Transcript Related Materials - CHCR

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
400,000
17%
Alcohol
85,000
4%
Microbial agents
75,000
3%
Toxic agents
55,000
2%
Motor Vehicle Crash
43,000
2%
Firearms
29,000
1%
Sexual Behavior
20,000
1%
Overview of Self-Determination
Theory and Health
 Self Determination Theory Overview
 Define Motivation as energy directed toward a goal
 Assumptions: innate aspects of self, needs
 Motivation and Medical Professionalism
 Incentives AND/OR Internalization to motivate change
 SDT Model for Health Behavior Change
 Meta-analysis
 Randomized controlled trials - SDT
 Tobacco abstinence
 Physical activity, weight loss
 Dental outcomes
 Implications for research, medical ethics, clinicians and policy.
Self-Determination Theory
 An organismic dialectic-individuals in the
context of their social surrounding
 Motivation is human energy directed to a goal
 Uses free choice paradigm
 Assumptions: humans are innately motivated
toward well-being (e.g., health) and personal
growth
Psychological Needs
 Needs are defined as:
“psychological nutriments that are essential
for ongoing psychological growth, integrity,
and well-being”
Deci & Ryan, 2000. Psychological Inquiry, 11, 227-268.
Psychological Needs: Supporting
Optimal Motivation
 Autonomy
 the need to feel choiceful and volitional in one’s behavior
 Competence
 the need to feel optimally challenged and capable of
achieving outcomes
 Relatedness
 the need to feel connected to and understood by important
others
Deci & Ryan, 1991, 2000
Ryan & Deci, 2000
Autonomy vs Independence

Autonomy has two definitions:
– Volition: willingness to act for oneself (even in relation to others’
intentions)


Associated with motivation, positive affect, better
health
People can want to stop smoking, and can accept
that others want them to stop, too. Consistent with
SDT.
– Independence: to act without input from others

Inconsistent with SDT—does not meet relatedness
need
Medicine’s Social Surround is
our Code of Biomedical Ethics
“These “ethics” are stated obligations of the
health profession and its professionals, and are
intended to ensure that patients who enter
relationships with physicians will find them
competent and trustworthy to provide expert
advice to the patient and society on matters of
health.”
Beauchamp & Childress, 2009
Medical Professionalism – A Physician
Charter & Biomedical Ethics
 Primacy of patient welfare:
 a dedication to serving patients’ interests.
 Patient autonomy:
 To empower patients to make informed decisions
 Social justice:
 To eliminate discrimination
ABIM Foundation, 2002
Motivation
 Autonomous Motivation
 Behaviors are chosen and volitional
 Behaviors are performed for their inherent value
 Controlled Motivation
 Behaviors are pressured or coerced
 Behaviors are performed for some separable outcome
Ryan & Deci, 2000; Deci & Ryan, 1991, 1995; Sheldon et al.,
1997; Nix et al., 1999; Ryan et al., 1995
The Role of Needs Support in
Autonomous Motivation
 Keys to facilitating autonomy:
 elicit & acknowledge feelings & perspectives
 provide a menu of effective options
 Emphasize choice when options are present
 provide meaningful rationale
 support patient initiations to change
 Expect failure in behavior change, reframe
 minimize control
Deci et al., 2006
The Role of Needs Support in
Relatedness Motivation
 Keys to facilitating relatedness:
 unconditional positive regard
 nonjudgmental stance
 continued relationship over time
 warm positive relationship
 develop empathy
 elicit & acknowledge patient perspective
The Role of Needs Support in
Competence Motivation
 Keys to facilitating perceived competence:






high levels of autonomy
be positive that the patient can succeed
provide effectance feedback
identify barriers
skills-building/problem-solving
build a plan with appropriate levels of challenge
 Needs support is important because…
Internalization
 an inherent, proactive process by which
autonomous and competence motivations are
increased naturally over time
Social Contextual Factors That
Undermine Autonomous Motivation
SDT meta-analysis of over 128 RCTS in lab
 Tangible Rewards
 Threat of punishment
 Deadlines
 Evaluations
 Competitions
Deci, Koestner & Ryan, 1999
Effects of Rewards and
Punishments
Cohen’s d
k
All people got expected
rewards
-0.36
92
When people got less that
max reward
-0.88
6
When some people got no
reward
-0.95
1
Verbal Rewards
0.33
21
Deci Koestner & Ryan, 1999
Kennedy et al., 2004
Path Model:
Motivation, Adherence, Health
HbA1c
.93***
Qual. of Life
HCCQ
.29***
Aut. Motiv.
Fit Indices
χ2= 149.5; df= 33
χ2 /df= 4.53
IFI/CFI= .97
TLI= .94
RMSEA= .03
Competence
.67***
Gly. Contr.
.35***
.42***
Gluc.
-.33***
.15***
Adhere
-.31***
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
Needs Support Auto. Mot.
Perc. Comp.
Depressive Sx
-.23 (5)
-.06 (6)
-.23 (6)
Anxiety
-.23 (4)
-.09 (3)
-.32 (7)
Qual. of Life
.22 (2)
.22 (1)
.40 (2)
Vitality
.35 (4)
.26 (2)
.43 (5)
Auto. Mot.
.39 (15)
-----
.59 (38)
Perc. Comp.
.31 (32)
.59 (38)
-----
SDT Meta-Analysis
Correlations-Physical Health
Needs Support Auto. Mot.
Perc. Comp.
Tobacco Abs.
.12 (4)
.16 (6)
.29 (3)
Physical Act.
.23 (30)
.20 (16)
.35 (31)
Wt loss
.28 (2)
.38 (3)
.22 (3)
Dental
.38 (3)
.23 (3)
.53 (2)
Med Adhere
.08 (2)
.11 (4)
.17 (3)
Healthy diet
.29 (3)
.41 (7))
.07 (2)
SDT Meta-Analysis
Figure 3. Path diagram of Williams et al.’s (2002, 2006) model using meta-analyzed correlations (n =
13,356). All paths are significant at p < .05; residual variances are omitted for presentation simplicity.
2 (3) = 76.25, p < .01, CFI = .98, RMSEA = .07, SRMR = .03.
Self-Determination Theory (SDT)
Meta-Analysis Limitations
 Correlations are bidirectional and thus do not support causal interpretation
of the results.
 Biomedical Ethics mandates respect for autonomy-thus directionality is
irrelevant.
 However, 6 previous RCTs with SDT-based health interventions designed
to respect patient autonomy have been shown to increase patient
perceptions of autonomy and competence and improve outcomes in:
 tobacco abstinence (Williams et al, J General Internal Medicine, 2006; Williams et al, Health Psychology, 2006; &
Williams et al, Annals of Behavioral Medicine, 2009)
 dental outcomes (Halvari & Halvari, Mot.& Emot. , 2006; Health Psych ,In Press)
 physical activity (Fortier et al., Psychology of Sport And Exercise, 2007)
 weight loss (Silva et al, Medicine & Science in Sports & Exercise, 2011)
Ng, Ntoumanis, Thøgersen-Ntoumani, Deci, Ryan, Duda, &
Williams (2012). Perspectives on Psychological Science.
Smoker’s Health Study Design
Randomized controlled trial of 30 mo. N=1,006
Questionnaire assessments:
* autonomous motivation
* perceived competence
* autonomy support
Outcomes:
* Took Medication
* Tobacco Abstinence at 6, 18, and 30 months
* Reduction in % calories from fat, LDL-C
Williams, McGregor et al., Health Psychology. 2006;25(1): 91-101.
The Intervention
 The clinical endpoint of the intervention
was to guide the patient to making a
clear choice about whether he wanted to
change or not.
 If the patient wanted to stop smoking or
change diet then the clinician provided
competence training on how to reach that
goal.
Baseline
Autonomous
Motivation
6-month
Autonomous
Motivation
.68**
.19**
Medication
Taking
.14**
1-month
Autonomy
Support
.52**
.33**
.32**
.05
+
Baseline
Perceived
Competence
.40**
18-month
Cessation
6-month
Perceived
Competence
.34**
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 18months
All Patients
6-month 7-day Point Prevalence
Patients who Did Not Want to Quit
6-month 7-day Point Prevalence
All Patients
12-month Prolonged Abstinence at 18-months
Patients with Elevated LDL-C
18-month Change in LDL-C
Odds Ratio
PHS Odds Ratio
2.9
2.5
Odds Ratio
2.7
Odds Ratio
2.6
Intervention
Control
p-Value
8.0 mg/dl
4.0 mg/dl
< 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
Intervention
Control
Mean ± SD
Mean ± SD
Moderate + Vig. PA (min/wk)
234
221
Walking (steps/day)
8837
0.75
Lifestyle PA Index (dif. 0-36 mo)
148
p
162
0.009
3661
7999 3823
0.206
0.88
0.39 0.70
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
Average: -1.7%
0
% Weight Change
- 1.4%
-2
- 1.7%
- 2.0%
- 3.9%
-4
- 5.6%
-6
-8
Intervention
Control
Average: -5.6%
- 7.4%
Difference: 3.9%
Error Bars Show 95.0% CI of Mean
-10
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 preand post-measures of:
 autonomous self-regulation
 perceived competence
 oral health outcomes (plaque & gingivites)
Halvari & Halvari, 2006, Motivation & Emotion
Plaque
T1
Perceived
competence
T1
.39***
Perceived
competence
T3
Health
behavior
T3
Autonomy
support
T2
Autonomous
motivation
T1
.43***
.13
.41***
.24*
.30**
Autonomous
motivation
T3
-.42***
.20*
Plaque
T3
.49***
Gingivitis
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:
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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
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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
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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,
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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 selfdetermination 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
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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.
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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