Attending and avoiding dental appointments: Do "bright" and "dark" motivational paths have a role?

OBJECTIVE: The aim of this study was to test a self-determination theory (SDT) process model of the "bright" and the "dark" motivational pathways through dental attendance or avoidance to oral health. METHODS: A cross-sectional study was conducted among 322 students from all study disciplines at the University of Oslo. Participants responded to a survey with validated questionnaires. Structural equation modelling was used to test the SDT model, and a bootstrapping procedure was used to test the indirect links in the model. RESULTS: Along the "bright" path: Autonomy support at the dental clinic was positively associated with need satisfaction in treatment, which was positively associated with autonomous motivation for dental treatment and reappraisal of dental anxiety. Further, autonomous motivation was positively related to dental attendance, which in turn predicted oral health. Also, both autonomous motivation and reappraisal of anxiety were negatively related to avoiding dental appointments. Along the "dark" path: Conditional regard at the dental clinic positively predicted need frustration in treatment, which positively predicted dental anxiety. In turn, dental anxiety positively predicted avoiding appointments, along with the negative predictions by autonomy and anxiety reappraisal. Finally, oral health was negatively predicted by avoiding appointments. A bootstrapping procedure indicated that all indirect links in the model were supported. A SEM fit the data very well. CONCLUSIONS: Because of the high level of explained variances for dental attendance (42%) and avoiding dental appointments (52%), promoting autonomy support and avoiding conditional regard at the dental clinic may be important for patients' oral health.

Physical activity and motivational predictors of changes in health behavior and health among DM2 and CAD patients.

This study tested a physical activity intervention and the self-determination theory (SDT) process model of health-behavior change and health among 108 adult patients with both diabetes mellitus type 2 (DM2) and coronary artery disease (CAD). Patients were randomly assigned to an organized physical activity intervention group (led by instructors) or a non-physical activity control group. At baseline and after 12 months, we measured the following: needs satisfaction, autonomous and controlled motivation for physical activity, perceived competence for physical activity and blood sugar testing, physical activity and blood sugar testing, body weight, glucose control (HbA1c), and self-perceptions of general health and vitality. The intervention produced, as hypothesized, significant changes in all study variables in favor of the experimental group (Cohen's d effect sizes: 0.23-0.72), except the non-significant result for controlled motivation and body weight. The data supported the SDT process model, in which the effect of the intervention significantly predicted indirect changes in behavior and health through motivation variables. Considering the moderate to large effects on increases in motivation, behavior, and health, promoting organized physical activity programs that are perceived as need-supportive may have important health implications for patients with DM2 and CAD.

Supporting autonomy to motivate patients with diabetes for glucose control.

OBJECTIVE: We applied the self-determination theory of human motivation to examine whether patient perceptions of autonomy supportiveness (i.e., patient centeredness) from their diabetes care providers related to improved glucose control over a 12-month period. RESEARCH DESIGN AND METHODS: We conducted a prospective cohort study of patients with diabetes from a diabetes treatment center at a university-affiliated community hospital. Participants were 128 patients between 18 and 80 years of age who took medication for diabetes, had no other major medical illnesses, and were responsible for monitoring their glucose and taking their medications. The main outcome measure was a change in HbA1c values over the 12 months of the study RESULTS: Patient perception of autonomy support from a health care provider related to a change in HbA1c values at 12 months (P < 0.05). Further analyses showed that perceived autonomy support from the staff related to significant increases in patient autonomous motivation at 12 months (P < 0.05); that increases in autonomous motivation related to significant increases in perceived competence (P < 0.05); and that increases in a patient's perceived competence related to significant reductions in their HbA1c values over 12 months (P < 0.001). CONCLUSIONS: The findings support the prediction of the self-determination theory that patients with diabetes whose health care providers are autonomy supportive will become more motivated to regulate their glucose levels, feel more able to regulate their glucose, and show improvements in their HbA1c values.

A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation.

A meta-analysis of 128 studies examined the effects of extrinsic rewards on intrinsic motivation. As predicted, engagement-contingent, completion-contingent, and performance-contingent rewards significantly undermined free-choice intrinsic motivation (d = -0.40, -0.36, and -0.28, respectively), as did all rewards, all tangible rewards, and all expected rewards. Engagement-contingent and completion-contingent rewards also significantly undermined self-reported interest (d = -0.15, and -0.17), as did all tangible rewards and all expected rewards. Positive feedback enhanced both free-choice behavior (d = 0.33) and self-reported interest (d = 0.31). Tangible rewards tended to be more detrimental for children than college students, and verbal rewards tended to be less enhancing for children than college students. The authors review 4 previous meta-analyses of this literature and detail how this study's methods, analyses, and results differed from the previous ones.

Presenting the facts about smoking to adolescents: effects of an autonomy-supportive style.

OBJECTIVES: To test the self-determination model of health-related behavior by examining whether the degree to which adolescents experience an appeal to not smoke as autonomy supportive would affect their autonomous motivation for not smoking and, in turn, their behavior of either refraining from smoking or smoking less, and to validate the measures of perceived autonomy support and autonomous motivation for not smoking. DESIGN: Two studies of physicians presenting information about not smoking using 2 message styles, 1 of which was designed to be more autonomy supportive. The preliminary study involved nonrandomized assignment to message style and only immediate assessment of perceptions, motivation, and behavior, while the primary study involved randomized assignment and 4-month longitudinal assessments. SETTING AND PARTICIPANTS: Nearly 400 ninth- through 12th-grade students at 2 suburban high schools in upstate New York. MAIN OUTCOME MEASURES: Adolescents' perceptions of the presentations' autonomy supportiveness of the presenters, as well as adolescents' autonomous motivation for not smoking and their self-reports of smoking. The primary study also assessed change in students' autonomous motivation and change in their self-reported smoking during 4 months. RESULTS: In both studies, the measures were reliable and valid. Students perceived significantly (P = .04 and P<.001, respectively) greater autonomy support in the "It's Your Choice" presentation, after controlling for whether the students were smokers. Perceived autonomy supportiveness of the presentation was positively correlated with autonomous reasons for not smoking in the preliminary study and with increases in autonomous motivation for not smoking in the primary study. Change in autonomous reasons for not smoking significantly (P<.001) predicted reduction in smoking during 4 months. CONCLUSION: When adolescents perceived messages about not smoking as autonomy supportive, they had more autonomous motivation for not smoking, and that, in turn, predicted a decrease in their self-reports of smoking.

Autonomous regulation and long-term medication adherence in adult outpatients.

Self-determination theory was applied to explore the motivational basis of adherence to long-term medication prescriptions. Adult outpatients with various diagnoses who had been on a medication for at least 1 month and expected to continue (a) completed questionnaires that assessed their autonomous regulation, other motivation variables, and perceptions of their physicians' support of their autonomy by hearing their concerns and offering choice; (b) provided subjective ratings of their adherence and a 2-day retrospective pill count during an interview with a clinical psychologist; and (c) provided a 14-day prospective pill count during a subsequent, brief telephone survey. LISREL analyses supported the self-determination model for adherence by confirming that patients' autonomous motivation for adherence did mediate the relation between patients' perceptions of their physicians' autonomy support and their own medication adherence.

The support of autonomy and the control of behavior.

In this article we suggest that events and contexts relevant to the initiation and regulation of intentional behavior can function either to support autonomy (i.e., to promote choice) or to control behavior (i.e., to pressure one toward specific outcomes). Research herein reviewed indicates that this distinction is relevant to specific external events and to general interpersonal contexts as well as to specific internal events and to general personality orientations. That is, the distinction is relevant whether one's analysis focuses on social psychological variables or on personality variables. The research review details those contextual and person factors that tend to promote autonomy and those that tend to control. Furthermore, it shows that autonomy support has generally been associated with more intrinsic motivation, greater interest, less pressure and tension, more creativity, more cognitive flexibility, better conceptual learning, a more positive emotional tone, higher self-esteem, more trust, greater persistence of behavior change, and better physical and psychological health than has control. Also, these results have converged across different assessment procedures, different research methods, and different subject populations. On the basis of these results, we present an organismic perspective in which we argue that the regulation of intentional behavior varies along a continuum from autonomous (i.e., self-determined) to controlled. The relation of this organismic perspective to historical developments in empirical psychology is discussed, with a particular emphasis on its implications for the study of social psychology and personality.

Internalization of biopsychosocial values by medical students: a test of self-determination theory.

Two studies tested self-determination theory with 2nd-year medical students in an interviewing course. Study 1 revealed that (a) individuals with a more autonomous orientation on the General Causality Orientation Scale had higher psychosocial beliefs at the beginning of the course and reported more autonomous reasons for participating in the course, and (b) students who perceived their instructors as more autonomy-supportive became more autonomous in their learning during the 6-month course. Study 2, a 30-month longitudinal study, revealed that students who perceived their instructors as more autonomy-supportive became more autonomous in their learning, which in turn accounted for a significant increase in both perceived competence and psychosocial beliefs over the 20-week period of the course, more autonomy support when interviewing a simulated patient 6 months later, and stronger psychosocial beliefs 2 years later.

Within-person variation in security of attachment: a self-determination theory perspective on attachment, need fulfillment, and well-being.

Attachment research has traditionally focused on individual differences in global patterns of attachment to important others. The current research instead focuses primarily on within-person variability in attachments across relational partners. It was predicted that within-person variability would be substantial, even among primary attachment figures of mother, father, romantic partner, and best friend. The prediction was supported in three studies. Furthermore, in line with self-determination theory, multilevel modeling and regression analyses showed that, at the relationship level, individuals' experience of fulfillment of the basic needs for autonomy, competence, and relatedness positively predicted overall attachment security, model of self, and model of other. Relations of both attachment and need satisfaction to well-being were also explored.

Motivational predictors of weight loss and weight-loss maintenance.

Self-determination theory proposes that behavior change will occur and persist if it is autonomously motivated. Autonomous motivation for a behavior is theorized to be a function both of individual differences in the autonomy orientation from the General Causality Orientations Scale and of the degree of autonomy supportiveness of relevant social contexts. We tested the theory with 128 patients in a 6-month, very-low-calorie weight-loss program with a 23-month follow-up. Analyses confirmed the predictions that (a) participants whose motivation for weight loss was more autonomous would attend the program more regularly, lose more weight during the program, and evidence greater maintained weight loss at follow-up, and (b) participants' autonomous motivation for weight loss would be predicted both by their autonomy orientation and by the perceived autonomy supportiveness of the interpersonal climate created by the health-care staff.

Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being.

Human beings can be proactive and engaged or, alternatively, passive and alienated, largely as a function of the social conditions in which they develop and function. Accordingly, research guided by self-determination theory has focused on the social-contextual conditions that facilitate versus forestall the natural processes of self-motivation and healthy psychological development. Specifically, factors have been examined that enhance versus undermine intrinsic motivation, self-regulation, and well-being. The findings have led to the postulate of three innate psychological needs--competence, autonomy, and relatedness--which when satisfied yield enhanced self-motivation and mental health and when thwarted lead to diminished motivation and well-being. Also considered is the significance of these psychological needs and processes within domains such as health care, education, work, sport, religion, and psychotherapy.

Motivation underlying career choice for internal medicine and surgery.

Self-determination theory (Deci and Ryan, 1985) was used to predict medical students' career choices for internal medicine or surgery based on their experiences of the autonomy support provided by the instructors in the two corresponding third-year clerkships. Fourth-year medical students (n = 210) at three medical schools completed questionnaires that assessed (1) retrospective prior likelihood (as of the end of second year) of their going into internal medicine and surgery, (2) their perceived competence with respect to these two medical specialties, (3) their interest in the problems treated in each specialty, (4) the autonomy support of the instructors on the two corresponding rotations, (5) the current likelihood (late in the fourth year) of going into each of the two specialties, and (6) their actual residency choices. For a subset (n = 64), actual prior likelihoods of going into the two careers had also been assessed at the end of their second year. Structural equation modeling confirmed, as hypothesized, (a) that perceived autonomy support of the corresponding clerkship would predict students' choices of internal medicine or surgery, even after the effects of retrospective (and actual) prior likelihood had been removed, and (b) that this relationship between perceived autonomy support and career choice was mediated by perceived competence and interest. The present study suggests that students' experiences on clerkships do affect the likelihood that they will select particular specialties, and that students' interest in the areas are good indicators of the selections they will make.

Autonomy and competence as motivational factors in students with learning disabilities and emotional handicaps.

Over 450 students (136 elementary, 321 junior and senior high school) with primary handicapping codes of learning disability (LD) or emotional handicap (EH) completed several questionnaires. All participants were from self-contained classrooms of a state-operated special education system. Questionnaires assessed students' self-perceptions and perceptions of home and classroom contexts, with all variables theoretically reflecting either the competence or the autonomy aspects of internal motivation or students' personal adjustment. Math and reading standardized achievement test scores were obtained from school records. Using multiple regression analyses, students' achievement and adjustment were predicted from the motivationally relevant self-perception and perception-of-context variables. Interestingly, different patterns of relations emerged for the students with LD and EH.

On happiness and human potentials: a review of research on hedonic and eudaimonic well-being.

Well-being is a complex construct that concerns optimal experience and functioning. Current research on well-being has been derived from two general perspectives: the hedonic approach, which focuses on happiness and defines well-being in terms of pleasure attainment and pain avoidance; and the eudaimonic approach, which focuses on meaning and self-realization and defines well-being in terms of the degree to which a person is fully functioning. These two views have given rise to different research foci and a body of knowledge that is in some areas divergent and in others complementary. New methodological developments concerning multilevel modeling and construct comparisons are also allowing researchers to formulate new questions for the field. This review considers research from both perspectives concerning the nature of well-being, its antecedents, and its stability across time and culture.

The importance of supporting autonomy in medical education.

Many thoughtful leaders in medicine have asserted their belief that when physicians are more humanistic in their interactions with patients, their patients have more positive health outcomes. Consequently, many advocates have called for the practice of teaching students and residents to provide more humanistically oriented care. This article reviews research from motivational psychology, guided by self-determination theory, that suggests that when medical educators are more humanistic in their training of students, the students become more humanistic in their care of patients. Being humanistic in medical education can be achieved through support of the autonomy of students. Autonomy support means working from the students' perspectives to promote their active engagement and sense of volition with respect to learning. Research suggests that when educators are more supportive of student autonomy, students not only display a more humanistic orientation toward patients but also show greater conceptual understanding and better psychological adjustment.

Activating patients for smoking cessation through physician autonomy support.

OBJECTIVE: Test whether physicians' counseling patients for smoking cessation with an autonomy supportive rather than controlling style would increase patients' active involvement in the counseling session and increase maintained abstinence. DESIGN: Randomized trial of 27 community-based physicians using two interview styles, with observer ratings of patient active involvement and assessments of patient smoking status at 6 months, 12 months, and 30 months. PATIENTS: Adult smokers: 336 recruited; 249 for final analyses. INTERVENTION: Physicians used an autonomy- supportive or controlling interpersonal style, randomly assigned within physician, to briefly counsel patients about smoking cessation, using the National Cancer Institute's 4-A's model. MEASUREMENT: Patient active involvement was rated from audio tapes of the interviews. Continuous abstinence came from self-reports at 6 months, 12 months, and 30 months, CO validated at 6 months or 12 months and at 30 months. RESULTS: Physician style did not have a significant direct effect on smoking cessation but did significantly increase patient active involvement in the interview. Active involvement, in turn, increased smoking cessation. Structural equation modeling confirmed a theoretical model in which the intervention positively predicted patient active involvement after controlling for patient reports of wanting to stop smoking, and active involvement significantly predicted continuous abstinence after controlling for previous quit attempts. CONCLUSIONS: Although physicians' autonomy- supportive style while counseling smokers to quit did not have a direct effect on smoking cessation, it increased patients' active involvement in the counseling session which in turn increased continuous abstinence over 30 months. Further research should clarify the direct effects of physician interpersonal style on health outcomes.

Nature and autonomy: an organizational view of social and neurobiological aspects of self-regulation in behavior and development.

The concepts of self-regulation and autonomy are examined within an organizational framework. We begin by retracing the historical origins of the organizational viewpoint in early debates within the field of biology between vitalists and reductionists, from which the construct of self-regulation emerged. We then consider human autonomy as an evolved behavioral, developmental, and experiential phenomenon that operates at both neurobiological and psychological levels and requires very specific supports within higher order social organizations. We contrast autonomy or true self-regulation with controlling regulation (a nonautonomous form of intentional behavior) in phenomenological and functional terms, and we relate the forms of regulation to the developmental processes of intrinsic motivation and internalization. Subsequently, we describe how self-regulation versus control may be characterized by distinct neurobiological underpinnings, and we speculate about some of the adaptive advantages that may underlie the evolution of autonomy. Throughout, we argue that disturbances of autonomy, which have both biological and psychological etiologies, are central to many forms of psychopathology and social alienation.

The relation of mothers' controlling vocalizations to children's intrinsic motivation.

Twenty-six mother-child dyads played together in a laboratory setting. Play sessions were surreptitiously videotaped (with mothers' permission), and each maternal vocalization was transcribed and coded, first into 1 of 24 categories and then ipso facto into one of three supercategories--namely, controlling, autonomy supportive, and neutral. The degree of mothers' controllingness was calculated as the percentage of vocalizations coded as controlling. This index was correlated with the intrinsic motivation of their 6- or 7-year-old children, as assessed primarily by the free-choice behavioral measure and secondarily by a child self-report measure of interest and liking for the task. Both correlations were significantly negative, thereby suggesting that the robust laboratory findings of a negative relation between controlling contexts and individuals' intrinsic motivation are directly generalizable to the domain of parenting. Results are discussed in terms of the processes that undermine intrinsic motivation and the means through which parental controllingness is communicated.

Medical students' motivation for internal medicine.

OBJECTIVE: To verify that motivational concepts tested in other educational settings are relevant to understanding medical students' choice of a career in internal medicine. More specifically, to compare the effects of "facilitating students' interest" versus "controlling students' learning" as educational models during the internal medicine clerkship. DESIGN: An observational retrospective study of 89 fourth-year medical students. Structural equation modeling compared the two models statistically. MAIN OUTCOME MEASURE: Student choice of internal medicine residency. RESULTS: Instructors who supported students' autonomy engendered in students greater feelings of competence and interest in internal medicine than did controlling instructors. Perceived competence further enhanced students' interest in internal medicine. In turn, interest predicted students' choosing an internal medicine residency. Overall, the facilitating students' interest model better explained students' choice of internal medicine than did the controlling students' learning model. CONCLUSIONS: The results verify that the nature of the learning climate during the internal medicine clerkship is an important predictor of students' subsequent pursuit of internal medicine training. Instructors who teach in an autonomy-supportive manner enhance students' perceived competence and interest in internal medicine, which increases the likelihood they will select an internal medicine residency.