Self-Determination Theory in the Clinic

It was William Miller in the 80's who began to investigate human motivation and ambivalence, the great leveler of motivated action.  In essence, human beings see where they are and know where they want to be, but the distance between the two may seem daunting, and saps our will.  Festinger's concept of cognitive dissonance applies here as well.  Giving up things, even when they are harmful, like drugs, involves sacrifice, and this may be hard. 

In illness, 'power' relationships involving complementary stances are common and endemic: doctor-patient, nurse-patient, doctor-nurse, medical and mental health settings are political hotbeds for personality dysfunctional patients, as well as those others who are ill. Larry Diller spoke of the patient's loss of sense of efficacy, loss of the sense that what THEY as person did, makes a difference to the outcome.

Consumer pressure, in the form of a 'recovery' revolving around a patient's return to wellness, even though technically still ill, has at its core the sense of personal efficacy in the journey towards recapturing the premorbid position in society, or at least, replicating it in the new world of mental disorder.  Patients became clients, then consumers, and now I am told, they just want to be known as service users, distinct from providers.

The health worker is thus being thrust from what David Manchester calls the 'sage on the stage position' to the 'guide on the side position', an empowered position in which the consumer dictates a series of needs around entitlements, and the provider accesses those and creates clinical competencies in the community to deal with the change in consumer status which has resulted in a loss of position and status in society.  Mental illness and more medical illness is thus not a specter without cure, cure is not possible but that is not a sine qua non for survival and happiness: empowerment, self-efficacy, recovery, self-esteem, these are the features of Anthony's work, and Deegan's laments about her care and wellness dilemmas.

The humanitarian stances of the recovery/rehabilitation groups have not been entirely integrated into mental health care.  Although the Meyerian, Boston, Rochester, and other biopsychosocial model philosophies have begun to dominate the psychiatric world, empirical science or sometimes pseudoscience still prevails against the more humanitarian, non-medical, non-linear, seemingly unproven and unscientific methods of care.  Along the way, Laing, Szasz and others have seemed too radical and hippie to be of value.  Here, the authors of this book are doing the same for medicine in the mainstream, but avoiding the radical stance.

Sheldon, Williams and Joiner have set out to address the above historical issues by applying a more humanist and general-systems informed approach, which also has the benefit of an evidence base, within mainstream clinical medicine:

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 naïve assumptions about the inherent "goodness" of human nature…..There was also a general shying away from causal analysis, as if scientific explanation itself were taboo….By seeking to reform both theoretical and methodological psychology simultaneously, the humanists overextended themselves and diluted their message.  Further, their attack on empirical methodology was wrong, and it undermined their credibility.  Research methods are, after all, only tools, not ideologies, and like all tools, they can be applied more or less thoughtfully (pages 8-9).

This is what the authors set out to do, integrating humanism with cognitive science, in creating a basis for self-determinism theory in a thoughtful, scientific way (SDT).

They begin with examining self-determination theory's supportive research base, heavily reliant on Edward Deci's and Richard Ryan's works.  Concepts of mastery or 'effectance' in efficacy are taken from Robert White's work in the late 50's in combating social withdrawal and disengagement. Obviously if one is to recover one's premorbid social position, one has to engage with the environment in an effective way, and may need help to do so.  Volition is, after all, problematic to achieve with severe mental illness dominating, and surrogate frontal and executive scaffolding seems called for.  As with ambivalence, issues of intrinsic motivation are important to, as exemplified in Deci and Ryan's work which overturned much of the behaviourist approach by demonstrating that people will often choose internal rewards rather than external, and seek their own satisfaction choosing their own poison so to speak, punished by reward rather than the other way round.  Following on Plato, James, Piaget, Dewey, SDT is thus an 'organismic' perspective (page 15).  It assumes that we are naturally curious and often seek challenge above other rewards.  In this way too, we are complicators of our lives, 'entropyreducing systems' in other sort-of words – I shall avoid describing the concepts of entropy and enthalpy and autopoesis and other thermodynamic/constructivist notions, which cloud the issue here.  The stance is that we seek to create, and evolutionary trends in the brain have driven this organ to thrive on increasingly complex and creative situations, not shrink or die off when stressed in this way.  We are thus engagers in creative complexity on different levels, and facilitating and integrative process with this complex entity to empower movement out of pathological stasis is a goal of healing.

This is presented as a dialectic: thesis and antithesis interact to form a gestalt-like greater whole, a synthesis, of inner and outer selves, and we seek to master our internal and external environs, drives and impulses, a dialectic that evolves around the synergic of the cognitive approach and the humanism that this approach has lost so much of, sliding backward into the mechanistic reductionism that characterized the early behaviourists.  In essence, we are either pawns or autonomous in the potentially alienating contexts of work and play, or of wellness or illness.  Hegel still has Marx on his head, with a bit of Rousseauian romanticism showing itself in the lineage of the arguments put forward here, and in the arguments reminiscent of dialectic versus scientific materialism.  SDT thus has a humanistic orientation supported by quantitative and experimental research, makes positive assumptions about human nature, whilst still accepting how the bad stuff can accrue anyway, assumes that there are three human needs that constitute wellness, namely autonomy, competence, and relatedness, focuses on people's need for ownership and mastery of motivated behavior towards wellness, and the target of this thin book is to show how those at the upper end of the complementary loop can best motivate the one-down sick people so that they internalize suggested behaviors and self regulate them (see page 22).

As they put it, SDT begins with the concept of intrinsic motivation, viewing it as the basis of the prototype of the self-organized state, and in this way we are epitomized as doing things in the interface of the environment for the challenge of it, not the external reward, but for the satisfaction that mastery of the self and other brings.  We all need to find what our intrinsic motivators are, so we can follow them, and not master things that are not reinforced internally, but merely supported by the environment: it's a kind of leaving home, leaving mum and dad's view of the world, and following our own view, if we know what that is.  In this way, psychosocial competency and maturity means we can also do what is aversive to us, mastering the external boundaries of the self, and relating therefore to other selves which are critical to the sense of relatedness above.

Such latter changes are thus unpleasant, and require abandonment of unhealthy in favor of healthy, changed behavior, and this book is about how we facilitate that in the use of our services.  Or rather, how we promote ownership of not-so-enjoyable behaviors, and how we get people to acquire motivation which is not intrinsically reinforced, not immediately gratifying anyway, lets say.

In the unequal, complementary situation, a power structure, supporting autonomy is thus the key, again a Deci and Ryan concept. In, this is often a meta-complementary stance, providing help.  The first challenge is to stay with what the user of service sees as illness perspective, letting them decide what to do, the most difficult part for any service provider to play in Anthony's recovery model anyway.  Providing of choice wherever possible is vital too, and finally, providing a meaningful rationale when choice is not offered, is a necessary part of the support game too.

Concepts of client resistance come into play here, some are less dutiful than others in following the clinicians prescriptions. Ownership of recommended behavior is the goal here.

From chapter four, SDT is applied to medical practice and physical health.  Here, the concept of motivation is examined closely with some clinical research, and chapter five becomes more specific with regard to tobacco dependence

Following on Prochaska and DiClementi, as did William Miller with MI and MET, time frames are allowed to extend, relapse is expected and accepted, each failure doing more to guarantee a better outcome next time, rather than worse, and relating this process to many health related behaviors. Case studies are used, as they are in the next chapter, where compliance in the face of ambivalence in diabetes mellitus is supported.

As expected, mental health has its turn here, and so they seek a unified psychology, of science and clinical work coming together.  The authors make good use of the controversy that emerged around the Temple University finding on the outcomes in child abuse, and the social pressure that arose rapidly when a survivor, rather than a victim perspective was adopted, in positive psychology frames.  Rind and colleagues were pilloried, after peer review and acceptance, to boot, as were Herrnstein and Murray when they published The Bell Curve, condemning the averaged sum of some to the lower, middle or upper ranks in a deterministic fashion, but with careful science to back them up.  Again, the public often confuse the statistical person with a real one.  One of course cannot divide 10 000 results by 10 000 to get one, one does not have the results of statistical averaging to create perfection, or regression to the mean.

Neither technical skill nor motivational abilities are enough, both are necessary and neither is sufficient (see page 113). The human condition is such that in the interaction, both expertise, and the capacity to sell that in such a way as to promote ownership, is the challenge of clinical work.  We knew that, and thanks to these authors, in some part, we learn how to better achieve that end: wellness, empowerment and recovery in medical settings.

Their final chapters look at substance abuse (predictable), and finally, and acceptably, motivational interviewing gets its time in the spotlight.  Anxiety and eating disorders also get attention, OCD, PTSD, bulimia gets a page or so, that is all.  Mood and personality are focused on in chapter 10, and here, the Cognitive Behavioral Analysis System rises to the fore, as does interpersonal therapy for depression, both focusing on manageable specificity.

They conclude:

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….There is a huge gap between clients' intended and actual behavior (page 185).

The book is more than mere philosophy, yet not enough.  It is more than hocus-pocus, but the evidence base is a tad thin.  I think however they are really where they need to be in providing a brief and somewhat scholarly, very readable and concise guide to becoming a better person, and more importantly, to quote Jack Nicholson, in his OCD laden compliment to Helen Hunt, they make me want to be a better person. 

© 2004 Roy Sugarman

Roy Sugarman, PhD, Clinical Director: Clinical Therapies Programme, Principal Psychologist: South West Sydney Area Health Service, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia.