mean not retracing the route after the rule had been violated. Cognitive correction for OCD patients might involve trying to find actual evidence for the thought ‘‘If I am near trash, especially if I touch it, I will definitely get extremely ill,’’ or ‘‘If I violate counting rules, it will cause a catastrophe.’’ Through constant practice of these behavioral and cognitive tech-

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niques, and with the encouragement and coaching of a cognitive-behavioral therapist, patients with anxiety disorders often experience considerable relief (perhaps particularly if they are also on an appropriate medicine; again, for many mental disorders the optimally effective treatment package includes the simultaneous administration of medicines and of extremely specific forms of psychotherapy). The following clinical anecdotes illustrate these approaches and their compatibility with self-determination principles. Here, as always, the combination of technical-clinical skill along with attention to the patient’s motivation via autonomy support creates the optimal intervention package.

Case 1: Post-Traumatic Stress Disorder A healthy and resourceful woman, S. C., was on her way to drop off her child at school, taking her usual route through a residential area with a low speed limit. She approached an intersection with a four-way stop sign; she had never had reason to notice, but a fence and bushes obstructed the sight lines for cars that were coming from her right to the left. So she never saw the van that ran the stop sign at high speed and barreled in to the right side of her car (not, that is, until minutes later, when she came to). Both S. C. and her child were wearing seatbelts; fortunately, her child was virtually unscathed—no more than a little bruised. She, too, was relatively fortunate—on impact, she banged the left side of her head and her left shoulder on the driver’s side window and door. She was unconscious for two minutes and her shoulder was badly bruised. She was taken to the hospital, where it was determined that neither injury would result in any lasting problems. S. C.’s recovery was swift and uneventful, and she was soon ready to resume her normal activities and routines. One morning she got in her new car to take her child to school and then on to work, when she was overwhelmed by fear and anxiety. She had intense visual images of the scene of her accident (actually, its aftermath; she could not recall the accident itself) and could not seem to make these images go away. She had trouble catching her breath, her heart was racing, and she was shaky. She sat in the car in her driveway for a minute or so, deciding what to do. Should she call a friend to come take her child to school? Then how would she get to work? Should they just both stay at home? Still quite anxious, S. C. decided that she could probably manage, started the car, and pulled out of the driveway. As she approached the intersection of the accident, even from quite far away, she felt her anxiety escalating intensely. She decided that she could not face that intersection and took an alternate,

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much longer route to the school and then to work. On her way home that day, a similar scenario occurred: C. S. was very anxious but managed to return home by avoiding the intersection. That night, S. C. dreamed of an awful car accident in which her child was badly injured. She did not sleep well, and the next day she was preoccupied with the accident as well as with the thought that something awful could have happened to her child. S. C. hoped that over time this problem would fade, and in the meantime, she limited her driving to essential trips. She began to walk to the grocery store, even though it was a considerable distance and she felt embarrassed about pushing the grocery cart through her neighborhood to her home. A resourceful and strong woman, S. C. felt undercut by her fear of driving and began to doubt and blame herself for the problem. She was often on edge, and this was affecting her relationships with her daughter, friends, and coworkers. Her symptoms continued essentially unabated: she experienced high levels of anxiety while driving, avoided driving and associated stimuli (for example, movies in which there might be car accidents), was preoccupied with the accident, and had nightmares about car wrecks. For a few weeks, S. C. put up with these symptoms. Then she decided that she wanted help and told her family physician about the problem. The physician was unsure about whether medicines would help (this case occurred before Zoloft had FDA approval as helpful for PTSD in women) and referred her to a clinical psychologist whom she trusted. The psychologist, P. W., quickly diagnosed PTSD; he also screened for other disorders and noticed possible depressive symptoms, such as self-blame, feelings of sadness, problems in concentrating, and sleeplessness. The psychologist told S. C., ‘‘You’ve been through something traumatic, and when people go through these things, they sometimes develop an anxiety reaction called post-traumatic stress disorder, or PTSD. People with this syndrome experience flashbacks and nightmares about the trauma; they may be thinking about the trauma a lot, and they may feel on edge and tense much of the time. I believe that you have developed PTSD in response to the car accident. You’ve also told me about some other problems—trouble sleeping, difficulty concentrating, negative mood—that are common signs of depression. It’s possible that depression is a separate problem for you, or it’s possible that the depression symptoms stem from the PTSD and will go away as the PTSD goes away. There are safe and effective treatments for PTSD and for depression that we can discuss. But first, let me ask you, which problem would you want to work on first—which do you find most troubling?’’ Here, the clinician showed reasonable attention to the perspective of the

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patient, made a good start with rationale provision by explaining his view of diagnoses in clear and accessible terms, showed clinical-technical skill in arriving swiftly at an appropriate diagnosis and in detecting the additional possibility of depression; and provided some choice by asking S. C. which problem she would prefer to prioritize. The patient answered, ‘‘My big problem is definitely with the car accident and PTSD. I really think the only reason I’m having trouble with sleep and concentration and all that is because of the accident.’’ Using language reminiscent of the motivational interviewing technique of reflective listening, P. W. responded, ‘‘So, you feel that the depression is only a consequence of the PTSD.’’ S. C. replied, ‘‘Yes, I’m pretty sure of that. What can I do about the PTSD?’’ ‘‘I can think of three choices,’’ he said. ‘‘One choice would be medicines, antidepressant medicines. Even though the name is ‘antidepressant,’ the same medicines are sometimes used for other things, including anxiety reactions. I’ve talked to some people who believe that antidepressants were helpful to them for PTSD symptoms. But I’m not aware of any controlled clinical trial with antidepressants for PTSD showing that they are effective. A second choice is a specific form of psychotherapy called cognitive-behavioral therapy. It involves facing up to the trauma in various ways and correcting thinking patterns about the trauma that may be causing emotional distress.’’ The patient interrupted, ‘‘You said facing up to the trauma. I’m not sure what that means.’’ The clinician said, ‘‘Well, it means gradually confronting everything about the car accident that currently makes you anxious. For example, we would work together to increase your driving, even driving near and eventually through the intersection where the accident occurred. We may agree for you to visit the site of the accident on foot. Perhaps we would arrange more conversations about the accident between your daughter and you; or maybe you would visit the hospital where you went after the accident. All of these things will be challenging, but we’ll work up to them together in a gradual way so that they won’t be overwhelming. The idea of it all is that if you do enough of this facing up to the trauma, you essentially just get used to it, and it stops being anxietyprovoking.’’ Nervously, S. C. said, ‘‘You said there was a third option.’’ ‘‘Well, it’s actually not a completely separate option,’’ said P. W. ‘‘The approach here would be to get all possible benefits by doing options one and two simultaneously. In other words, take the medicine and do the cognitivebehavioral therapy. I should mention that at this point in time, the cognitivebehavioral therapy appears to have the best scientific support behind it; but

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adding the medicine to the therapy might increase the therapy’s benefits somewhat. The other advantage of having the medicine is that, because it’s an antidepressant, it might help you with sleep and mood.’’ Throughout this exchange, the clinician paid reasonable attention to both clinical-technical skill and to self-determination principles. On the count of clinical-technical skill, he summarized the treatment options that are most effective for PTSD. On the count of self-determination principles, he offered as much choice as is possible given his understanding of the scientific literature, and he provided a brief rationale for the ideas and techniques behind cognitive-behavioral therapy. Rationale provision is particularly crucial here, because the patient was being asked to confront very painful and scary material (the experienced trauma). Thus, the logic of doing so needed to appear quite clear. In addition, the clinician attended to the patient’s perspective by acknowledging that confronting the trauma would be difficult and by reassuring her that it would be a relatively gradual process. He also supported the patient’s needs for relatedness by sympathizing and stating that he was there for the patient and that they would work on the problems together. The woman agreed that the combined drug and psychotherapy approach sounded best but said that the ‘‘confronting the trauma’’ idea made her a little scared. The clinician responded that he would probably feel the same way if he were in her shoes and that feeling anxious and scared was a natural reaction— indeed, an important part of the therapy—because in order to get used to something scary, it stands to reason that one would need to go through some fear, at least at first. A prescription for an antidepressant medicine was arranged, and S. C. began taking the medicine a few days after the first interview. She returned a week after the first interview to begin the cognitive-behavioral therapy. At this session, P. W. first checked in with S. C. about PTSD and depressive symptoms. The patient stated, ‘‘I feel good that there’s a plan in place and that treatments are being started, but on the other hand, I really don’t feel very different. Driving is still a big problem; so are nightmares. My sleep is still not good.’’ He explained that both the medicine and the cognitive-behavioral therapy would take time to affect her symptoms; whatever benefits occurred in response to medicines would, in all likelihood, be apparent in around four weeks, and usually, some relief from cognitive-behavioral therapy would occur within eight weeks or so. The clinician then offered another overview of what cognitive-behavioral therapy involves—behavioral confrontation of the feared and avoided things associated with the accident, as well as an examination of and, if needed, changes in thinking patterns related to the accident. As a first step, P. W.

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suggested that the patient make up a list of feared situations and stimuli associated with the car accident. In generating the list, S. C.’s perspective was prioritized—she was the one developing the list based on her own feelings and views, and the therapist was simply assisting her (for example, in helping make it more detailed). Also, it was a collaborative process, with patient and therapist working together on a joint project, in keeping with the self-determination principle of autonomy and relatedness need-fulfillment. Her initial list looked something like this: Driving Being anywhere near the scene of the accident, especially if driving Ambulances Vans (her car was hit by a van) Any television show or movie with car accidents P. W. said, ‘‘Let’s work with this list for the moment. You listed driving as a difficult situation, but driving is a pretty general process, including lots of specific behaviors. For example, where do you keep your car keys?’’ ‘‘In my purse usually.’’ ‘‘So what about that? Taking the keys from your purse—that’s part of driving, or at least a necessary step toward it; does taking the keys from your purse make you anxious?’’ The patient said, ‘‘Actually, yeah, it does; not the same kind of anxiety as when I’m actually driving, but yes, I can notice anxiety then.’’ Together, the patient and clinician went on to break down the category of ‘‘driving’’ into smaller parts, such as taking her keys out of her purse, opening the car door, starting the engine, backing out of the driveway, turning a certain direction to go to work or elsewhere, and so on. For each of the other things on the list (for example, ambulances, vans, shows containing car accidents), they performed the same process of breaking the item down into specifics. S. C.’s list was now longer and more detailed. At this stage, the therapist is in an ideal position for choice provision. As a preliminary step, P. W. said, ‘‘Now that we have a pretty full list here, let’s go through each item, and I’d like you to assign each item a score from 1 to 10, in terms of how anxious it makes you feel. A rating of 1 means it doesn’t make you very anxious at all, and a rating of 10 means it gives you intense anxiety, at or near the highest anxiety level you’ve ever experienced.’’ Some of S. C.’s ratings were: Actually driving through the accident intersection: 10 Driving within one hundred yards of the accident intersection: 9 Being at the scene of the accident on foot: 8

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Seeing a car accident scene in a movie or TV show: 7 Driving in traffic, away from the accident scene: 7 Driving when there’s little traffic, away from the accident scene: 6 Backing out of the driveway: 5 Seeing ambulances: 4 Seeing vans: 3 Getting in her car and putting on the seatbelt: 3 Taking her car keys out of her purse: 2 P. W. then encouraged S. C. to look over the list and her ratings and to choose two or three things to work on during the coming week. He explained that she was free to choose whatever she liked but noted that things rated closer to 1 would be less likely to be overwhelming and thus might be a good starting point. She responded, ‘‘This thing with driving is really getting to me, and it’s a major inconvenience, so I think I’d better focus there—how about ‘taking the car keys from my purse,’ ‘getting in the car and putting on the seatbelt,’ and ‘backing out of the driveway.’’’ Here, the patient, not the therapist, was choosing the parameters of her therapeutic activity. Also in keeping with providing choice, P. W. agreed that these were reasonable to try and asked how often per day C. S. felt that she could do each task. She replied, ‘‘I don’t understand—you mean how many times per day can I, for example, take my keys from my purse? Or back out of my driveway?’’ He affirmed that the latter was what he meant. ‘‘Well,’’ she said, ‘‘I think I could do that multiple times per day, but I just want to make sure I understand—you want me to get in the car and buckle the seat belt and sit there for a while, and then get back out and do the same thing again later? And you want me to back out of my driveway and then pull right back in, and then do it all again later? The neighbors will think I’ve really lost it now.’’ He replied, ‘‘It’s ultimately up to you whether you do these things, but yes, I do think these small steps toward conquering fear of driving and of the accident will be good starting points, and although they may make you a little selfconscious with the neighbors to begin with, my sense is that it will be worth it, and plus, your feelings of self-consciousness will probably fade quickly.’’ The patient decided that she would try this, and specifically, that she would handle her car keys and get in the car and buckle the seatbelt at least four times a day and, after doing this for two or three days, that she would start backing her car out of the driveway at least twice a day (in addition to the times she drove for essential purposes). At the next session, C. S. reported substantial success. She had done the keys

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and seatbelt exercises and now would rate those as a 1 on the rating scale— they were no longer problems. She had also performed the driveway exercise as planned, and her anxiety about that had gone down to a 2 or 3 on the rating scale (down from 5). She had even decided to ‘‘get ahead’’ a little and drove around the block a few times during the week for no reason except just to do it. This helped with her anxiety about driving in ordinary conditions away from the accident site (rating of around 4, down from 6). Incidentally, C. S. stated that she initially felt silly doing the exercises—and wondered what the neighbors thought—but she quickly forgot these feelings and came to view the exercises as challenges she enjoyed meeting, much as if she were trying to run a certain distance or lift a certain amount of weight. The therapist’s main response was simply to admire the week’s accomplishments, using such phrases as ‘‘I’m really impressed by how you took the bull by the horns here.’’ In making such statements, he was affirming that the impetus for action and change resided with her, the patient. He was also curious about the status of such symptoms as nightmares, flashbacks, and preoccupations with the accident. Here, too, C. S. reported progress—in previous weeks, she estimated that she experienced five or so nightmares per week; during the last week, she recalled only two. Flashbacks about the accident’s aftermath, as well as brooding about the accident and associated issues, though still present, had also decreased noticeably. And, in keeping with choice provision, P. W. then posed the question, ‘‘Well, where to now?’’ Encouraged by the week’s success, C. S. responded, ‘‘I think I’d just like to work my way up the list we made. I can tell that I’m going to make the most progress with things related to actually driving, so I’d like to focus there. Maybe this week I’ll step up the drives around the block, and then also do more driving in busy areas.’’ These goals were also met, with further decreases in C. S.’s PTSD symptoms. In subsequent weeks, she rented and watched a movie that she knew contained a serious car accident, began driving in traffic daily, had several conversations with her daughter about the accident, drove her car to within a half-block of the accident intersection, visited the intersection on foot, and, near the end of her treatment, drove through the intersection, first alone and later with her child. By the end of twelve weeks of combined drug plus cognitive-behavioral therapy, C. S.’s PTSD symptoms were completely remitted. Throughout this process, the therapist monitored the patient’s cognitions related to the accident, driving, and so forth. She did have some cognitions that might have been a therapeutic target (such as ‘‘Driving, no matter what the conditions, is inherently extremely dangerous and life-threatening’’). However, as C. S. made progress with the exposure exercises (keys, seatbelt,

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driveway, movies, driving in traffic, and so on), these cognitions receded naturally, without need for special therapeutic attention. There are patients, it should be noted, for whom a cognitive focus is necessary and beneficial. For the woman who experienced the motor vehicle accident, however, exposure exercises sufficed. Together with her therapist, the woman had participated in what is variously known as a ‘‘manualized’’ treatment, an ‘‘empirically validated’’ therapy, or a ‘‘scientifically supported’’ treatment. Apparently, the terms ‘‘manualized’’ and ‘‘scientific’’ confuse some nonscientifically oriented practitioners, who sometimes caricature manualized treatments as robotic, scripted, or confining and as ignoring patients’ individuality. This misperception overlooks two basic facts: (1) ‘‘robotic and scripted’’ procedures are often helpful to people with mental disorders, as the literature on bibliotherapy and computerized treatments clearly show; and (2) in any case, cognitive-behavioral therapy, as illustrated in this example, is far from ‘‘robotic and scripted’’—the patient’s individual experience was always front and center, and a warm, trusting relationship developed between patient and therapist. Thus, SDT prescriptions were implemented throughout the treatment. The worst aspect of the common misperception that exposure therapies are dehumanizing is that it prolongs real suffering—as we write there are people with PTSD who could be remitted two to three months from now but whose symptoms will persist for many months because their therapists do not want to be ‘‘robotic and scripted.’’

More on the Interface Between Clinical-Technical Skill and Motivational Principles: An Ersatz PTSD Diagnosis The refrain should be familiar by now—attention to self-determination principles in the absence of clinical-technical skill is unlikely to help (and may harm); ignoring self-determination principles undermines clinical-technical skill. In this context, consider this remarkable account. A woman and her husband are fast asleep in their bed on a mundane weekday night, like many hundreds they had experienced before. They awake suddenly to find themselves flying through the air at great speed as debris pummels them from all directions. A tornado has hit their home, and the woman vividly remembers waking up in the air. She can recall the details of the stings and bruises of debris flying into her, of the roar of the wind, and of her impact on the ground in a grassy field about two hundred yards from her home. Miraculously, she was not seriously hurt—according to her, her ‘‘whole body was black and blue and scraped and cut’’—but she broke no bones, damaged no organs. Her husband landed in the same grassy field; he, too, was very fortunate, but less so than his wife: he sustained a severe concussion (and

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remembered nothing of the event) and a broken pelvis. That either of them survived was really incredible. Others were not as fortunate; a friend from their neighborhood was killed. She approached one of us (Joiner) at a break during a meeting, told this incredible story, and mentioned that she was undergoing ‘‘eye movement treatment for PTSD.’’ Joiner responded, ‘‘Well, I’m not sure I’ve ever heard a more interesting story; I’m so glad you were not badly hurt; I hope your husband’s well; and I’m very sorry to hear about your neighbor.’’ She expressed gratitude, and Joiner continued, ‘‘With something as traumatic as that, PTSD would not be unusual at all. If I may ask, what kinds of PTSD experiences are you having?’’ Mildly, freely, she said, ‘‘PTSD experiences? I’m not sure what you mean.’’ Joiner: ‘‘Well, for example, I imagine you might be having nightmares about the tornado.’’ ‘‘Actually, no.’’ ‘‘Oh. Well then, flashbacks about it?’’ ‘‘Not really.’’ Joiner, with slightly increasing concern: ‘‘Then you must think about it a lot.’’ ‘‘Well, as you might imagine, people ask me about it all the time—it gives you a kind of celebrity, you know—and I’ve enjoyed telling people about it. So, yes, in that sense, I think about it a lot.’’ ‘‘Do you dwell on it in a sort of negative way when you’re alone?’’ ‘‘No.’’ ‘‘Are you more jumpy now than you were before the incident? In other words, do you startle or scare easily?’’ ‘‘I don’t think so.’’ ‘‘Just after the tornado, before you started treatment, did you have jumpiness, or nightmares, or flashbacks?’’ ‘‘No.’’ ‘‘Well, I have two reactions to all this. The first one is admiration for the way you’ve handled all this—you flew through the air in a tornado and now you enjoy telling about it! The other reaction is to wonder if you really do have PTSD. What has your therapist told you about this? In fact, why did you start therapy in the first place?’’ ‘‘Relatives and friends who knew what happened said therapy would be a good idea. The therapist I see said that I’d clearly been through a trauma and so I probably had PTSD at some level, even if I wasn’t really aware of it. He said that the only real choice for PTSD was ‘eye movement therapy’ and that through the therapy, I could become more aware—and get beyond—my reactions to the whole thing.’’

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‘‘What has the therapy involved?’’ ‘‘Often I’ll just tell the details of what happened, and while I do this, I’ll follow this kind of light-stick with my eyes as he waves it back and forth. We’ve also talked about the aftermath of it all—my husband’s injuries and recoveries, the death of our neighbor, plus of course the house was destroyed.’’ Joiner, thinking he had missed something: ‘‘Yes, of course, the house; and I’m sorry, I should have asked, was anyone else in the house with you? Do you have any children?’’ ‘‘Our two girls were off at college, luckily. And, yeah, I guess the house was a kind of trauma, but we had good insurance luckily, and that all turned out pretty well, fortunately.’’ ‘‘Yes, well, good. Then I’m back to the same place—trying to understand why you’re being treated for symptoms you appear not to have.’’ ‘‘Well, you tell me.’’ Joiner, with a short laugh: ‘‘I’m not sure that I know. Why do you keep going in for treatment?’’ ‘‘Oh, my therapist is great. He is really understanding, warm, and a great listener. It’s comforting to have someone to really listen to you every week. Why, do you think something’s wrong?’’ Joiner, conflicted: ‘‘Not necessarily. It’s just that, if you do not experience PTSD symptoms, it’s hard to understand why you’d be treated for the condition! On the question of PTSD, I wonder if a second opinion might be in order. On the other hand, apart from the question of PTSD, you’re certainly right that an attentive and warm therapist can be a comfort.’’ The meeting was starting back up, and the woman and Joiner said goodbye. During the rest of the meeting, Joiner pondered the resilience of this woman, as well as the irony of an ersatz therapy being recommended for an ersatz diagnosis. From the description, the woman’s therapist had excellent motivational skill; he had motivated the woman to keep attending therapy sessions even though they were unnecessary! Unfortunately, his lack of clinical-technical skill—on both diagnostic and therapeutic fronts—was obvious. Again, clinical-technical skill (based on science) and motivational skills (based on SDT and science) are each necessary—and neither is sufficient—for good therapeutic outcomes.

Case 2: Severe Obsessive Compulsive Disorder When M. A. is about thirty, her OCD begins to dominate her life. It becomes debilitating. Keeping a job, relating to her husband, caring for her adolescent son—all these become difficult, even secondary, to her consuming

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concerns over contamination with dirt and germs and her intricate washing and cleaning rituals. She spends at least an hour in the shower every day, sometimes more if she does not follow a specified sequence of washing and has to start over. Cleaning the house is similar—it absorbs hours per day and again involves a sequence of activities that, if violated, must be repeated from the beginning. At her husband’s insistence, M. A. tells her family physician of the problem, and he refers her to a psychiatrist. The psychiatrist prescribes chlomipramine, a leading treatment for OCD. Several weeks later, M. A. meets with her psychiatrist again, and both are encouraged by the progress. The disorder has not remitted, but the amount of time spent in washing and cleaning has been cut approximately in half, and M. A. can point to ways in which her quality of life has improved (for example, better family relations). The psychiatrist recommends continuation of the medicine, with hopes that progress will continue; a follow-up appointment is scheduled for two months later. At the follow-up appointment, the hoped-for improvement has not occurred. Things are still better than they were initially, but some of the original gains from the medicine appear to have eroded. The psychiatrist recommends an increased dosage of chlomipramine, with a follow-up appointment in six weeks. By the next meeting, the situation has deteriorated somewhat. M. A.’s adolescent son invited a girl over to their house when she was not there. Later, she saw that they had rented a movie (the movie and its container from the rental store were still there) and that they had eaten microwaved popcorn. She imagined that they had watched the movie while eating the popcorn on the couch. Furthermore, she wondered whether they might have had sex on the couch. This thought was very disturbing to her, and her worries ‘‘mushroomed’’ from there: What if the sex was unprotected? What if fluids had gotten on the couch? Was her son now ‘‘contaminated’’? If they had sex before they prepared the popcorn, might the microwave have been contaminated? Her reaction was to throw the microwave away and to arrange for a charity to pick up her couch (she felt guilty about donating a ‘‘contaminated’’ couch, but her trash service would not haul it away). She understood that her reaction was out of proportion but felt that she could not control it. This state of affairs was very distressing to her and her family alike. When the psychiatrist learned of the situation, he concluded that a different approach was needed. He recommended continuation of chlomipramine but also recommended the addition of cognitive-behavioral therapy, specifically, exposure with response prevention. This technique involves confrontation of the feared stimulus—in the woman’s case, germs, dirt, and other

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contaminants—as well as short-circuiting the typical response—here, engaging in washing and cleaning rituals. A meeting with a cognitive-behavioral therapist was arranged. With M. A.’s consent, the psychiatrist and therapist had already discussed her symptoms, and so the therapist had little doubt about the diagnosis and started immediately with the therapy. In a general sense, the process of the therapy was similar to that we described above for the woman with PTSD associated with a car accident. First, a detailed rationale was provided for the ‘‘exposure with response prevention’’ technique. Again, although rationale provision is important in any motivational situation, it is particularly important with anxiety disorders, because patients are asked to do things that they really fear and do not want to do. Patients with OCD may struggle with this even more than those with other anxiety disorders—the intense quality of their fear and disgust can make exposure and response prevention an excruciating experience, for the therapist as well as the patient! Successfully enacting the therapy requires ‘‘selfapplying’’ motivation, as we discussed at the beginning of Chapter 6. Notice that rationale provision, but not choice provision, had been highlighted up to this point. For OCD, the research base clearly shows that the range of treatment choices is limited: chlomipramine or a selective serotonin reuptake inhibitor and exposure paired with response prevention comprise the entire range of choice. Thus, it is crucial to make the procedure understandable to the patient! However, choice provision became more important in the next phase of the treatment. The next step was to form a list of specific objects or situations that M. A. obsessed over and were tied to her compulsions to wash and clean. In fact, three lists were formed—one regarding her house, one regarding the therapist’s office and surrounding area, and one regarding a public place of her choice (she chose a local mall). The list for her house was of central importance, because this was the location of most of her compulsive behavior and would be the primary place where she practiced exposure with response prevention on her own between therapy sessions. The list for the mall was important, too, because it offered an opportunity to generalize progress from her home to other places. For the therapy sessions themselves, the list for the therapist’s office was important, because this would form the basis for insession exposure with response prevention exercises. Again, in keeping with the autonomy-supportive and collaborative emphases of SDT, the patient generated these lists while the therapist threw in some ‘‘brainstorming’’ tips, particularly regarding his office and surrounding areas. For example, after the ‘‘office list’’ was completed (it included things like the trash cans, bathroom area, doorknobs, welcome mats, and dumpsters

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outside the office), the therapist stated, ‘‘Many people with contamination fears are very worried about medical settings, because of fears that disease may be around, or that blood or other body fluids may be around. Is that a concern of yours?’’ With a grimace, M. A. said, ‘‘Most definitely.’’ ‘‘There is a medical practice here in the building on the third floor,’’ the therapist said (his office was on the first floor). ‘‘What about adding that to our ‘office list’ of feared things?’’ She agreed that this was a good idea. For the rest of the session they went over the lists, rating each object or situation on a scale of 1 to 10 in terms how anxiety-provoking it was. For the office list, the most anxiety-provoking objects were the medical practice, the bathrooms, and the outdoor dumpsters; lower on the list were doorknobs and welcome mats. The therapist said, ‘‘We’re about out of time, so I’d like to suggest this: I’ll photocopy these lists in a minute, so that you can take one with you and I can keep one here. During the week, you might try to experiment with the things on your home list that are not too tough; things that you rated around a 3 or so. The idea is to expose yourself intentionally to the things and to persist until you notice your anxiety level subsiding. Once you notice that your anxiety has clearly lessened, you can stop, but then here’s the crucial part. You have to resist the urge to go through washing rituals. Don’t overdo it; just experiment some so you can get a sense of the procedure, and feel free to check in with me by phone if you feel that your experimenting is too troubling.’’ At the next session, the therapist inquired how things had gone during the week. The patient reported that she’d done some minor experimenting; for example, her son had cut an apple in two, eaten one half, and left the other half on the kitchen counter. The half on the counter was still relatively fresh, but she could notice some discoloration on it. Her usual approach would be to place several paper towels over the apple, quickly pick it up and throw it into the trash, and then engage in a hand-washing routine lasting about three minutes and a counter-cleaning routine lasting about five minutes. She stated, ‘‘As I put the paper towels on it, I thought, ‘Well, here’s a good chance to try this stuff out.’ So, I picked it up with my bare hand, and just stood there for a while. Like you said, I paid really close attention to how anxious I was. At first, I was definitely anxious—I wanted pretty badly to just get rid of it and start cleaning up. But I stayed with it, and after a couple of minutes, I still was uncomfortable, but I could see I wasn’t quite as anxious as before. So I threw it away, and then was able to wait several minutes before I washed up. I still went through some routines, but I was able to cut them a little short.’’ The therapist expressed his congratulations and admiration at this, noting

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that M. A. had been particularly successful at self-monitoring her anxiety levels on an ongoing basis, at least over the few minutes of the ‘‘apple experiment.’’ This self-monitoring is a straightforward matter but often something that OCD patients have simply lost the habit of doing. Self-monitoring is also quite consistent with SDT’s emphasis on the self’s quest to master events at the ‘‘internal boundary’’—here, M. A.’s self was actively monitoring internal information and making decisions and executing behaviors on this basis. The therapist suggested that they build on this excellent start by turning to the office list. ‘‘Where should we begin?’’ he asked. ‘‘Starting off gradually seems to work well, so we probably should not start with things you rated as 10.’’ M. A. chose doorknobs and welcome mats as good starting places. The therapist continued, ‘‘As we go through these exercises, and as you do them on your own, it can be helpful to use a scale to monitor your anxiety level; in fact we can just use the same 1-to-10 scale we used to rate how anxiety-provoking things are for you. Only here, you’d be rating how anxious you currently are as you go through the exercises. For these exercises, it’s important that they last long enough for anxiety to noticeably decrease; let’s say at least by a point or two on the scale. In other words, if you start out at a 9, you’d want to persist at least until your anxiety decreases to around a 7, preferably even longer. For all of these office exercises, I want to show you that we are in this together, so I will never ask you to do anything that I don’t do first. You may notice that it makes you nervous even for me to do the exercises, and so that will be another opportunity for you to monitor your anxiety levels. As I do the exercises, I’ll periodically ask you to rate your anxiety from 1 to 10; then, as you do them, you’ll again rate your anxiety, and try very hard to persist until anxiety clearly subsides.’’ Only half-jokingly, M. A. said, ‘‘What’s to keep me from cheating? I could say I went from a 9 down to a 6, when really I’m still at a 9, and then I could stop.’’ The therapist replied, ‘‘Good point! Of course, we’re on the honor system here—it’s up to you how honest you are with your ratings, and I have no real way of knowing if you’re only saying your anxiety has decreased when really it hasn’t, just so you can stop doing the exercise. What we do is up to you, but I should point out that cheating at these exercises will keep all these problems in place. The other thing we could do is agree on a minimum amount of time for an exercise. For example, we could say that even if your ratings drop 2 or more points, the minimum amount of time you’ll engage in the exercise is x number of minutes?’’ M. A. said, ‘‘Okay, I could do that. How many minutes?’’ ‘‘What are your thoughts on that?’’ he asked.

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M. A. said, ‘‘How about two minutes, as a minimum?’’ He replied, ‘‘It’s agreed then. So let’s get right into this. I’ll put my hand on the doorknob now, we can time me on the clock over there, and periodically, I’ll ask you for your anxiety rating. You’ll get the most out of this if you don’t distract yourself; try to focus on the doorknob and my hand.’’ The therapist grasped the doorknob for two minutes and asked M. A. for her anxiety rating every fifteen seconds. The ratings were 7, 6, 6, 6, 5, 5, 5, and 4. The therapist then said, ‘‘Good. Just in the course of two minutes it seems that your anxiety decreased noticeably, to a fairly tolerable level. What’s on your mind right now?’’ M. A. answered, ‘‘I’m anxious about doing it myself, and I’m having the urge to go wash my hands.’’ The therapist said, ‘‘Of course, that’s the other key part of this—the urges about the rituals. Let’s monitor those, too, using the same 1-to-10 scale; 1 for no urges, and 10 for an overpowering urge. Where would you rate your urge to wash right now?’’ The patient assigned her urge to wash a score of about 6. The therapist then encouraged M. A. to do the doorknob exercise. She approached the door somewhat reluctantly, closed her eyes, and quickly grabbed the doorknob. Her facial expression and body posture indicated substantial but not overwhelming anxiety. At the fifteen-second point, the therapist said, ‘‘You’re doing great. What is your anxiety rating now?’’ ‘‘About an 8, I’d say.’’ ‘‘Okay, hang in there; you’re doing fine. If you can, you might get more out of this if you opened your eyes and focused on the doorknob.’’ She did this, and at the thirty-second mark she reported a rating of 8. Subsequent ratings were 8, 8, 8, 7, 7, and 7. After the last rating, the therapist said that she could let go of the doorknob if she liked and asked her to rate the strength of the urge to engage in washing rituals. The patient assigned a score of 9. The therapist said, ‘‘Okay, let’s just track the strength of that urge for a while. We can just relax for a while here, and every so often, I’ll ask you to rate the urge.’’ Over the next five minutes, the therapist asked for ratings at thirtysecond intervals, and the last rating was a 5. The therapist remarked, ‘‘Interesting. Over the course of only five minutes, the power of your urge really lessened, just by waiting it out.’’ The rest of the session was devoted to a repetition of the doorknob exercise, similar work with the doormats, and planning between-session exercises at home and at the mall. The therapist reiterated M. A.’s in-session success at waiting out the cleaning urges and encouraged continued practice of this, especially just after arriving home from the session (the therapist sought to prevent the possibility that M. A. would immerse herself in rituals at home in

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response to the in-session exposures). The two also discussed pleasant activities to replace ritualistic activity. The patient identified walks with her husband, playing board games and watching movies with her son and husband, and helping her son with homework as activities she would feel good about increasing. Subsequent sessions followed in this same vein, with escalating intensity and length of exposure. Over fifteen or so weeks, M. A. mastered a series of previously feared things, ranging from handling paper trash in the therapist’s office to touching the dumpsters outside his office to touching things associated with the medical practice (for example, a special overnight delivery bin where blood and urine samples were kept; permission was obtained from the practice’s medical director, who also affirmed that touching the bins was medically safe). She ended the therapy with no OCD symptoms; regular follow-up visits with her psychiatrist were scheduled, however, as was a ‘‘check-in’’ session with her therapist six months after therapy ended. An interesting footnote to this woman’s experience was that the hardest obsessions and rituals for her to overcome involved her bedroom. When asked why, she replied, ‘‘It’s my special territory. Everything in there is mine and just the way I like it. I feel safe there, and I want to make sure no one violates my special territory.’’ Desires for safe and special territory are universal in people and animals, and indeed, there is conceptual overlap between desires for territory and needs for autonomy and self-determination. Interestingly, though, people with OCD may suffer from excessive ‘‘territoriality.’’ It is instructive to consider the nature of territoriality in greater detail. First, human territoriality has been described as an ordering of the environment (Malmberg 1980), and thus there is an obvious phenomenological similarity between territoriality and OC symptoms (such as counting, partitioning, stacking, and so on). Further, territory restrictions are clearly associated with a range of OCD-like behaviors in animals, including fish, reptiles, birds, and mammals (for example, Draper and Bernstein 1963). One such behavior is canine acral lick dermatitis (compulsive self-licking, to the point of causing skin damage), which can be induced by territory restrictions (Stein et al. 1992) and which, interestingly, can be treated with the anti-OCD medicine chlomipramine. Joiner and Sachs-Ericsson (2001) have empirically documented the connection between territoriality and obsessive compulsive symptoms and disorder, showing, among other things, that extreme territoriality serves as a risk for the future increase of OC symptoms and that OCD patients manifest territoriality needs by choosing to sit farther from their therapists than nonOCD patients. The clinical implications of this are interesting to consider in light of self-

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determination principles. Is the patient being ‘‘controlled’’ by territorial obsessions? One potential prescription is that therapists should be encouraged to intrude into the territory of OCD patients! However, such intrusiveness is hard to reconcile with the idea of supporting a patient’s autonomy. A contrasting implication is that, because severe territorial restrictions appear to produce OC-like phenomena in people and animals, ‘‘most-prized’’ territories should probably remain intact and available so that they can buffer against symptom relapse. This supports patients’ wishes, but it may permit patients to hide in a cocoon of their own devising. We support a middle position: we advocate approximately normal territory use, such that territories serve as places for autonomy, self-determination, privacy, security, and rest but not as havens for OC symptoms. Indeed, for the woman described earlier, M. A., some of her most challenging—and ultimately most beneficial—homework assignments involved bringing ‘‘contaminants’’ into her bedroom. As M. A. and the therapist gradually reduced M. A.’s distressing obsessions regarding her bedroom, she was enabled both to extract full benefit from her ‘‘home space’’ and to free herself from her disorder at a level closest to her sense of self. The description of M. A.’s experiences with treatment illustrate the best empirically supported treatment of OCD—namely, ‘‘exposure with response prevention.’’ What has also been demonstrated is the compatibility of this very technical behavioral therapy with the self-determination principle of autonomy support. In particular, rationale provision was highlighted, especially in the beginning stages of treatment. Later, choice provision, too, was emphasized (for example, in generating lists of feared situations and in choosing which to prioritize). Throughout the process the patient’s perspective on matters was continually elicited, reflected, and supported. An additional aspect of the therapy was the therapist’s willingness to first do everything he asked the patient to do; this showed solidarity and enhanced the sense of partnership and relationship between the two of them. To summarize again: the therapist’s attention to clinical-technical elements was crucial for successful treatment, but attention to self-determination principles was also crucial, because motivation failure is the main obstacle to treatment success. Clinical-technical skill and self-determination principles facilitate each other and maximize benefits for people who are suffering.

Other Anxiety Disorders The examples of the women with PTSD and with OCD illustrate the general cognitive-behavioral approach to the anxiety disorders. The approach is straightforward and involves the behavioral confrontation of and habituation

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to feared things, as well as correction of any exaggerated anxiety-related thoughts. The research support behind the approach is compelling. In general, the same approach applies to other anxiety disorders, such as panic disorder, social phobia, and generalized anxiety disorder. For generalized anxiety disorder, however, the focus is often more cognitive than behavioral. This syndrome involves worry and tension centered on major life themes, such as finances (‘‘Can I support myself and my family?’’), relationships (‘‘What if she leaves me?’’), or work success (‘‘Am I doing well enough to keep my job?’’). For someone worried about the stability of relationships, for example, the clinical task would be to identify cognitions underlying the worry (for example, ‘‘My partner is not satisfied with me and there’s nothing I can do about it,’’ or ‘‘If my partner is not with me, I will not survive’’) and to evaluate and counter these cognitions with objective information. For example, to evaluate the thought ‘‘My partner is not satisfied with me and there’s nothing I can do about it,’’ the patient might be encouraged to actually ask the partner about satisfaction. If dissatisfaction actually does exist (and it may not—‘‘you can’t know for sure until you ask’’), the patient might be encouraged to determine the specific areas of dissatisfaction, as well as list areas where things are going well in the relationship. Regarding areas of dissatisfaction, the patient might be encouraged to negotiate ways of decreasing dissatisfaction. As soon becomes apparent, something can be done about it! Throughout all this, the capable cognitive therapist will emphasize and prioritize the patient’s perspective, but, it is key to point out, this does not include the therapist’s validation of anxiety-producing cognitions. For example, a patient with generalized anxiety disorder might state, ‘‘I’m so worried that my wife will leave me that I’m not concentrating at work, and so that makes me worried about work performance, and I know that if I screw up my job, my wife will have even less reason to be with me, so it is all just snowballing inside of me.’’ A clinician who is only attending to perspective-taking might reply, ‘‘You’re concerned about the future of your relationship and of your work; you’re worried that both might end badly and that things could spiral downward.’’ This is a good example of ‘‘listening with empathy,’’ mentioned in the chapter on motivational interviewing, but by itself, it would probably not be helpful to a patient with generalized anxiety disorder (and given the propensity of people with this disorder to catastrophize, the statement, if left hanging, could provoke and consolidate anxiety). By contrast, the following statement incorporates perspective-taking and listening with empathy but uses those techniques as a foundation on which to base effective clinical-technical interventions: ‘‘You’re concerned that your marriage and work life aren’t going well and that the problems feed off of each

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other, so that it all seems very overwhelming to you. I see that you’re in a lot of distress about this. I have a suggestion for something that you and I can do together that may help. Let’s first focus on the thoughts underneath your conclusions that things aren’t well. Once we’ve identified the thoughts, I want to play a game of ‘prove it’ with you. In other words, your thoughts on all this may well be on target, but how can we know for sure? For each thought, try to convince me of its accuracy, using only objective information. Through this process, we may discover that you’re right about your marriage and work, in which case we’ll discuss how to cope with that. But we may discover some misperceptions, and if so, then uncovering these and correcting them could be quite a relief.’’ Here attention to the self-determination principle of perspective-taking is not therapeutic by itself; rather, it lays the groundwork for cognitive interventions that are therapeutic. It is also worth pointing out how readily one can acknowledge another’s perspective without necessarily agreeing that it is true. Clear insistence on evidence is just as important for evaluating individual patients’ maladaptive beliefs as it is for evaluating advertised claims regarding such ‘‘alternative’’ therapies as eye-blink desensitization! BULIMIA NERVOSA

Bulimia nervosa is the binge-purge syndrome. It commonly affects women, but as many as 15 percent of people with bulimia are male. People with the disorder regularly binge on large amounts of food (often feeling unable to control the binge) and then regularly engage in compensatory purging behaviors, such as self-induced vomiting, abuse of laxatives, and the like. The disorder is serious. Without treatment it can persist and recur throughout most of adult life. It is associated with numerous physical health problems (such as damage to the digestive system), and it is occasionally fatal (usually through electrolyte imbalance, which leads to cardiac problems). Cognitive-behavioral therapy is a leading treatment for bulimia (Fairburn et al. 1995). As with generalized anxiety disorder, the cognitive component of the therapy is key, and the use of perspective-taking as a platform from which to engage in cognitive interventions is an approach that combines effective therapeutics and self-determination principles. Bulimia is sometimes compared to obsessive-compulsive disorder because the two syndromes share some similarities. Both involve obsessions—for the bulimic patient, food, diet, weight, appearance, and attractiveness are common obsessions. Both syndromes involve compulsions tied to the obsessions— for the bulimic patient, binging and purging behaviors both have compulsive qualities. It has been found also that eating-disordered patients, when

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compared to general psychiatric patients, display higher levels of rumination and rituals as well as excessive cleanliness and orderliness (Rothenberg 1990). Also relevant to the overlap of the two syndromes, selective serotonin reuptake inhibitor medicines have been demonstrated to be helpful for both, and perfectionism—which is clearly related to OCD—is a reliable predictor of future bulimic symptoms (Joiner et al. 1997). Given the overlap of bulimia and OCD, exposure with response prevention for bulimia (as an adjunct to empirically supported cognitive therapy, perhaps in combination with SSRI medicines) may be worthwhile. The approach would be similar to that described earlier for the woman with severe OCD, but the list of feared stimuli would include foods and associated experiences (such as grocery shopping) as well as appearance-related issues, and the responses to prevent would involve binging and purging. In-session exercises might involve the eating of particular foods and countering the impulse to purge the food. In this approach, rationale provision is crucial; a bulimic woman is likely to be extremely reluctant to bring food to eat during therapy sessions. The therapist can emphasize choice by asking patients to take the lead in planning and structuring the contours of the exercises. Modeling—the therapist engaging in the same exercises as the patient—may lead to shared perspective and experiences as well as an enhanced connection between therapist and patient. In caricature, scientifically supported treatments ignore self-determination principles and construe therapists as robots reading from a script. Of all the scientifically supported treatments for mental disorders, it is easiest to apply the caricature to anxiety disorder treatments, because they are among the most structured of all such treatments. But in reality, the treatments require clinical-technical skill, sensitivity, warmth, and attention to motivational issues. There are clear areas of complementarity regarding these treatments and self-determination principles, and we have illustrated these areas in this chapter through several clinical examples. We believe that clinicians who ignore scientifically supported treatments for anxiety disorders cause harm by needlessly prolonging real suffering in patients. However, clinicians who ignore self-determination principles may also cause harm by failing to motivate their clients to take full advantage of these clinical and technical procedures. In our final chapter, we demonstrate this once again in considering mood and personality disorders.

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Supporting Self-Determination in the Treatment of Mood and Personality Disorders

In the early nineteenth century, the French psychiatrist Jean-Etienne Esquirol described depression in much the same way that we would characterize the condition today. Here’s what he said in 1811: ‘‘There are individuals who fall into a state of torpor and mental depression. They complain of want of appetite . . . there is a kind of compression in the head, which prevents them from fixing their attention or arranging their thoughts . . . they become indifferent and filled with gloomy ideas, and desire or even invoke death.’’ Esquirol had it essentially right almost two centuries ago. You might protest that the ancient Greeks anticipated this definition two thousand years ago. Although it is true that the Greeks wrote about melancholia and had their theory of ‘‘bile’’ (that is, too much of a certain bodily fluid, black bile, leads to melancholia), what they meant by melancholia was far broader than what Esquirol meant by depression. The Greeks’ melancholia covered all sorts of things, including what we today would call anxiety disorders, delusional disorder, and schizophrenia. Not until Esquirol and his colleagues came along was the concept of depression narrowed down into its modern form. In fact, Esquirol’s words compare very favorably to the current description of ‘‘major depression,’’ which consists of the following nine symptoms: (1) sadness and irritability; (2) anhedonia; (3) low energy; (4) low self-esteem and guilt; (5) ‘‘motor’’ changes; (6) appetite changes; (7) sleep changes; (8) concentration problems; and (9) suicidality. 165

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A comment on each of these symptoms in turn: 1. Sadness and irritability. When most people think of ‘‘depression,’’ they assume that sadness is part of the picture. Of course it frequently is, but sadness is not required for a diagnosis of major depression. Neither is irritability, but irritability is often a key part of depression’s picture, even in the absence of sadness, especially among children and adolescents. 2. Anhedonia. This means the loss of the capacity for enjoyment or pleasure, and is a telling symptom. That is, if you’re anhedonic, depression is a good bet; by comparison, if you’re sad, depression is a possibility, but so are many other problems. 3. Low energy. Not only might a depressed person not be able to get pleasure out of things, but he or she may not have the energy even to do them in the first place. 4. Low self-esteem and guilt. It is common for depressed people to be selfblaming and to harbor negative self-views. 5. ‘‘Motor’’ changes. This usually involves feeling slowed down, like walking in glue or gel, or as if one’s limbs were really heavy (what Esquirol meant by ‘‘torpor’’). For those with no energy, feeling slowed down is not surprising. Another form of movement-related symptom is agitation. Patients who experience extreme forms of this symptom say that they feel so stirred up inside that they ‘‘just want to scream,’’ and they pace and fidget to the point that it’s very obvious that they’re quite uncomfortable. 6. Appetite changes. Usually, depressed people lose their appetite, but overeating can also be a symptom, and when this symptom is present, it’s usually either carbohydrates or sweets that people crave. 7. Sleep changes. Usually, depressed people lose sleep; they get insomnia. But they can also oversleep, and in severe forms, people may sleep most of the time (up to sixteen hours per day). The appetite and sleep symptoms often ‘‘work in tandem’’—that is, oversleeping and overeating often go together, as do insomnia and loss of appetite (not a hard and fast rule, but generally true). 8. Concentration problems. Keeping focus can be a struggle for depressed people. For example, it may take four or five readings of a few lines of the newspaper for it to register. Relatedly, decision-making can be a problem for depressed people. If one is having trouble focusing, and low in energy to boot, it stands to reason that decision-making would be difficult. 9. Suicidality. Depressed people consider suicide, they plan it, and tragically, in a surprisingly large proportion of cases (as high as 10 percent), depressed people die from their disorder, the mechanism of death being suicide.

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The diagnosis of major depression is assigned to people who have either or both anhedonia and sadness and irritability, and who have at least five of the nine symptoms, for more days than not, for at least two weeks. So, for someone who is experiencing no pleasure, is low on energy, is self-blaming, is having sleep problems, is talking of suicide, and in whom symptoms have persisted for at least two weeks, the diagnostic label applies (and treatment should be obtained). Another mood disorder also deserves mention here. Dysthymia (pronounced dis-thigh-me-uh) can be viewed as a less intense but more chronic version of major depression—it’s a chronic, low-grade form of the disorder. The only good news about dysthymia is that there are usually fewer symptoms than for major depression, and usually dysthymic symptoms are milder. To be assigned the diagnosis of dysthymia, one must have depressed mood (or, for youth, irritable mood) more days than not and have two or more of the following: appetite change, sleep change, low energy, low self-esteem, difficulty in concentrating, and feelings of hopelessness. But the real problem with dysthymia is that it is so chronic—its minimum duration is two years for adults, one year for children and adolescents. Incredibly, the average length of dysthymic episodes is about ten years! Because dysthymia lasts so long, it tends to work its way into the fabric of people’s everyday lives. That is, people with dysthymia may view their symptoms as ‘‘just the way it is’’ or ‘‘just the way I’ve been for years’’; one of us worked with a person with dysthymia who stated that she had been ‘‘depressed since I was in the womb.’’ Because people with dysthymia may see the symptoms as usual, they may not seek treatment. This is a shame, because the same treatments that work for major depression (certain specific forms of psychotherapy and antidepressant medications) also appear to work for dysthymia. It is perhaps surprising, though true, that decades’ worth of dysthymia can be quickly improved by certain short-term treatments. Disorders like major depression and dysthymia are serious. Both cause distress and impairment on a par with major medical conditions; both are longlasting (for example, the average episode length in major depression is around eight months), and in the case of major depression, once it finally does go away it tends to come back; and both are potentially lethal through their association with suicidal behavior (Rudd, Joiner, and Rajab 2000). Accordingly, treatments that work, that work relatively quickly, and that keep people well over the long term are at a premium. We describe some of these treatments here and illustrate their clear compatibility with and enhancement by self-determination principles. In the following sections, we present some basics regarding two effective psychotherapies: the

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cognitive-behavioral analysis system of psychotherapy (McCullough 2000) and interpersonal psychotherapy (Klerman et al. 1984).

Cognitive-Behavioral Analysis System of Psychotherapy (CBASP) This approach, mentioned in Chapter 7 regarding the man with treatment-resistant depression, involves repeated analysis of specific situations in patients’ lives. Essentially, the method consists of six regimented steps. As indicated by recent clinical trials (Keller et al. 2000), ideally the cognitivebehavioral analysis system of psychology is simultaneously accompanied by a regimen of antidepressant medication. Step 1 is to identify a specific situation that meets the following criteria: it must be (1) recent (that is, within the past several days); (2) specific and discrete, covering a small ‘‘slice of time’’ (that is, something that began on a given day and was over minutes later that same day); and (3) somewhat distressing. The approach requires working only with specific situations, because they are manageable—the idea is that progress is more likely under manageable conditions and that, once initiated regarding small things, it will generalize to larger issues in a ripple effect. Patients with major depression and dysthymia often struggle to identify specific distressing situations to work on. The problem is not that they do not encounter such situations—quite the contrary. Rather, the issue is that they are drawn, understandably, to talk about major, more general issues (for example, marriage or the meaning of life). The problem with focusing on such general issues is that it is very hard to make rapid progress on them. And for someone with a syndrome as painful as major depression, rapid progress is important and potentially life saving. Even at this simple step of identifying a specific, stressful situation, the relevance of self-determination principles emerges. When patients have difficulty focusing on specifics and instead try to escape to the general, the therapist has a clear opportunity to understand and acknowledge the patient’s perspective. For example, a therapist might say, ‘‘I see how concerned and upset you are about this long-standing problem in your marriage. It has so many facets to it; it’s very complex. It’s even a little overwhelming hearing about it, so I imagine it must be extremely difficult to be in the middle of it.’’ Now, the opportunity for rationale provision, together with an enhanced connection between therapist and patient, is set up: ‘‘Because the problem is so complicated, with so many different aspects to it, you and I—as we work on this together—might find the whole thing more manageable if we broke it up

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into small pieces. That might be a more strategic approach. We can come at this thing bit by bit.’’ Now, choice provision: ‘‘If you were to pick out a small piece of all this—something that was recent and brief; it doesn’t have to be anything big or earth-shattering—what would you choose?’’ Step 2 is to focus on the patient’s interpretations of the situation identified in Step 1. To get this idea across to patients, a therapist might say, ‘‘When you were there in the situation, what did it mean to you? Fill in the blank—when I was in the situation, it meant ———, ———, and ———.’’ Obviously, the therapist is emphasizing the patient’s perspective and experience in this step as well. Thus, Step 2 is almost entirely a patient-driven process, with minimal steering from the therapist. Step 3 involves considering the patient’s behaviors during the situation. The therapist might say, ‘‘When you were there in that situation, you did and said what? Give me lots of detail about your behaviors—even down to your facial expressions and tone of voice.’’ Here the details of a specific situation are being collected in a systematic way. Of course, the patient’s interpretive perspective is still important here, but the therapist is primarily concerned with eliciting the facts of the patient’s behavior. Steps 4 and 5 are crucial, and represent another juncture at which selfdetermination is highlighted. These steps involve asking what the patient wanted from the situation (the desired outcome) and what the patient actually got from the situation (the actual outcome). The entire therapy is geared toward identifying and reducing discrepancies between desired and actual outcomes, by helping clients to think (Step 2) and act (Step 3) in ways that maximize their chances of getting the desired outcomes. This focus on patients’ desired outcomes is very clearly consistent with SDT. From the perspective of self-determination theory, an important problem for severely depressed patients is their failure to obtain psychological needsatisfaction. That is, people with this diagnosis may simply not be getting enough psychological ‘‘nourishment’’ in their lives (that is, experiences of autonomy, competence, and relatedness), and they may ‘‘wither’’ as a result. The focus of Steps 4 and 5 is to help patients identify their needs and to become aware of the extent to which these needs are not being fulfilled. Of course, the patient has full choice as to what to prioritize in his or her life; the therapist merely serves as a coach, applying a simple and commonsense system to help the patient focus on his or her true desires and priorities. Incidentally, the original CBASP approach recommended that actual outcomes be assessed in Step 4, followed by assessment of desired outcomes in Step 5. The reverse sequence also works well, however, and has some advantages. If desired outcomes are noted at Step 4, they are prioritized; patients can

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then directly compare what they did (Step 3) with what they wanted (Step 4). Then, by analyzing what they got (Step 5), patients may easily see things they could have done differently and can intend to do differently next time (Step 6). Again, for the vast majority of depressed patients, Steps 4 and 5 demonstrate a glaring discrepancy between desired and actual outcomes, which the therapist works to help them reduce in the future. Patients often find the large discrepancy between desired and actual outcomes both painful and motivating. It is painful to face the reality that one is not getting what one wants and needs. But it is motivational to see that there is way to alter this painful reality. In other words, the therapy gives patients the possibility of a choice between currently painful actual outcomes and more desirable future outcomes. Also, the rationale of the therapy is very straightforward and easy to communicate: anyone can understand the concrete problem focus of this therapy. Of course, another rationale for the therapy is that it works; as we mentioned in Chapter 7, Keller and colleagues (2000) have clearly demonstrate the effectiveness of the treatment, especially in combination with antidepressant medicines. Again, we regard scientific validation for particular treatments as crucial, part of the skill–technical accuracy (as opposed to the motivational) facet of truly effective treatment. Steps 1 through 5 of CBASP simply comprise an assessment of a given specific situation and contain no procedures directly geared toward actual therapeutic change (recall from Chapter 7, however, that the indirect therapeutic action of assessment alone should not be underestimated). Step 6 is where change is specifically addressed and sought. In Step 6 the therapist might say, ‘‘Now, let’s go back through this specific situation, especially what you thought and did, and for each interpretation, and for each behavior, let’s ask the question, ‘‘Did your interpretation or behavior help you or hurt you in getting what you wanted from the situation; that is, did it help or hurt in terms of your desired outcome?’’ This is a large step, because it involves going through each of several interpretations, and each of several behaviors, and evaluating each one on the sole criterion of whether it helped or thwarted the desired outcome. If it is clear that a given interpretation or behavior helped, then not much needs to be done, except to conclude that the interpretation/behavior was good one and that increasing its frequency might be worthwhile. By contrast, if it is clear that a certain interpretation/behavior was not helpful, then alternatives are sought. In other words, the approach is neither to analyze the deep roots of the interpretation/behavior nor to beat oneself up about it. Rather, the approach is simply that if something is not helping, then how about trying something else, to see if that would help.

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And so, regarding a situational interpretation made by the patient that was not likely to lead to a desired outcome, a therapist might ask, ‘‘I wonder what interpretation you might have formed instead, that would have helped you get what you wanted in that situation?’’ Through repetitions of this process, patients develop mindful ways of interpreting situations and behaving in situations that are likely to lead to desired outcomes. In other words, by slowly gaining control of their thought process (the internal boundary), patients slowly learn to meet their psychological needs (autonomy, competence, and relatedness, according to SDT). And the process is repetitious. In fact, Steps 1 through 6 comprise the entire therapy. This process is repeated over and over, in every therapy session; and then the same process, regarding new situations, is repeated at the next session. Patients are encouraged to go through the steps on their own between sessions and to bring in written summaries of this between-session activity (recall the discussion in Chapter 7 of the merits of this type of homework, as well as its compatibility with self-determination principles). The cognitive-behavioral analysis system of psychotherapy teaches a clear and simple way for the self to regulate itself, based on the identification of internal needs and desires, and the specification of better ways to meet these needs. What could be more consistent with self-determination principles? Moreover, the treatment is relatively brief (the usual course of treatment would involve fifteen to twenty weekly sessions); its effectiveness is documented, even among a difficult-to-treat population (that is, those with severe episodes of major depression lasting twelve months or more; Keller et al. 2000); and cognitive-behavioral approaches in general have been supported as ways to keep people well over the long term. This is a therapy worth knowing about. Although the treatment emphasizes cognitive and behavioral elements, it does not neglect interpersonal issues. In fact, an interpersonal history should be taken as part of the first session or two. Like most of CBASP, this is a straightforward (but really useful) matter. The therapist might state, ‘‘I’d like you to list all the people in your life, from early on to the present, who have significantly affected you, either positively or negatively. I’ll be writing down the names as you list them.’’ Often, about ten names are listed (for example, parents, siblings, early friends, romantic partners, spouses, children). The next step is say, ‘‘Okay, now let’s go back through the list, and for each person, I want you to give me a brief answer to this question, ‘‘What did you get out of the relationship with ———?’’ (It is important to say ‘‘a brief answer,’’ otherwise this exercise takes up too much time, and time is at a premium in most managed-care settings). The therapist writes down the patient’s answers. Clear benefits can emerge from this exercise. For example, a therapist might

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show the notes based on the exercise to the patient. Often, relationship patterns leap off the page to therapists and patients alike. It is not rare for a patient to say something like, ‘‘Well, let’s see here. When I was eighteen, I was in an abusive relationship, from which I got almost nothing; I got out of that, but then I was back in another abusive relationship at age twenty, and another at age twenty-two—no wonder I’m depressed!’’ When patients see these patterns in black-and-white, it sends the message that choice was involved in these relationships, which suggests that patients can perhaps make different choices. Another benefit of the taking the patient’s interpersonal history is that the therapist gets a sense of how the relationship with the patient might unfold. For example, if a patient is in hostile conflicts with most of the people on his or her list, it stands to reason that conflicts may also develop between therapist and patient. Therapists who know this in advance will be better prepared to handle it and to maintain a solid working alliance with the patient. Yet another potential benefit of this procedure is that it can alert therapists to the possibility that complicated grief reactions are playing a role in the current depression. This is not necessarily common, but when it occurs, it is useful to know about it up-front, as we will discuss when we turn to interpersonal psychotherapy in a moment. The patient’s life issues often emerge directly within the therapeutic relationship. For this reason, it can be very effective to apply the six CBASP steps to analyze ‘‘distressing situations’’ that occur during sessions (that is, misunderstandings between therapists and patients). In analyzing situations that involve the therapist, patients will often say something like, ‘‘Well, this situation isn’t really a real one; I mean, after all, you get paid to talk to me.’’ A useful tactic in this scenario is for the therapist to reply, ‘‘What, you don’t think I’m a real person? We’re working closely here together on intense and personal things. When people do that together, real feelings and connections surface. So this really isn’t so artificial a situation.’’ The value of this statement (aside from being true) is that it enhances the connection between therapist and patient and it deflects emphasis from material things (‘‘you get paid’’) to interpersonal and emotional topics. All of this is plainly consistent with SDT’s emphasis on needs for relatedness and its deemphasis on extrinsic motivators.

Interpersonal Psychotherapy (IPT) for Depression Like CBASP, IPT encourages manageable specificity. The main tactic for generating specificity is to identify one of four interpersonal areas as problematic, and then to focus rather relentlessly on that one area. The four areas are grief, role transitions, role disputes, and social skills deficits (incidentally, the

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interpersonal history exercise, mentioned above, provides a way to choose which area to emphasize with a patient). Grief is the focus when a loved one has died or left. Role transitions involve the loss of one major life role and the taking on of a new one (for example, married to divorced, career focused to retired, child focused to ‘‘children now grown’’). Role disputes are the focus when people are embroiled in conflictual relationships, often marital or familial in nature. Social skills deficits are addressed when the patient’s ways of thinking about and behaving in relationships appear to be backfiring. Often patients will report problems in several areas (for example, role disputes and social skills deficits). Nevertheless, maintaining focus on one area is a more manageable and strategic technique; progress in one area is likely to ripple outward to influence other areas positively. The rationale for IPT is straightforward: interpersonal matters make up the stuff of life—they are central to our well-being and health. Depressive episodes, moreover, are frequently linked to interpersonal disruptions. For these reasons, highlighting interpersonal issues may well be therapeutic for depression (and the outcome literature supports this, for example, Klerman and Weissman 1993). In terms of SDT’s postulated three psychological needs, IPT focuses especially on the individual’s unmet needs for relatedness. Of course, needs for autonomy and competence are also salient, as the patient chooses which relationships to focus on and is helped to develop better skills for managing them. Although no study as yet has compared the effectiveness of CBASP to IPT, our suspicion is that CBASP would likely have the edge, certainly for people who are experiencing role disputes or social skills deficits, and possibly for people undergoing role transitions. Interpersonal psychotherapy is clearly indicated over CBASP when the issue is grief, however (and because many role transitions, such as the end of a marriage, involve grief, IPT may be indicated here, too). The advantage of CBASP is its extremely clear method—therapists tend not to stray from it. By contrast, IPT’s recommendations as to what therapists actually ought to do are more general and diffuse (nevertheless, its general effectiveness is well supported; Klerman and Weissman 1993). Because IPT is excellent for depressions related to complicated grief situations (and role transitions involving grief), we describe this IPT module more fully here. There are two essential goals in IPT grief work: to facilitate mourning, and to help people learn from the experience so that future interpersonal matters go well. How to facilitate mourning? Interpersonal psychotherapy takes a refreshingly simple approach to this question. In contrast to fine-grained theorizing about stages and processes of grief, IPT assumes that people have the natural

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capacity for grief and that most go through the process in their own way, with no need for help from a therapist. However, some small proportion of people get stuck in the process or short-circuit it altogether, and depression can result. These ideas are clearly consistent with the organismic metatheory we discussed in Chapter 2 (on which SDT is based), which assumes that people have innate self-healing abilities that can sometimes be undermined. To get the grieving process back on track, the therapist simply focuses the patient on the person who has died or otherwise left them, by repeatedly posing questions about the person. Questions like ‘‘How did you meet ———?’’ ‘‘What did you like about ———?’’ ‘‘What did she or he like about you?’’ ‘‘What didn’t you like about each other?’’ ‘‘What did you enjoy doing together?’’ ‘‘What did you fight about?’’ ‘‘What date was your anniversary?’’ ‘‘What did you do on your first anniversary?’’ and on and on and on. People who have short-circuited or otherwise avoided their grief reactions cannot avoid them for long under such questioning. Here, as with anxiety disorders, it is crucial to provide a rationale for the treatment because patients are being asked to confront something difficult and painful. In the case of an anxiety disorder, patients are asked to face up to a feared stimulus; in the case of grief, the request is to face up to some memory or fact that is distressing, horrible, or deeply saddening. Patients may ask, ‘‘Why do you keep hounding me about this? I don’t see the point of stirring all of this up again!’’ This is hard for therapists to answer, especially when the situation is acutely painful (as in, for example, the death of a child). But answer they must, combining perspective-taking and rationale provision: ‘‘The depth of your grief is hard for me to imagine; how painful this must be for you. It’s so painful that I sympathize with the idea of just leaving it be. But I also worry about the idea of leaving it be. My worry is that, one way or another, grief and pain are just in the cards for you here, as they are for anyone who has suffered such a loss. My sense is that leaving it be will only prolong it and complicate it; facing up to it, as hard as it is, will get the recovery process going.’’ Most patients can accept this rationale. Besides helping patients mourn, IPT grief therapy attempts to help patients learn from the experience, so that future interpersonal matters go well. The therapist might ask, ‘‘What did you take from your relationship to ———, and how will you apply this in the future?’’ ‘‘What do you feel you did well in that relationship?’’ ‘‘What would you change about that relationship?’’ and so forth. When the topic is role transitions, the approach is quite similar. That is, the goals remain the facilitation of mourning and learning from the past to enhance the future. But of course, the focus is on a lost role (and the transition to a new role) rather than on a lost person (and the transition to new relationships).

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One should not imagine that most depressions are related to ‘‘shortcircuited’’ grief experiences (whether pertaining to a lost person or a lost role)—they are not. Still, unresolved grief plays a role in a surprising number of depressed patients and can sometimes be found lurking behind other problems. For example, Joiner worked with a woman with severe and recurrent depression. Her symptoms were usually most intense during a given time of the year; seasonal affective disorder was considered and ruled out. The patient was asked whether something had happened to her at this particular time of the year in the past. ‘‘Not that I can think of,’’ she replied. Antidepressant medicines were suggested and refused. Cognitive-behavioral therapy was suggested and accepted. Five sessions went by, with no progress. In the sixth session, however, the patient disclosed a highly traumatic interpersonal loss, which had indeed occurred at that time of year and about which she stated she had ‘‘always felt very little.’’ The therapist switched gears to the IPT grief module, to the initial annoyance of the patient. However, because the therapist supported her autonomy while suggesting the switch, she was able to develop internal reasons for continuing to engage in the process. Thus, during the seventh and subsequent sessions, deep sadness about the loss—and a river of tears—emerged. This patient was remitted by the fifteenth session and had remained symptom-free at her two-year follow-up session. To take another example, Alan Ball, creator of the Home Box Office series ‘‘Six Feet Under,’’ was interviewed on National Public Radio (‘‘Fresh Air,’’ June 30, 2001). Ball related that he was in a serious car accident at age thirteen; his sister was driving, and she was killed. His family physician advised him to be strong for his family. His family also had a generally suppressed way of dealing with emotions, he said. He reacted by staying frantically busy and overachieving, which he kept up for about twenty-five years. By then, he had had enough success as a writer to slow down a little, at which point he experienced a severe major depressive episode—one that, in his mind, was clearly related to his sister’s death (for example, he found himself brooding and dreaming about her). By his report, a course of therapy that focused on his suppressed grief regarding the loss of his sister was curative. Again, IPT is obviously compatible with people’s needs for relatedness and feelings of belonging. That is, when IPT is properly conducted, patients both resolve past losses of connection (with deceased siblings, spouses, and others) and gain a new sense of being connected and understood (with the therapist). In fact, in any kind of therapy, not just interpersonally oriented therapies, the quality of the relationship between patient and therapist is a strong predictor of success (Saunders 2000). It is also worth noting that the connection between practitioner and patient does not have to be intense and complex for it to be helpful. For example, Jerome Motto (1976) developed and tested a

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suicide prevention program targeting more than three thousand high-risk persons who refused sustained treatment. Half of the participants were contacted by telephone or letter on a set schedule; the contact simply involved an expression of interest in the person’s well-being. Over four years, mortality was lower among people who had been contacted than among those who had not. The benefits of smooth interpersonal functioning are of course not limited to mental health—they extend to health in general. As one of many examples, Joiner and colleagues showed that college students whose roommates appraised them negatively reported more physical illness and more cigarette and alcohol use. (They also reported more depression, anger, physical aggression, and lower self-esteem.) Longitudinal analyses indicated that social appraisal was more an antecedent than a consequence of mental and physical health functioning (Joiner, Vohs, and Schmidt 2000).

Choosing Between CBASP and IPT As we emphasized in Chapter 7, patient dropout is a significant issue in the field of psychotherapy delivery. Self-determination theory clearly indicates that treatment-related choice provision could be helpful, as long as the choices have been empirically validated (which is true for both CPASP and IPT). Although asking patients to make informed choices about their treatment is useful for any patient, we suggest that it may be especially useful for adolescents, who are typically struggling with issues of independence and personal responsibility. For example, one of us (Joiner) has been involved in the treatment of a severely depressed adolescent. The patient’s score on a popular depression measure, the Beck Depression Inventory, was greater than fifty; the maximum for this scale is sixty-three, and anything over thirty-five is suggestive of serious symptoms. To complicate matters, at first this adolescent strongly resisted the idea of treatment of any sort. At the initial interview, the therapist described CBASP and IPT in clear terms, gave the patient some brief readings about each, and noted that he was looking forward to hearing the adolescent’s opinion of these treatments in general and, more specifically, whether one of them might suit him. With an adolescent as depressed as this, the expectation that he would actually do the readings might ordinarily have been unrealistic. But this adolescent was very academically inclined and, even when depressed, reported that he enjoyed reading and evaluating for himself the merits of ideas in various readings. The patient returned the next week and had indeed done the readings and formed opinions. He believed that both treatments made sense but felt that CBASP was clearer and stated that he was willing to give it a try. His atten-

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dance and his motivation (for example, with homework) was consistent, and after about ten CBASP sessions, his Beck Depression Inventory score had decreased by more than forty points, and his symptoms related to sleep, appetite, energy, and concentration had entirely remitted.

Important Background Considerations Encouraging positive emotions. Thus far in the chapter we have focused primarily on depression, with its lack of positive emotions and its predominance of strong negative emotions. Although both CPASP and IPT focus on negative emotions and what can be done to remediate them, recent work in the ‘‘positive psychology’’ movement (Seligman and Csikszentmihaly 2000; Sheldon and King 2001) indicates that positive emotions should not be overlooked either. Understanding the nature and sources of the patient’s most positive experiences (even if they are all in the past) can be very helpful for both the therapist and the patient. Specifically, it is often useful for therapists to assess, near the beginning of the treatment, patients’ ‘‘previous best level of functioning.’’ A therapist might say, ‘‘Well, I’ve had a chance to learn about your symptoms, how they’ve come and gone over time, and how they are currently affecting your relationships and work and so forth. But now I would like to change gears and ask you a different question. When these symptoms are not present, when they are not pulling you down, how do things go for you? Tell me about your functioning when you’re at your best.’’ One advantage of the therapist’s asking this boils down to the fact that, if you have been depressed for a few years, you may well have forgotten that you were ever at your best—it is nice to be reminded of that. A more important advantage is that the answer to this question informs treatment goals and suggests realistic expectations for patients. Neither CBASP nor IPT (and antidepressant medicines) is a magic wand that can transform people into completely new personalities. What these therapies can do, however, is return people to their previous best level of functioning. Setting an up-front, clear, functioning-related treatment goal is a good idea in general and is often required in managed-care settings. Asking about previous best functioning often accomplishes this. Yet another advantage of asking this question is that people who ponder their ‘‘best times’’ often experience noticeable increments in positive emotions (for example, hope). Positive emotions are nice in and of themselves, but there is more to them—they set the stage for the accrual of many other benefits. Indeed, Barbara Fredrickson’s (1998) broaden-and-build model posits that

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positive emotions broaden people’s thought-action repertoires, encouraging them to discover novel lines of thought or action. A key incidental outcome of these broadened mindsets is an increase in personal resources: as individuals discover new ideas and actions, they build their physical, intellectual, social, and psychological resources. In general terms, positive emotions ‘‘enlarge’’ the cognitive context, and there is intriguing preliminary evidence that this effect is linked to increases in brain dopamine (Ashby, Isen, and Turken 1999). For example, Fredrickson and Joiner (2002) empirically demonstrated that positive emotions broaden the scopes of attention and cognition and, by consequence, initiate upward spirals toward increasing emotional well-being. In their study, 138 undergraduates completed self-report measures of affect and coping at two assessment periods five weeks apart. As Fredrickson and Joiner hypothesized, regression analyses showed that initial positive affect predicted improved broad-minded coping, and initial broad-minded coping predicted increased positive affect. Further analyses showed that positive affect and broad-minded coping serially enhanced each other. These findings provide prospective evidence to support the prediction that positive emotions initiate upward spirals toward enhanced emotional well-being via enhanced coping abilities. Joiner and colleagues (2001) evaluated this model as it applied to patients with suicidal symptoms. They found that patients prone to positive moods, as compared to those less prone to such moods, displayed more positive problem-solving attitudes following treatment for suicidal symptoms and, partly as a function thereof, displayed enhanced treatment response. These findings suggest that clinicians may improve their chances of achieving successful treatment outcomes if they present skill-building treatments during windows of positive mood for the client rather than in times of crisis. Might it backfire to ask depressed patients about their prior ‘‘best’’ times? Occasionally, when asked about their best level of past functioning, a patient will answer, ‘‘I’ve never functioned well; I’ve never had a ‘best time.’’’ In fact, the patient mentioned earlier who stated that she had been depressed since she was ‘‘in the womb’’ answered in this way. Yet this same patient, later in the same interview, spontaneously mentioned a time in her life when things were clearly better, and the therapist responded, ‘‘Things seemed much better for you then. Earlier, when I asked you about ‘best times,’ that’s what I meant. Let’s work together to see if we can get you back to that same level.’’ So, no, backfiring is not a problem. It takes only a few seconds to ask the question, which may in return yield multiple dividends in terms of helping patients remember what it is like when they are functioning well and their needs are being met. Responding to negative emotions and self-attitudes. Negativism (for exam-

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ple, gloom, bitterness, pessimism), including negative feelings about oneself, is part and parcel of the depressive syndrome. Consider the following exchange that occurred between one of us and a depressed patient, in the initial interview: patient: . . . I did bad things as a kid; never been a nice person; there’s nothing nice about me. therapist: Hmm . . . (doubtful look). patient: It’s true; it is true. therapist: I’m not sure I see it. patient: People don’t think I’m good; only those who can tolerate a lot like me. This is true. therapist: Still not sure I see it. patient: Well, perhaps you will . . . you know, there is no need to make me feel better; I just want you to be honest.

This exchange presents an interesting challenge for the therapist who wants to attend to self-determination principles. Negative thoughts (for example, ‘‘I’ve never been a nice person’’) can make depression worse, and they may even play a causal role in depression (Lewinsohn, Joiner, and Rohde 2001). A goal of cognitive therapy is to alter such thoughts. Although therapists may thus be tempted to dispute or deny patient’s negative self-beliefs, they should resist this temptation. The patient’s negative self-concept is an important part of his or her perspective and experience, which SDT indicates should be acknowledged and respected. Indeed, we believe that therapists’ failure to acknowledge their clients’ perspective is one of the most important causes of early dropout from therapy. How can a patient’s negative views be acknowledged but not condoned? Again, a simple solution to this dilemma is use neutral or ‘‘disidentified’’ acknowledgment of patients’ negative self-views. For example, the therapist in the exchange above might have stated, ‘‘I see that, from your perspective, you feel that you have negative characteristics. I know this makes sense to you now, but let’s keep thinking about it.’’ Statements like this can build early understanding, confidence, and trust between patient and therapist, even though it is clear that the therapist does not necessarily agree with the patient. Once trust and confidence are established, negative self-views can be challenged (but notice that in CBASP, unlike in traditional cognitive therapy, direct challenge of cognitions is not central; rather, evaluation of whether or not cognitions facilitate desired outcomes is more important). Suicide risk assessment. When therapists are preoccupied with patients’ potential for suicidal behavior, they may have special difficulty being autonomy

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supportive. Therapists who support a patient’s right to choose death may even be held legally liable for that patient’s suicide! Exacerbating this problem is e that suicide risk assessment has several complexities and ambiguities. If therapists develop the clinical-technical skill to assess suicide risk efficiently and routinely, this pressure will be lessened, and attention to other things, including self-determination needs, may be heightened (see Joineret al. 1999 for an objective, science-based, and efficient framework for suicide risk assessment). Here clinical-technical skill can facilitate attention to self-determination principles, rather than the other way around. Of course, the assessment of the patient’s risk for suicide may produce a situation in which self-determination needs become secondary to safety. Specifically, patients who are categorized in the highest risk category, based on an objective framework such as that developed by Joiner and colleagues (1999), must go to the hospital, even involuntarily if necessary. Still, even here, selfdetermination values can be incorporated; the therapist can listen empathically to patients’ crisis-related experiences and worries about hospitalization and can calmly provide a rationale for the need for hospitalization, even if he or she cannot honor the patient’s (momentary) choice to die. An emphasis on self-determination may also help clinicians cope with the reality of patients’ suicidal behavior, including death by suicide, by helping them acknowledge that patients, not clinicians, are ultimately responsible for and in control of their behavior. One of us was involved in a treatment research project on suicidal behavior. The project was successful in that interventions seemed effective, and to our knowledge, no participant had died by suicide by the time of the long-term follow-up. During the initial screening for entry into the project, however, it became clear that an applicant was acutely suicidal and in need of immediate hospitalization (he certainly was not an appropriate candidate for entry into the treatment project, which was conducted on an outpatient basis). Project staff made the correct clinical-technical decision (hospitalization), without any doubt whatsoever. The man was very resistant to the idea of hospitalization, but project staff remained calm, listened to his concerns intently and with empathy, and quietly explained the rationale for his hospitalization. At every turn, the staff’s performance was excellent. By the time an ambulance arrived to take the man to the hospital, he was calmer. On the way to the hospital, however, the man assaulted the ambulance staff, broke out of the ambulance, and ran to his home, where he later died by self-inflicted gunshot wound. In short, as in health-care settings generally, death is a reality in mental health-care settings. Clinicians who imagine that they determine patients’ behavior will not cope well with this reality; clinicians who understand self-determination principles will be

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saddened by the reality of death by suicide, but as long as they are attending carefully to standards of care regarding risk assessment and treatment, they are unlikely to feel excessive responsibility and guilt.

A Brief Note on Personality Disorders Personality disorders involve long-standing patterns of thoughts, feelings, and ways of relating to others that cause problems in many domains of life. We mentioned one of these disorders, borderline personality disorder, in Chapter 7 when discussing the patient who diagnosed with borderline personality disorder and was forced to find out about it from the Internet, with negative consequences. Other personality disorders include narcissistic personality disorder (excessive sense of self-importance and entitlement; extreme sensitivity to criticism), avoidant personality disorder (pervasive fear and avoidance of all social situations), dependent personality disorder (extreme dependence on others for sense of worth and decision-making), and schizotypal personality disorder (pattern of odd and eccentric behaviors and belief patterns). For patients with personality disorders, issues related to self-determination tend to be especially important. Independence, autonomy, control—these are not easy topics for people with long-standing interpersonal problems. Indeed, a failure to develop true autonomy is at the heart of many types of developmental psychopathology, as manifested in the excessive but immature independence concerns evidenced by many with personality disorders (Ryan, Kuhl, and Deci 1997). Of course, these dynamics can easily affect relationships with therapists, making clients with personality disorders especially hard to treat. Although CBASP was originally developed for and tested regarding depression, it has considerable promise in the treatment of personality disorders. One of its main merits for these disorders is that it circumvents many problems that can arise between therapists and patients. CBASP is all about the patient’s own desired outcomes, and this focus tends to neutralize—that is, take the sting out of—any therapist-patient interpersonal conflicts. The CBASP technique for personality disorders proceeds as we described it above, with two simple amendments. First, instead of the usual course of therapy of fifteen to twenty sessions, therapy for personality disorders often requires more time (for example, weekly sessions over the course of a year). Second, Steps 2 and 3 of CBASP, which are concerned with patient’s interpretations of situations and his or her behaviors in those situations, are focused specifically on interpretations and behaviors related to the personality

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disorder. For example, a patient with narcissistic personality disorder may, in Step 1, describe a situation in which an interpersonal dispute occurred. In Step 2, he may list the following interpretations: ‘‘The other person wasn’t appreciating my unique abilities.’’ ‘‘I was disappointed about how this was going.’’ ‘‘I thought that I need to stop hanging around with this person.’’ Of course, in the CBASP system, these interpretations can only be evaluated in light of their connection to the desired outcome. Assuming for this example that all three interpretations were not helpful in achieving desired outcomes, the therapist might want to prioritize the first interpretation (‘‘The other person wasn’t appreciating my unique abilities’’) in a narcissistic patient, because the interpretation is a clear expression of the personality disorder. A similar logic applies to Step 3, concerning behaviors: those behaviors most clearly associated with the personality disorder are prioritized. Except for these two simple amendments, CBASP for personality disorder proceeds much as it does for major depression or dysthymia. One of us has supervised the CBASP therapy of a series of patients with personality disorder diagnoses, and in each case, progress has been marked and relatively rapid. In the most remarkable of these cases, the diagnosis was unmistakably schizotypal personality disorder (odd and eccentric behaviors and thought patterns, which were substantially interfering with major domains of life). As one small example of the patient’s symptomatology, the patient preferred to sit at a ninety-degree angle to his therapist, with his chair parallel to and contiguous with the wall (this symptom has an obsessivecompulsive quality, but OC features were not a prominent aspect of the clinical presentation). Astoundingly, the patient had been seen in the same setting, by a variety of therapists using a variety of approaches, with no progress, for well over fifteen years. The supervisor and the patient’s therapist, both new to the case, made two decisions: they would use CBASP, and therapy would be terminated in six months. They reasoned that the six-month deadline would be motivational for everyone involved and that if the patient was no better in six months, by then he would have had almost twenty years of therapy in the same setting with no progress, and so a change of setting would seem advisable. Indeed, this was the rationale for the time limitation that was presented to the patient (another situation where, when choice is restricted, rationale provision assumes added importance). The therapy, combined with this deadline, was very effective; the patient left after six months, at which point it was hard to defend a diagnosis of any personality disorder.

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CBASP and IPT Work and Are Enhanced by Self-Determination Principles Patients with major depression and dysthymia, as well as personality disorders, are experiencing a lot of pain, distress, and life disruptions. We have argued that treatment programs based on CPASP and IPT principles are effective, as evidenced by the best and most recent scientific data. Although some might argue that to run clients through a ‘‘program’’ is to deny them their humanity, we have tried to show that self-determination principles are actually paramount in these kinds of treatment. In other words, although structured treatment programs are sometimes mistakenly seen as incompatible with concepts like self-actualization, self-determination, and autonomy support, in reality, they can go hand in hand. Indeed, a main goal of this book has been to demonstrate the harmony between clinical science and humanistic theory (see Chapters 1 and 2) and to show that patients benefit most when clear, proven techniques are employed in ways that maximize their motivation to engage those techniques. Like it or not, patients make their own choices about their lives and the course of their therapy: we must learn to respect and support these choices, trusting that as we do so, patients’ natural inclinations for health and positive change will emerge.

Conclusion

We hope that we have shown that the self-determination theory approach to promoting health motivation works and that its principles are worth integrating into the routine care of clients. Self-determination theory is in basic agreement with other prominent approaches to behavioral change, such as motivational interviewing (Miller and Rollnick 2002) and the stages of change model (Prochaska et al. 1992). With its emphasis on the support of the individual’s autonomy, SDT is also consistent with important precepts concerning the ethical delivery of health care (Beauchamp and Childress 1989). Yet SDT goes beyond these approaches by offering an elaborated theory of optimal human functioning and development that is supported by extensive experimental and longitudinal research. Indeed, the SDT perspective informs much of the contemporary debate in the empirical mainstream regarding the nature of effective self-regulation (see Psychological Inquiry 4 [2000], for an example of such a debate), because it supplies one of the most comprehensive, integrated, and well-supported theories of human nature in existence. Thus, we believe that the vocabulary and concepts of SDT are well worth mastering. But even if not all our readers wish to master that vocabulary, we hope that we have made it clear that applying the theory’s recommendations may help providers to increase their clients’ motivation. The basic message is simple, and certainly not so new: when clients feel that their personhood and right to

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choose are respected, then they are much more inclined to accept responsibility for behaving in healthier ways and to engage actively in attempts to improve their mental and physical health as well as their quality of life. More specifically, when clients feel that their needs for autonomy, competence, and relatedness are supported, then they are enabled to go further in their efforts to change and to maintain healthy behaviors they have already adopted. Why? Because these experiences afford a connection of their sense of the self to the behavioral intention, providing a vital spark (or intrinsic energy) that helps them to invest lasting effort. It is certainly hard to argue that the converse is true: that clients are more motivated when providers try to control them or make them feel alienated, misunderstood, incompetent, or ineffective! Of course, given the subtle interpersonal dynamics involved in SDT therapy, supporting clients’ needs is no easy job. Ours is an intensively client-centered approach, one that requires skill and insight on the part of the provider, as well as a willingness to focus first on the client’s perspective, then negotiate goals and agree on plans with this information in mind. Because providers face many stresses (often resulting from a failure of the work environment to support providers’ own psychological needs), in addition to having their own personal issues, this can be a lot to ask. Indeed, we ourselves are constantly learning about ‘‘the delicate discipline’’ of motivating and empowering others. As just one example, imagine our embarrassment when a reviewer of a draft of this book pointed out that our list of recommendations to providers (given near the end of Chapter 3) was phrased as a list of ‘‘shoulds’’! The tendency to assert subtle control over others is deeply ingrained in human nature and hard to overcome. But when considering behaviors that clients must be selfmotivated to maintain, cases where the ‘‘authority’’ has little real authority (which we believe characterizes most clinical cases), overcoming this tendency is essential. A master clinician need not be a master speaker or communicator to facilitate the client’s motivation. Indeed, highly polished verbal skills can impede the client’s empowerment, to the extent that they induce clients to locate the causality for their behavior within the provider. From the perspective of SDT, what matters is not weaving a spell of inspired speech but, rather, creating an interpersonal context and relationship in which clients can encounter their own resolve. Such relationships can be forged in many ways for those who make the effort. Is the effort worth it? We believe so. As we argued in Chapter 4, there is often a huge motivation gap between clients’ intended and actual behavior. Closing that gap, even slightly, can make a huge difference for our clients and for public health more generally. In sum, as we have argued throughout this book, clinicians need two basic

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attributes to succeed in their mission: they need technical knowledge backed up by the best research data, so that they know what to recommend, and they need sensitivity to motivational dynamics, so that they know how to recommend. Training programs in medical and mental health disciplines do an excellent job in imparting technical knowledge. In many cases, however, they give insufficient attention to the question of motivation and how to support clients to use this knowledge to achieve mental and physical health. This book represents a modest step in advancing this knowledge.

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Index

The abbreviation ‘‘t’’ indicates a table, ‘‘f’’ a figure Abramson, L. Y., 9 adolescents, 56, 60, 176–77 Affleck, G., 31 agenda setting techniques, 94–95, 100t alcoholism treatment: abstinence and, 137–38; attendance at therapy sessions in, 55–56, 121–22, 134–37; change plan worksheets in, 138–39; cognitivebehavioral psychotherapy in, 129; consequences of action and inaction in, 136–38; failure experiences in, 134– 35; motivational interviewing in, 130– 32, 136–39; Project MATCH and, 139–40 Alloy, M. E., 9 alternative therapies, 110–12, 117, 153– 54 Amabile, T. M., 14 American Psychological Association (APA), 110–11

Anderson, C. W., 30–31 Anderson, Craig, 122, 133, 137 anxiety therapy: cognitive-behavioral therapy and, 127, 162–63; confrontation in, 144–45, 147–49, 156–60; medication adherence in, 143; motivational interviewing in, 127–29; social anxiety and, 127–29, 143. See also depression therapy Aron, A., 19 Aron, E. N., 19 Ashby, F. G., 178 attendance at therapy sessions, 55–56, 121–22, 134–37, 179 autonomy support: attendance at therapy sessions and, 55–56, 121–22, 134–37, 179; in client-provider relationships, 29–30, 37–38, 51–54t(52t), 59–61, 75; in depression therapy, 114–16; in diabetes management, 92–93, 96–97;

199

200

Index

autonomy support (continued) diagnosis delivery and, 87–88, 90–91, 114–15, 118–21; education and, 34– 35, 39–40; medication adherence and, 56–57, 60, 62; in obesity/weight-loss programs, 55, 59, 60; OCD and, 156– 57; perspective-taking and, 30, 33, 162–63, 174; in smoking cessation therapy, 48, 56, 59–61, 69–74(71t), 77–81; suicide risk assessment and, 179–81; volition and, 51, 63–64, 71t; in work environment, 36f–37. See also choice; competence; motivation; relatedness Ayanian, J. Z., 44 Baard, P., 36 Baars, B., 7 Ball, Alan, 175 Bandura, A., 62, 66 Barett, Marty, 34 Bargh, J. A., 9 Baumeister, R. F., 18 Beauchamp, T. L, 184 Beck Depression Inventory, 176, 177 Becker, M. H., 47, 56, 66 Beckman, H. B., 53, 61 behavioral confrontation, 144–45, 147– 49, 156–60 behaviorism, 6–7, 21–22, 63 behavioristic psychology, 6–7, 9, 13–15, 23 Belmont, Michael, 35 Bernstein, I. S., 160 Bettencourt, B. A., 19, 51 bipolar disorder, 114, 122–23 Blais, M. R., 25 Boggiano, Ann, 34 borderline personality disorder, 118–20 Boucher, C., 25 Braddock, C. H., 62 Bruner, Jerome, 6 bulimia nervosa, 163–64 Butler, S., 91, 94

Calhoun, L. G., 57 Carducci, D., 25 Cervone, D., 9 change plan worksheets, 124, 138–39 Chartrand, T. L., 9 Cheavens, J., 31 Child, I. L., 8 Childress, J. F., 184 choice: attendance at therapy sessions as, 55–56, 121–22, 134–37, 179; autonomy and, 30–38, 52–53(52t), 76–78, 128, 136–41, 145–51; of client and provider responsibility, 34–35, 124– 25, 134–35, 180–81; in cognitivebehavioral psychotherapy, 129, 147; in diabetes management, 92–93; ill health as, 46–47; in motivational interviewing, 135–36; in PTSD therapy, 147–51; self motivation in therapy and, 133; of treatment, 52–53(52t), 71t, 76–78, 128, 136–41, 145–51, 176; volition and, 51, 63–64, 71t cholesterol reduction, 46 Cleary, P. D., 44 client-provider relationships: agenda setting techniques in, 94–95, 100t; assessment of clients in, 71–74(71t), 121, 177–81; attendance at therapy sessions and, 55–56, 121–22, 134–35, 137, 179; authority of providers in, 5, 30– 31, 53, 57, 61–62; autonomy support in, 29–30, 37–38, 51–54t(52t), 59– 61, 75; of client and provider responsibility, 34–35, 124–25, 134–35, 180– 81; diagnosis delivery in, 87–93, 114– 15, 118–21; energy-based motivation of, 46–47; information delivery in, 56, 76, 78–79, 93–94, 131, 137–38; interpersonal history of client in, 171–72; monetary aspects of, 38–39; Project MATCH and, 139–41; quality and success in, 175–76; teachable moments in, 91, 99; treatment choice and, 52–53, 71t, 76–78, 128, 136–41,

Index 145–51, 175–76. See also interviews; motivational interviewing clients. See client-provider relationships coercion, 24, 30–31, 48–49 cognitive-behavioral analysis system of psychotherapy (CBASP): adolescents and, 176–77; depression and, 168– 70; interpersonal history in, 171–72; IPT compared to, 173; personality disorders and, 181–82; positive emotions and, 177–78; steps in, 169– 70 cognitive-behavioral therapy: alcohol consumption and, 129; anxiety therapy and, 127, 162–63; bulimia nervosa and, 163–64; coping skills in, 139–40; homework assignments in, 123–24, 138–39, 149–51, 157–61; Project MATCH and, 139–41; for PTSD, 147–52; scientific support for, 146 cognitive psychology, 7, 9–10 competence: agenda setting techniques and, 94–95, 100t; coercion and, 30– 31, 48–49; diabetes management and, 56, 57, 60, 62–63, 88–89; diagnosis internalization and, 89–90, 120; in empirical model of health motivation, 53–58(54f); failure experiences, 68– 70, 73–77, 134–35; interviewing techniques and, 100t; for mastery (effectance), 13–14; medication adherence and, 56–57, 60, 62; need satisfaction and, 26, 36f; negotiation of goals in treatment, 76–81, 185; self-efficacy and, 62, 63 confrontation in anxiety disorders, 144– 45, 147–49, 156–60 Connell, J. P., 20, 25, 55 control: authority of providers and, 5, 30–31, 53, 57, 61–62; autonomy support and, 39–40, 63–64, 99t; behaviorism and, 6–7, 21–22, 63; clients’ motivation and, 50t, 72–74;

201

coercion as, 30–31, 48–49; GCOS and, 58–59, 60; personality styles and, 35–38(36f), 57–59. See also motivation coronary artery disease (CAD), 56, 59, 60 Cox, E., 56, 60 Csikszentmihalyi, M., 12, 14, 29, 110, 177 Curry, S. J., 48 Dale, L. C., 75 Damasio, A., 10 Davidson, P. R., 117 Decharms, R., 19 Deci, Edward L.: on adolescent smoking cessation, 56, 60; on autonomy, 19, 29–30; on control orientation and coronary-prone behaviors, 59; diabetes treatment study and, 56, 59, 60, 62–63; employee need-satisfaction study and, 36–37; General Causality Orientation Scale (GCOS) and, 58–59, 60; on health behaviors, 57, 68–69, 72, 87; on human values in SDT, 5, 26; on internalization, 33, 49, 72, 87; on monetary aspects of client-provider relations, 39; on motivation, 13, 14–16, 23, 35, 46; on personality disorders, 181; on the phenomenal self, 18; Treatment Self-Regulation Questionnaire (TSRQ) and, 134 depression therapy: adolescents and, 176–77; autonomy support in, 114– 16; CBASP and, 168–73; dysthymia and, 167, 168; grief and mourning in, 172–75; IPT and, 173; negativism and, 178–79; patient evaluation of behavior in, 170–71; positive emotions in, 177– 78; previous best level of functioning assessment in, 177–78; relatedness in, 114–15; suicide and, 166, 167; symptoms of, 166 Dewey, John, 15

202

Index

diabetes treatment: diabetes defined, 85– 86; family support in, 89–90, 104–5; goals in, 92–93, 95–99t; medication adherence in, 86–87, 91–92, 102; patient motivation and, 56, 59, 60, 62–63 diagnosis: delivery of, 87–88, 90–93, 114–15, 118–21; internalization of, 89–90, 120; Internet and, 119; multiple diagnoses, 101–4 diagnostic tools: agenda setting techniques, 94–95, 100t; Beck Depression Inventory, 176, 177; change plan worksheets, 124, 138–39; General Causality Orientation Scale (GCOS), 58–59, 60, 61; Health Care Climate Questionnaire (HCCQ), 60; homework assignments, 123–24, 138–39, 149–51, 157–61; interpersonal history of client, 171–72; Minnesota Multiphasic Personality Inventory-2 (MMPI-2), 120–21; treatment motivation questionnaire, 134; Treatment Self-Regulation Questionnaire (TSRQ), 55, 61, 134 DiClementi, C., 64, 66, 68 Donahue, E. M., 11 Draper, W. A., 160 Duncan, N., 19 dysthymia, 167, 168 education: control in primary education, 24–25, 33–34; instructional strategies for autonomy support, 39–40; of patients (teachable moments), 91, 99; for providers, 71, 72, 74–76, 128, 185– 86; rewards and motivation in, 23–25; student-teacher relationships, 33–34, 39–40 effectance, 13–14, 15 Eghrari, H., 33 Elliot, Andrew, 17, 26, 57, 87 Emery, Jolee, 34 Emmons, R. A., 11 emotions, 177–79 empathy, 130–31, 162–63

energy, 46–47 Enzle, M. E., 38 Erikson, Erik, 21 Esquirol, Jean-Etienne, 165 Eye Movement Desensitization and Reprocessing (EMDR), 117, 153–54 failure experiences: in alcoholism treatment, 134–35; competence and, 68– 70, 73–77, 134–35; controlled v. selfdetermined motivation in, 73–74; in smoking cessation treatment, 69–70, 73–74, 76–79 Fairburn, C. G., 163 family support, 74, 89–90, 104–5 Farkas, A. J., 75 feedback, 98–99t, 100t Ferguson, M., 8 Finn, Stephen, 120, 134 Fiore, M. C., 44, 45, 67–68, 71, 74, 85 5 A’s model, the (smoking cessation therapy), 71t Flink, Cheryl, 34 flow, 14 Foege, W. H., 43 Frankel, R. M., 53, 61 Fredrickson, Barbara, 177–78 Freedman, Z.: diabetes treatment study and, 56, 59, 60, 62–63; on internalization of behaviors, 56, 87; on patients’ responsibility for treatment, 56, 87; Treatment Self-Regulation Questionnaire (TSRQ) and, 134 Freud, Sigmund, 7 Friscella, K., 55 Funder, D. C., 8 Gagne, M., 56, 59, 60–61, 63 General Causality Orientation Scale (GCOS), 58–59, 60, 61 Giorgi, A., 8 Glansdorff, P., 15 Glantz, S. A., 48 Glasgow, R. E., 56, 62

Index Glynn, T. J., 60 Green, D., 14 Greenfield, S., 61–62 grief and mourning, 172–75 Grolnick, G. S., 34, 35 Grolnick, Wendy, 24–25 Grothaus, L. C., 48 Grow, V. M., 25, 55, 59, 60 Harris, M. I., 65 Hawkins, W. L., 38–39 Haynes, R. B., 44 He, J., 44, 46 health behavior changes, 43–48, 50t, 63– 64, 66–69t, 74 Health Care Climate Questionnaire (HCCQ), 60 health care plans, 48 health maintenance. See physical health maintenance Hillsdon, M., 49 Hodgins, H. S., 19 homework assignments, 123–24, 138– 39, 149–51, 157–61 Horn, Miriam, 111 Howorka, K., 62 Hu, F. B., 43 Hulley, S., 46 humanism, 5, 7–9 humanistic psychology, 7–9, 19–20 Ilardi, Barbara, 26 Ilardi, S., 31 information delivery to clients, 56, 76, 78–79, 93–94, 131, 137–38 internalization: autonomy support and, 33, 50–51, 81; control and, 33–34, 49–50, 53, 72; diabetes management and, 86–91, 96–97; of diagnosis, 89– 90, 120; health-related behavior changes and, 49–51(50t), 72, 81; PLOC and, 20–21, 25, 31; reflection and, 91–92, 100t, 147. See also motivation

203

interpersonal psychotherapy (IPT): CBASP compared to, 173; grief and mourning in, 172–75; positive emotions and, 177–78; relatedness in, 173, 175; role transitions in, 172–73, 174– 75; social skills deficits and, 172–73 interviews: controlling behaviors in, 53, 61–62; internalization and, 33–34, 49–50, 53; interpersonal history in, 171–72; personality disorders and, 181; personality styles in, 35–38(36f), 57–59; providers’ authoritarian style in, 5, 30–31, 53, 57, 61–62; research on, 33–34; rewards as motivation in, 14–15, 23, 48; techniques of, 100t. See also motivational interviewing Isen, A. M., 178 James, William, 15 Janz, N. K., 47, 56, 66 Jeffrey, R. W., 49 Jencius, S., 9 Joiner, Thomas E.: on borderline personality treatment, 118–19; on bulimia nervosa, 164; on client’s life choices and provider responsibility, 125; on grief and depression therapy, 175; on health correlated with social appraisal, 176; on negative emotions and depression, 179; on positive emotions, 177– 78; on PTSD diagnosis, 153–54; on self-determination and suicide risk assessment, 179–80; on suicide, 121, 167, 178–80; on territoriality and OCD symptoms, 160 Jones, J. A., 66 Jourard, S., 8 Journal of Humanistic Psychology, 8 Journal of Personality and Social Psychology, 23, 25 Kanani, R., 44 Kaplan, S. H., 61–62 Karoly, P., 30–31

204

Index

Kasser, T., 17, 25 Keller, M., 114, 168 Kendler, K. S., 142 King, K., 25 King, L., 11 Klerman, G. L., 173 Koch, S., 8 Kochanek, K. D., 44 Koestner, Richard, 19, 23–24, 25 Kohn, A., 14 Kouides, R., 56 Kruglanski, A. W., 14 Kuhl, Julius, 181 LaRossa, J. C., 44, 46 Leary, M. R., 18 Leone, D. R., 33 Lepper, M. R., 14 Lewisohn, P. M., 179 Lichtenstein, P., 43 Lightwood, J. M., 48 Losier, G. F., 25 Lynch, J., 51 Malmberg, T., 160 manic depression. See bipolar disorder Manley, M. W., 60 Manson, J. E., 43 manualized treatment in PTSD, 149–51 Markus, H., 11 Marvel, K. M., 53, 61 Maslow, Abraham, 5 Mason, P., 91, 94 Masten, Ann S., 110 May, Rollo, 5 Mayne, T. J., 3 McCaul, M. D., 56, 62 McClelland, D., 46 McCullough, J., 168 McGinnis, M. J., 43 McGregor, H., 18 McKibbon, K. A., 44 medication adherence: in anxiety disorder, 143; in bipolar disorder, 123;

competence and, 56–57, 60, 62; diabetes management and, 86–87, 91–92, 102; frequency of, 43–44; in smoking cessation therapy, 67–68. See also physical health maintenance Metalsky, G. I., 9 Michael, S. T., 31 Miller, William, 64, 66, 68, 91, 92, 133 Mims, Valerie, 23 Minnesota Multiphasic Personality Inventory-2 (MMPI-2), 120–21 motivation: for attendance at therapy sessions, 55–56, 121–22, 134–37, 179; for diabetes management, 56, 59, 60, 62–63, 86–87, 96–98; energy-based, 46–47; failure experiences and, 68– 70(69t), 73–77, 134–35; for healthy behaviors, 46–48, 50t, 53–58(54f), 73–74, 140–41; independence and, 51, 75; internalization and, 25, 33, 49–50, 72, 81; intrinsic, 13, 14–16, 21, 23, 26; medication adherence and, 56–57, 60; obesity/weight-loss programs, 55, 59, 60; personality styles and, 35–36f, 38; PLOC and, 19, 20–21, 25, 31; rewards as, 13–15, 20, 21, 23–25, 48; in smoking cessation therapy, 48, 56, 59–61, 69–74(71t), 77–81. See also control motivational interviewing: in alcoholism treatment, 130–32, 136–38; in anxiety therapy, 127–29; empathy in, 130–31, 162–63; negative indicators in, 133– 34; patients’ reasons for change in, 135–36; phase changes in, 133–34; Project MATCH and, 139–41; reflective listening in PTSD treatment, 147; self-determination and, 140–41 motivation enhancement therapy. See motivational interviewing motivation for mastery (effectance), 13–14 Motto, Jerome, 175–76 Mueller, M., 121 Murphy, S. L., 44 Mushlin, A., 56, 59, 60

Index narcotics addictions, 55–56 need satisfaction, 26, 35–37(36f), 53– 58(54f), 169 negativism, 178–79 negentropicism, 15, 16, 17 neurophysiology, 10–11, 22 Nezlek, John, 23 nicotine dependence treatment. See smoking cessation therapy Nisbett, R. E., 14 Nix, G., 38 Norcross, J. C., 3, 64, 66, 68 Nouwen, A., 87 Nowak, A., 10, 11 Nurius, P., 11 obesity/weight-loss programs, 55, 59, 60 obsessive compulsive disorder (OCD) treatment: behavioral confrontation in, 144–45, 147, 156–60; bulimia nervosa and, 163–64; cognitivebehavioral therapy for, 155–56; medication for, 155, 156, 160; response prevention technique and, 156–60; ritual in, 154–55, 157, 159–60; territoriality in, 160–61 O’Malley, S., 55, 134 organismic theory: autonomy-supportive approach in, 32; dialectic processes in, 16–18; holism in, 17, 18; of motivation, 15; need satisfaction and, 26; selfdetermination theory (SDT) and, 15– 16 Overton, W. F., 15 Parker, K. C. H., 117 Patrick, B. C., 33 Pearson, T. A., 44 Pechacek, T. F., 60 Pekarik, Gene, 121 perceived locus of causality (PLOC), 19, 20–21, 25, 31 Perls, Fritz, 21 personality disorders, 181–83

205

personality styles, 35–38(36f), 57–59 perspective-taking, 30, 33, 70–72, 162– 63, 174 Peters, K. D., 44 Peters, T. D., 44 Petry, N. M., 31 Phibbs, C. S., 48 Phillips, G. M., 66 physical health maintenance: alternative therapies as, 110–12, 117, 153–54; coronary artery disease (CAD) and, 56, 59, 60; diagnosis delivery and, 87– 88, 90–92, 114–15, 118–21; health behavior changes and, 43–48, 50t, 63– 64, 66–69t, 74; health-seeking nature and, 11–12, 90, 129–30; preventative services use (e.g., pap smear) in, 48 Piaget, Jean, 6, 15 Pittman, Thane, 34 Plant, R. W., 55, 134 Plato, 15 positive psychology movement, 11–12, 177–78 post-traumatic stress disorder (PTSD) treatment: clinical-technical skill in, 145–48, 152–54; cognitive-behavioral therapy and, 147–52; reflective listening in, 147; treatment choice in, 147– 51 Prigogine, I., 15 Prince, Morton, 109 Prochaska, J., 64, 66, 68 Project MATCH, 139–41 Pronk, N. P., 48 providers. See client-provider relationships psychological science, 3–4, 110–13, 140–41 questioning (in motivational interviewing), 131, 132 Rajab, M. H., 121, 167 Rawsthorne, Laird, 26

206

Index

Reeve, Johnmarshall, 39 reflection and internalization, 91–92, 100t, 147 reflective listening (in PTSD treatment), 147 Reis, H. T., 11 relatedness: autonomy and, 17–19, 32; in client-provider relationship, 38, 76; in depression therapy, 114–15, 169; family support and, 74, 89–90, 104–5; IPT and, 173, 175; need satisfaction and, 26, 36f; in patient motivation, 102–5; in PTSD treatment, 149–50; reflection and internalization as, 91– 92, 100t, 147 resistance (in motivational interviewing), 132 response prevention technique (in OCD therapy), 156–60 rewards as motivation, 13–15, 20, 21, 23–25, 48 Reynolds, T., 68 Rigby, S., 25 Rimm, E. B., 43 Rind, Bruce, 110 ritual in OCD, 154–55, 157, 159–60 Rodin, G. C., 56, 57, 60, 62 Rogers, Carl, 5, 11, 21, 28, 130 Rohde, P., 179 role transitions in IPT, 172–73, 174–75 Rollnick, Stephen, 64, 66, 68, 91, 92, 94, 133 Roter, D. L., 44 Rothenberg, A., 164 Rudd, M. D., 121, 167 Ryan, Richard M.: on addiction recovery, 55; on alcohol treatment programs, 55; on autonomy, 19, 29–30, 51; on control orientation and coronaryprone behaviors, 59; employee needsatisfaction study and, 36–37; General Causality Orientation Scale (GCOS) and, 58–59, 60; on health behaviors, 55, 68–69; human values in SDT, 5,

26; on internalization, 33, 49, 72, 87; on motivation, 14–16, 20, 23–24, 35, 46; on perceived locus of causality (PLOC), 25; on personality disorders, 181; on the phenomenal self, 18; on primary education, control in, 24–25, 34, 35; on relatedness, 51; on rewards, 23–24; Treatment Self-Regulation Questionnaire (TSRQ) and, 134 Rychlak, J., 5, 9 Sabourin, S., 25 Sachs-Ericsson, N., 160 Sackett, D. L., 44 Saunders, S. M., 175 Sayette, M. A., 3 Schafer, L. C., 56, 62 Schauffler, H. H., 48 Schmidt, N., 176 Schultz, D. P., 7 Schultz, S. E., 7 self: in behaviorism, 6–7, 21–22, 63; client autonomy and, 30–31; healthrelated behavior change and, 50t, 81; health seeking in, 11–12, 90, 129– 30; in humanistic psychology, 19–20; nature of, 10–11, 17; neurophysiology and, 10–11; in reward and coercion, 24; in social relations, 16– 18 self-actualization, 3–4, 29 self-determination: autonomy and, 22t– 25, 73–74; failure experiences and, 73–74; human values and, 25–27; motivation and, 73–74, 140–41; in organismic theory, 15–16; suicide risk assessment and, 179–80; in therapy, 133–34, 140–41, 157–60 self-motivational statements (in motivational interviewing), 132–33 Seligman, M. E. P., 12, 110, 177 Senecal, C. A., 87 Shadel, W. G., 9 Shakow, David, 109

Index Sheinman, Louise, 23 Sheldon, Kennon: on autonomy, 17, 18, 19, 26; on controlled v. autonomous motivation of clients, 57; on human values in SDT, 26; on internalization of behaviors, 87; on patients’ responsibility for treatment, 87; on relatedness, 19, 25, 26; on the self, 11 Sherman, Roberta, 122, 133, 137 Skinner, B. F., 6, 21 Skinner, Ellen, 35 Smith, B., 8, 11 smoking cessation therapy: adolescents and, 56, 60; failure experiences in, 69– 70, 73–74, 76–77; the 5 A’s model in, 71t; medication adherence in, 44–45, 67–68; motivation in, 48, 56, 59–61, 69–74(71t), 77–81 Snow, J. C., 44 Snyder, C. R., 31 Sober, E., 18 social anxiety, 127–29, 143 Solanki, G., 48 Sperry, R. W., 10, 22 Stampfer, M. J., 43, 67 Stein, D. J., 160 Stephenson, B. J., 56 studies: on autonomy support, 33–34, 39–40; diabetes treatment study, 56, 59, 60, 62–63; empirical model of health motivation in, 53–58(54f); on healthy behaviors, 53–58(54f), 61– 62, 67–68, 134; on the highly motivated patient, 102–5; in humanistic psychology, 7–9; on internalization process, 33; on medication adherence, 56, 57, 60, 62; of treatment efficacy, 110–12, 117; Treatment SelfRegulation Questionnaire (TSRQ) in, 55, 61, 134 suicide: borderline personality disorder and, 118–20; of client and provider responsibility, 125, 179–81; depression and, 166, 167; personal interest and

207

suicide prevention, 175–76; positive emotions and, 178; risk assessment of, 121, 179–81 summarizing (in motivational interviewing), 132–33 Tang, J. L., 49 Tedeschi, R. G., 57 Tennen, H., 31 territoriality in OCD, 160–61 Thorndike, A. N., 45 Thorogood, M., 49 Tolman, Richard, 6 Tonsager, Mary, 120, 134 treatments. See alcoholism treatment; anxiety therapy; depression therapy; diabetes treatment; obesity/weight-loss programs; obsessive compulsive disorder (OCD) treatment; post-traumatic stress disorder (PTSD) treatment; smoking cessation therapy Treatment Self-Regulation Questionnaire (TSRQ), 55, 61, 134 Turken, A. U., 178 Vallerand, R. J., 25 Vohs, K., 176 volition, 51, 63–64, 71t Vupputuri, S., 44, 46 Wagner, E. H., 48 Wallston, B. S., 57 Wallston, K. A., 57 Ware, J. E., 61–62 Wegner, D. M., 9 Weinstein, N. D., 44 Weissman, M. M., 173 Wertz, F., 8 Wheatley, T., 9 White, D., 87 White, R. W., 109 White, Robert, 13–14, 15 Wild, Cameron, 38–39 Willett, W. C., 43

208

Index

Williams, Geoffrey C.: on autonomous motivation, 59, 60; on coronary artery disease (CAD), 56; diabetes treatment study and, 56, 59, 60, 62–63; on health behaviors, 49, 57, 68–69, 72, 87; on internalization, 49, 72, 87; on medication adherence, 60; on obesity and weight loss, 25, 55, 59, 60; on

smoking cessation, 59, 60–61, 63; Treatment Self-Regulation Questionnaire (TSRQ) and, 134 Wilson, D. W., 18 Woolf, Stephen H., 44–45 Zeldman, A., 55