Self-Determination Theory in Practice

University of Michigan Geoffrey Williams, MD, PhD

Healthy Living Center, University of Rochester, Rochester, New York, US May 13, 2013

Causes of Death In the US

Mokdad et al, JAMA, 2004

Cause Number Percentage Tobacco 435,000 18% Diet & Activity Alcohol Microbial agents Toxic agents Motor Vehicle Crash Firearms Sexual Behavior 400,000 85,000 75,000 55,000 43,000 29,000 20,000 17% 4% 3% 2% 2% 1% 1%

Overview of Self-Determination Theory and Health

   Self Determination Theory Overview  Define Motivation as energy directed toward a goal  Assumptions: innate aspects of self, needs  Motivation and Medical Professionalism  Incentives AND/OR Internalization to motivate change  SDT Model for Health Behavior Change  Meta-analysis Randomized controlled trials - SDT  Tobacco abstinence   Physical activity, weight loss Dental outcomes Implications for research, medical ethics, clinicians and policy.

Self-Determination Theory

    An organismic dialectic-individuals in the context of their social surrounding Motivation is human energy directed to a goal Uses free choice paradigm Assumptions: humans are innately motivated toward well-being (e.g., health) and personal growth

Psychological Needs

 Needs are defined as: “psychological nutriments that are essential for ongoing psychological growth, integrity, and well-being” Deci & Ryan, 2000.

Psychological Inquiry, 11

, 227-268 .

Psychological Needs: Supporting Optimal Motivation

 Autonomy  the need to feel choiceful and volitional in one’s behavior  Competence  the need to feel optimally challenged and capable of achieving outcomes  Relatedness  the need to feel connected to and understood by important others Deci & Ryan, 1991, 2000 Ryan & Deci, 2000

Autonomy vs Independence



Autonomy has two definitions

: –

Volition:

intentions) willingness to act for oneself (even in relation to others’  Associated with motivation, positive affect, better health  People can want to stop smoking, and can accept that others want them to stop, too. Consistent with SDT.

–

Independence:

to act without input from others  Inconsistent with SDT —does not meet relatedness need

Medicine’s Social Surround is our Code of Biomedical Ethics

“These “ethics” are stated obligations of the health profession and its professionals, and are intended to ensure that patients who enter relationships with physicians will find them

competent

and

trustworthy

to provide expert advice to the patient and society on matters of health.” Beauchamp & Childress, 2009

Medical Professionalism – A Physician Charter & Biomedical Ethics

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

 Patient autonomy:  To empower patients to make informed decisions  Social justice:  To eliminate discrimination ABIM Foundation, 2002

Motivation

 Autonomous Motivation   Behaviors are chosen and volitional Behaviors are performed for their inherent value  Controlled Motivation   Behaviors are pressured or coerced Behaviors are performed for some separable outcome Ryan & Deci, 2000; Deci & Ryan, 1991, 1995; Sheldon et al., 1997; Nix et al., 1999; Ryan et al., 1995

The Role of Needs Support in Autonomous Motivation

 Keys to facilitating autonomy:   elicit & acknowledge feelings & perspectives provide a menu of effective options  Emphasize choice when options are present   provide meaningful rationale support patient initiations to change  Expect failure in behavior change, reframe  minimize control Deci et al., 2006

The Role of Needs Support in Relatedness Motivation

 Keys to facilitating relatedness:  unconditional positive regard  nonjudgmental stance  continued relationship over time  warm positive relationship  develop empathy  elicit & acknowledge patient perspective

The Role of Needs Support in Competence Motivation

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

Internalization

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

Social Contextual Factors That Undermine Autonomous Motivation

    SDT meta-analysis of over 128 RCTS in lab  Tangible Rewards Threat of punishment Deadlines Evaluations Competitions Deci, Koestner & Ryan, 1999

Effects of Rewards and Punishments

Cohen’s d

-0.36

k

92 All people got expected rewards When people got less that max reward When some people got no reward Verbal Rewards -0.88

-0.95

6 1 0.33

21 Deci Koestner & Ryan, 1999

Kennedy et al., 2004

Path Model: Motivation, Adherence, Health

HbA1c Gluc.

.67*** .93*** Qual. of Life Gly. Contr.

HCCQ

.35*** .42***

Aut. Motiv.

.29***

Competence

.15***

Adhere

-.33*** -.31*** Fit Indices

χ 2 = 149.5; df= 33 χ2 /df= 4.53 IFI/CFI= .97 TLI= .94 RMSEA= .03

Non HDL Chol Williams, et al.,

Diabetes Educator.

2009;35(3):484-92

SDT Meta-Analysis

Figure

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

SDT Meta-Analysis

 We conducted a meta-analysis of studies within the health care and health promotion contexts based on (figures on next slide)…  SDT model of behaviour change  Figure 1; Ryan, Patrick, Deci & Williams, 2008

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

SDT Meta-Analysis Methods

 184 data sets from 165 sources (journal articles, theses, etc.)  correlation coefficients were meta-analyzed using methods by Hunter & Schmidt (2004)

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

SDT Meta-Analysis Correlations- Mental Health

Depressive Sx Anxiety Qual. of Life Vitality Auto. Mot.

Perc. Comp.

Needs Support

-.23 (5) -.23 (4) .22 (2) .35 (4) .39 (15) .31 (32)

Auto. Mot.

-.06 (6) -.09 (3) .22 (1) .26 (2) ---- .59 (38)

Perc. Comp.

-.23 (6) -.32 (7) .40 (2) .43 (5) .59 (38) -----

SDT Meta-Analysis Correlations-Physical Health

Tobacco Abs.

Physical Act.

Wt loss Dental Med Adhere Healthy diet

Needs Support

.12 (4) .23 (30) .28 (2) .38 (3) .08 (2) .29 (3)

Auto. Mot.

.16 (6) .20 (16) .38 (3) .23 (3) .11 (4) .41 (7))

Perc. Comp.

.29 (3) .35 (31) .22 (3) .53 (2) .17 (3) .07 (2)

SDT Meta-Analysis

Figure 3.

Path diagram of Williams et al.’s (2002, 2006) model using meta-analyzed correlations (

n

= 13,356). All paths are significant at

p

< .05; residual variances are omitted for presentation simplicity.



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



Self-Determination Theory (SDT) Meta-Analysis Limitations

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

 Biomedical Ethics mandates respect for autonomy-thus directionality is irrelevant.  However, 6 previous RCTs with SDT-based health interventions designed to respect patient autonomy have been shown to increase patient perceptions of autonomy and competence and improve outcomes in:  tobacco abstinence (Williams et al,

J General Internal Medicine,

2006; Williams et al,

Health Psychology,

2006; & Williams et al,

Annals of Behavioral Medicine,

2009)    dental outcomes physical activity (Fortier et al.,

Psychology of Sport And Exercise

, 2007) weight loss (Halvari & Halvari,

Mot.& Emot.

, 2006; Health Psych ,In Press) (Silva et al,

Medicine & Science in Sports & Exercise,

2011)

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

Smoker’s Health Study Design

Randomized controlled trial of 30 mo. N=1,006 Questionnaire assessments: * autonomous motivation * perceived competence * autonomy support Outcomes: * Took Medication * Tobacco Abstinence at 6, 18, and 30 months * Reduction in % calories from fat, LDL-C Williams, McGregor et al.,

Health Psychology

. 2006;25(1): 91-101.

The Intervention

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

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

Baseline Autonomous Motivation .68** 6-month Autonomous Motivation .19** .52** 1-month Autonomy Support .14** .05

+ .33** Medication Taking .32** 18-month Cessation Baseline Perceived Competence .34** .40** 6-month Perceived Competence Note: Model Fit: adequately χ2(248) = 1193.14, p < .001, CFI = .92, IFI = .92, RMSEA = .066 ; Values represent standardized path estimates. + p = .10; * p < .05; ** p < .01.

Health Outcomes at 6-months and 18 months All Patients Odds Ratio PHS Odds Ratio 6-month 7-day Point Prevalence 2.9 2.5 Patients who Did Not Want to Quit 6-month 7-day Point Prevalence Odds Ratio 2.7 All Patients 12-month Prolonged Abstinence at 18-months Patients with Elevated LDL-C 18-month Change in LDL-C Odds Ratio 2.6 Intervention 8.0 mg/dl Control 4.0 mg/dl p-Value < 0.05

The “PESO” study

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

...based on Self-Determination Theory RCT : 1-year intervention + 2-year follow-up (n=239) Main Outcomes/Mediators: Exercise Motivation (Intrinsic/Autonomous), PA/Exercise (1y) , Weight (2 to 3 years)

Silva et al. (2008) BMC Public Health 8:234 Silva et al. (2010) J Behav Med 33:110 Silva et al. (2010) Psych Sport Exerc 11: 591 Teixeira et al. (2010) Obesity 18:725

Exercise-specific Elements

Promote Intrinsic Motivation, Autonomy

No fixed exercise prescription!

Provide options, active experimentation Include challenging PA opportunities Promote personally-meaningful activities Ask for leadership, autonomy in organizing Three-month dance curriculum

Walking/pedometers, safety, skills,...

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

Physical Activity at 3 years

Moderate + Vig. PA (min/wk) Walking (steps/day) Lifestyle PA Index (dif. 0-36 mo) Intervention Mean

± SD

234

221

8837

3661

0.75

0.88

Control Mean

± SD

148

162 7999 3823 0.39 0.70

p

0.009

0.206

0.002

Minutes of moderate and vigorous PA

Net difference: +86 min/wk

Teixeira et al., (in preparation)

3-year weight change (completers-only)

2 0 -2

- 1.7% - 2.0%

Average: -1.7%

- 1.4% - 3.9%

-4 -6 -8 Intervention Control

Error Bars Show 95.0% CI of Mean

-10

- 7.4% - 5.6%

Average: -5.6% Difference: 3.9%

Baseline 12 Months 24 Months 36 Months

Teixeira et al., (in preparation)

Summary “PESO”

Group treatment for overweight and obese women, changed motivation, phys activity, and weight 36 months after intervention Autonomy, and Competence Mediated the effect of the Intervention on: PA/Exercise, and Weight Effect was large enough to be clinically important for diabetes prevention and reducing blood pressure

Dental Study

 86 university students (21-35 yrs., X = 27.34 yr., SD = 3.99)  A randomised two-group field experiment pre and post-measures of:  autonomous self-regulation   perceived competence oral health outcomes (plaque & gingivites) Halvari & Halvari, 2006,

Motivation & Emotion

Plaque T1 Perceived competence T1 Autonomous motivation T1

.39*** .41***

Autonomy support T2

.24* .30**

Perceived competence T3

.43***

Health behavior

-.42***

T3

.13

Plaque T3

.49***

Gingivitis T3 Autonomous

.20*

motivation T3

.33**

Gingivitis T1

Munster -Halvari & Halvari (2006).

Motivation and Emotion

,

30

, 294-305 Munster Halvari, et al., (2012). Health Psychology.

Clinical Implications

 Medical Professionalism, and biomedical ethics indicate that promoting patient autonomy is a primary outcome of the clinical encounter.

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

 

Clinical Implications

      Health Care Practitioners who learn to support psychological needs:   Elicit perspectives (listen) Acknowledge affect (reflect) Provide effective options for change Provide clear advice (rationale) for change Support initiative for change Minimize control and remain non-judgmental Skills build/problem solve with those willing Provide a positive relationship May be more likely to motivate change, health, and improve quality of life for their patients.



Research Implications & Summary

Interventions may have a greater impact if centered around facilitating internalization of patient autonomy and competence.

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

Health Policy Implications

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

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

Virtual Clinicians

 We offer intensive interventions that increase motivation to take medications and make lifestyle changes for  Tobacco dependence 4-8 visits 30-300 min.

  Hyperlipidemia – 6 visits 3 MD, 3 RD Weight Loss – 22 visits

Virtual Clinician

 3 NIH grants to develop and test VC’s  NIDA – research tool “VCRT” R21-DA024262  NHLBI – SBIR Clinical Advisory Tool- ICAT R44HL097506  LM – Virtual Weight Loss RC1-LM010410

Hypotheses

 Can we deliver intensive intervention content with a VC for patients?

  At home In the waiting room  On Smart Phone  Can we increase well being and autonomy for same or lower cost?

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

Next Steps

 Behavioral Economics and Motivation based interventions  Effect of presenting health risk information on motivation and adherence  SDT model for change in cholesterol and blood pressure management  Motivation of health care practitioners

Thank You!

Citation Ng, J., Ntoumanis, N., Thøgersen-Ntoumanis, C., Deci, E. L., Ryan, R. M., Duda, J. L., & Williams, G. C. (2012). Self-Determination Theory applied to health contexts: A meta-analysis.

Perspectives on Psychological Science, 7

(4), 325-340

.

References

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

Annals of Internal Medicine, 136

(3), 243-246.

Beauchamp, T. L. & Childress, J. F. (2009).

Principles of biomedical ethics.

New York: Oxford University Press. Cahill, K., & Perera, R. (2011). Competitions and incentives for smoking cessation (Review).

The Cochrane Library.

Deci, E. L., La Guardia, J. G., Moller, A. C., Scheiner, M. J., & Ryan, R. M. (2006). On the benefits of giving as well as receiving autonomy support: Mutuality in close friendships.

Personality and Social Psychology Bulletin, 32,

313-327.

Deci, E. L. & Ryan, R. M. (1991). A motivational approach to self: Integration in personality. In R. Dienstbier (Ed.),

Nebraska symposium on motivation: Perspectives on motivation

(Vol. 38, pp. 237-288). Lincoln: University of Nebraska Press.

Deci, E. L. & Ryan, R. M. (1995). Human autonomy: The basis for true self-esteem. In M. Kernis (Ed.),

Efficacy, agency and self-esteem

(pp. 31-49). New York: Plenum Publishing Co.

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

Psychological Inquiry, 11,

227-268.

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

Journal of Obesity,

epub ahead of print.

References

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

Williams, G. C. (2012). Self-Determination Theory applied to health contexts: A meta-analysis. Perspectives on

Psychological Science, 7(4), 325-340.

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

Journal of Experimental Social Psychology, 35,

266-284.

Ryan, R. M. & Deci, E. L. (2000). Intrinsic and extrinsic motivations: Classic definitions and new directions.

Contemporary Educational Psychology, 25,

54-67.

Ryan, R. M. & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being.

American Psychology, 55

(1), 68-78. Ryan, R. M., Deci, E. L., & Grolnick. W. S. (1995). Autonomy, relatedness, and the self: Their relation to development and psychopathology. In D. Cichetti & D. J. Cohen (Eds.),

Developmental psychology – Vol. 1: Theory and methods

(pp.618-655). New York: Wiley.

Sebire, S. J., Standage, M., & Vansteenkiste, M. (2008). Development and validation of the goal content for exercise questionnaire.

Journal of Sport and Exercise Psychology, 30,

353-377.

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

Journal of Personality and Social Psychology, 73,

1380-1393.

   

The Contract with Society

Nonmaleficence (a norm of avoiding the causation of harm) Hippocrates 400 BC Beneficence (a group of norms of pertaining to relieving, lessening, or preventing harm and providing benefits and balancing benefits against risks and costs). Percival 1802 Justice (a group of norms for fairly distributing benefits, risks, and costs) - 2000 Medical Ethics & Professionalism Respect for Autonomy (a norm of respecting and supporting autonomous decisions). 2000 AD Beauchamp & Childress 2009