People are centrally concerned with motivation—how to move themselves or others to act. Everywhere, parents, teachers, coaches, and managers struggle with how to motivate those that they mentor, and individuals struggle to find energy, mobilize effort and persist at the tasks of life and work (http://www.selfdeterminationtheory.
org/theory/)
Self Determination Theory (SDT) is a theory of motivation that focuses on the social factors and contexts that either foster or inhibit motivation (Ryan and Deci 2000). Motivation is defined as an influence that guides and modulates be- havior based on both internal and external forces or conditions (Wilson and
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Keil 2001). According to SDT, “conditions supporting the individual’s experi- ence of autonomy, competence, and relatedness are argued to foster the most volitional and high quality forms of motivation and engagement for activities”
(website), including health-related activities and adherence (Ryan et al. 2008
; Williams 2002). Motivation can either be internally-driven (by a person’s own wants, needs, goals, beliefs, interests, values, etc.) or controlled by external fac- tors (e.g., rewards, punishments, someone else’s goals). Of course, the distinction between internal and external motivation is not always so clear—consider the case of a reward that a person wants badly—but the critical factor, according to SDT, is whether and to what degree the external motivator is internalized and taken on as a personal value or goal.
A wealth of research supports the contention that external factors such as re- wards (Deci et al. 1999), threats of punishment, and surveillance all tend to reduce intrinsic motivation for an activity and satisfaction in its accomplishment (Deci and Ryan 2008). These approaches often result in an initial increase in the desired activ- ity, but maintenance of the activity rarely lasts, and often declines further, especially when the strength of the reward fades or the threat of punishment elapses. This finding suggests that attempts to foster adherence using rewards or punishments are likely to be effective only in the very short term. Indeed, as will be discussed later, most studies of adherence-promoting interventions show just this pattern, of initial benefit with poor maintenance of gains over time (Cortina et al. 2013).
On the other hand, providing people with choices tends to enhance intrinsic mo- tivation (Deci and Ryan 2000). As Deci and Ryan (2008) note, “when people are rewarded, threatened, surveilled, or evaluated, they tend to feel pressured and con- trolled,” whereas being given the opportunity to make choices enhances their sense of behaving autonomously (Deci and Ryan 1987). People resist being controlled and are unlikely to continue a behavior they feel they are being forced to do.
The critical factor here is autonomy, which is seen as one of three core psycho- logical needs (the other two being competence and relatedness). Autonomy refers to “acting with a sense of volition and the experience of willingness” (Deci and Ryan 2012), that your actions are based on your own values, goals, and desires.
The opposite of behaving autonomously is being controlled. Extrinsic motivators (rewards) are often effective in helping people initiate a behavior change, but their effect rarely lasts. Maintaining a behavior change requires that the motivation be in- ternalized, to become the person’s own; and internalization depends on the person’s belief that she is acting on her own volition and is capable of doing what needs to be done (Ryan et al. 2008).
The concept of autonomy as understood within SDT potentially provides a way of understanding the ways in which the goals of different actors (child, parent, healthcare provider) interact to promote or impede adherence. The theory would predict that approaches taken by parents and providers that make the child feel controlled or coerced would backfire, resulting in poorer adherence, whereas ap- proaches that are autonomy-supportive would result in better adherence over time.
There is certainly strong though indirect evidence to support this prediction with regards to teens, as will be discussed in Chaps. 6 and 10.
Numerous studies have validated the importance of autonomy for adult health- behaviors. In one study of adults, having a sense of autonomy (as reflected in ques- tionnaire items such as “Improving my health is something that I am doing by my own choice”) accounted for 68 % of the variance in self-report of medication adher- ence and pill counts (Williams et al. 1998). Autonomy and autonomy-supportive clinician practices have also been shown to relate to improvement in glycemic con- trol in adults with type 2 diabetes (Williams et al. 2004; Williams et al. 2009).
Fewer studies have explicitly examined the importance of sense of autonomy in pediatric adherence. In an observational study of children aged 2–8 years with type 1 diabetes and their mothers, Chisholm et al. (2011) found that children whose moth- ers involved their children in decision-making during a diabetes-related problem- solving task and used “gentle guidance” (e.g., suggestions) rather than commands had better adherence to dietary restrictions and showed a trend for better glycemic control. They concluded that “treatment adherence and health are optimized when children are offered developmentally sensitive opportunities to participate in deci- sions about their diabetes care,” and that “maternal statements which are ‘autonomy supportive’ and which promote shared responsibility are key features of children’s treatment cooperation.” Gillison et al. (2006) found associations between intrinsic (versus extrinsic) motivators and perceived self-determination, and between self- determination and exercise behaviors in over 500 adolescents in the UK. In an older study of youth with type 1 diabetes, Karoly and Bay (1990) found worse metabolic control when youth felt that disease-management goals amounted to being “told what to do” by their parents, versus goals that were self-selected.
More indirect support for the importance of autonomy comes from the general parenting literature, which has consistently shown a strong relation between au- thoritative parenting—that is, parenting that involves high levels of limit-setting in combination with warmth and autonomy support—and health outcomes in a range of areas (see Chap. 7).
Finally, it has recently been recognized that there is substantial overlap, concep- tually and practically, between SDT and motivational interviewing (MI)(Patrick and Williams 2012). MI is a clinical approach to fostering behavior change by aligning with the patient, helping the patient explore ambivalence to change, and supporting change that is congruent with the patient’s goals and values. MI originally evolved out of clinical experience and has largely been atheoretical, and it has been sug- gested that SDT might provide the theoretical background for understanding how and why MI works (Markland et al. 2005). MI has a growing evidence-base for adherence promotion in teens, as discussed in Chap. 4.
Autonomy versus independence Finally, it is important to note a distinction made in SDT between autonomy and independence (Deci and Ryan 2012). As noted ear- lier, autonomy means acting out of a sense of willingness and volition—doing what you want to do. In contrast, independence means acting by yourself, on your own.
Logically, these are separate concepts. One can willingly decide to be independent or to be dependent, i.e. whether or not to rely on someone else. In other words, the opposite of autonomy is not dependence, but heteronomy, or lack of volition—
i.e., being (or feeling) controlled (Soenens et al. 2007). Thus, SDT identifies two
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