Self-determination theory gets applied in many different areas, but there's probably none that's more dear to my heart as I clinical psychologists than the area of psychotherapy. Now, most of you probably know what psychotherapy is. The word psyche means the soul or the spirit, and therapy really means healing, and so psychotherapy is really about the healing of the soul or the spirit, and throughout the ages, there has been many many different techniques for how to go about doing that. Today practitioners, some psychologists, social work, nursing occupational therapy, medicine, coaching among other professions, perform psychotherapy in various forms. Franco always defined psychotherapy as an activity in which one consults with a professional, somebody who was guided by theory, to find a pathway to healing, and we like that definition, and self-determination theory has some ideas about what it is that provides a pathway toward healing. Among the central issues in all forms of psychotherapy is the issue of motivation because unlike some kinds of medical healing, you have to participate in psychotherapy in order for it to do you any good. The client has to actively embrace the process of behavior change if anything is going to be maintained and to follow from it. Yet motivation is not always straightforward in psychotherapy, people come to see clinicians with a great deal ambivalence about the conflicts they might have, about the disclosure that they might have to do, they often aren't even clear about the goals they might accomplish, and so we see this across types of psychotherapy with very high attrition rates or dropout as a frequent problem. So, self-determination theory has a lot to say about psychotherapy because it is primarily a motivational theory. Among its hypotheses relevant to all psychotherapies is number one that the relative autonomy of the client in undertaking or engaging in psychotherapy is going to be important to the attainment of treatment outcomes and especially with regard to maintenance of outcomes after the therapy has stopped. A second fundamental assumption of self-determination theory is that across modalities of therapy whether you're doing cognitive behavior therapy or psychodynamic therapy or even just a prescription drugs for mental illnesses, the behavior change in client engagement is going to be enhanced by practitioners being Autonomy Supportive. Autonomy support is going to contribute to wellness and psychotherapy through two means, both by directly satisfying basic psychological needs in the therapeutic relationship, but also by really supporting the internalization of change that's got to come about through the process of therapy itself. Now, there's been a number of studies to show the importance of this. I'm just going to tell you one, early one that I did with Alan Zeldman and Dr. Fiscella which was at Methadone clinic here in Rochester New York. What we did is we looked at patients who were opiate addicts who very difficult to treat population in a clinic where they had to go in every day, where they were subjected to random urine test and testing, where they were required to attend various meetings, and we followed these patients for six months. The first thing we saw is that autonomy support from their counselors was associated with fewer relapses as indicated by the chemical testing of urine, in other words they were less likely to fall back into opiate habits, to better attendance of the meetings, and being rated by their therapists making more progress across a six months worth of treatment. In addition, when we looked at the motivation of the clients themselves, it was really those with internal motivation that were likely to show these positive treatment outcomes and most likely to look like they're going to be successes in this very difficult therapy. Let me take another empirical example of the importance of autonomy support in therapy and this comes from studies by Zuroff and his colleagues at McGill University the first of which came out in 2007. They were looking at treatments for depression, and they were comparing actually treatments that were based on cognitive behavioral therapy, interpersonal therapy, or a third approach which was cycle pharmachology with clinical management in other words treating depression with anti-depressant medications. Looking at all three of these therapies across a 16-week treatment regimen, they found that all three of them worked. But they also looked at the autonomy supportiveness of the therapist in each approach, and as it turned, out autonomy supportive therapy, therapist styles were very predictive of treatment outcomes. If you had an autonomy supportive therapist, no matter what modality you were in, you were twice as likely as average to show success, four times more likely to show success than those who had controlling therapists. It turns out that autonomous motivation was more predictive than therapeutic alliance in terms of predicting treatment outcomes. So, we see that it doesn't matter what modality you're in. Whether you're practicing again behavioral, interpersonal, psychodynamic, or medical treatments when you're supporting the autonomy of your clients, you're more likely to have them be engaged in treatment, and they're more likely to maintain any gains that happened from that. Now, as a psychotherapist myself, I can say it's not always easy to supply a need supportive environment, but when we do so, we're creating a really safe space for our clients. When we're supporting their autonomy, we're not being judgmental, we're helping them understand what the guidelines and the structure of treatment is, and in that case, they can feel safe. When they're in psychotherapy, they can authentically reflect on aspects of their life. They can integrate new ideas about change, and they can feel safe and experimenting in that direction of change. Feel more empowered and a sense of choice and all these things are going to be associated with better maintained outcomes.
