Today we're going to talk about an area where SDT research and interventions have been heavily applied and that's the area of health care. Why is health care such an important domain for us motivational psychologists? Well, now usually when we think about health care, we think about the care that's given to us by doctors and other professionals, but really most of the health outcomes that people achieve in life or the health problems that they have have a lot to do with their own motivation and with their own lifestyle. In fact, if you think about it, lifestyles are the biggest predictor of health problems people have. We know and there's lots of evidence about how people can live healthier and longer lives for instance, if we avoid tobacco, or we improve our diets, or we engage in regular physical activity, or minimize our alcohol use. All of these things are things that have to do with voluntary behavior that affect health outcomes and yet many times when physicians or other health professionals tell us what's best for us, we don't follow their advice. In fact, if we look at annual mortality in the United States, over half of it's related to these kind of lifestyle choices that people are making. Over 70% of all health care costs are really stemming from people's elective behaviors. Furthermore, it's not just these lifestyle issues that are going on but also the fact that people often don't listen to their health professionals as we discussed before when people get a prescription from a physician. They often don't take the prescription as prescribed. Medical compliance is very low, and so all of these behaviors that have to do with lifestyle changes or doing what your healthcare professionals suggest that you do, all of these things require sustained motivation. So we have to ask why don't people do these things? Well, first thing is it's hard. I mean think about the number of people you probably know who could lose some weight to be healthier but you don't see them really altering their exercise or their dietary patterns. The reason why this motivation matters here weight-loss is hard work. It takes a sustained commitment over time and unless you've got really good reasons for doing it, you're not going to be able to maintain that behavior for very long. A lot of times, the reasons that people are doing at these health-related behaviors come from not autonomous sources, they feel pressured by their healthcare professionals or by their spouses or friends to make a change and that kind of motivations we've already seen that controlled external motivation typically doesn't lead to lasting change. We saw this early on in our research in this area, one of the very first studies that I was able to do with Jeff Williams at DC, and Virginia, Grow and other colleagues was at a clinic here in Rochester New York for a morbidly obese individuals. Morbid obesity is when you are over twice the healthy weight that you should be at. We looked at people's motivation for participating in a six month weight-loss program and we also looked at the style of the practitioners who were giving them care or whether they were autonomy supportive or controlling, and what we found first of all is that the autonomous reasons for making behavior change we're very predictive of how people did in the program.. It predicted their attendance in the program. It also predicted their weight loss over the first six months of the program. Most importantly, having autonomous reasons for making a change was resulting in a sustained change so at a 23 month follow up in this study, those people who had more autonomous reasons were still more likely to have maintained their weight loss change over that period of time. Controlled motivations on the other hand didn't predict at all. Now, we also saw in the study how the autonomy support from the counselors and caregivers in this clinic were really also responsible for promoting more autonomous motivation. So over time, if you had an autonomy supportive counselor you tended to become more autonomous in your reasons for losing weight and that led to the maintained changes over time. Recent studies have just born all this out there's a recent study by Goran and colleagues of a weight-loss among adults. They too found that baseline autonomous motivation for losing weight predicted better eating six months later. Interestingly so did the autonomy support they had from the close others around them when their friends family. Close others were autonomy supportive they were more likely to lose weight and eat healthier six months later. Those autonomous reasons and the autonomy support they received also were predictive of the long-term weight loss at 18 months. Again controlled motivation didn't predict any of these outcomes. So we see how important motivation could be in something like weight loss and we already mentioned how important it is just to complying with what we know to be healthy for you that your physicians might tell you. A good example of this comes from a study by Sara Kennedy who's looking at people with HIV. HIV is really very much able to be contained by medications but you have to take the medications for that to be the case and they looked at medication adherence in HIV patients, and they found that autonomous reasons for taking them out of cases were really predictive of adherence. Most importantly, in this study they found that the most proximal predictor, the most important local predictor of whether you were autonomously engaged in taking your HIV medication was whether your practitioner was autonomy supportive. Very predictive of whether people form to the kind of intentions that they willingly carried out over time. So we've tried to put the wisdom from this research into practice and interventions in SDT because we've seen how important autonomy Support is in health care professionals. We've trained health care professionals to be autonomy supportive as they promote change. One of our earliest studies with which was led by Dr. Jeff Williams here in Rochester was a smokers health intervention. We recruited over a thousand patients to participate in a study of smokers health and we particularly went after patients who were in low socioeconomic circumstances and also those who had no intention of quitting smoking. In fact, we recruited people for a health study not a smoking cessation study so that the majority more than six and 10 didn't want to quit when they joined. So this group of difficult to change individuals mostly because they didn't necessarily want to change came in for a conversation with our counselors and the endpoint of our conversation was not to get people to quit smoking but rather to have them make a clear reflective and autonomous decision about whether they'd like to continue smoking and what they'd like to do about their health. As it turns out if you provide a really autonomy supportive atmosphere most people who are smokers will say, well I'd like to quit but here are the obstacles and now we're in the right place to start discussing what those obstacles are and whether they can be overcome. To make a long story short, an autonomy supportive intervention for smoking was very effective at both produced more autonomous reasons for change in individuals who went through the program that led them to feel more competent about changing, that lead them to have better attempts at quitting and also more sustained, adherence to medication that's nicotine replacement. Both of these things leading to better outcomes. So very successful and we've continued these interventions over time particularly Dr. Williams has done a number of these successful randomized control trials. In fact meta-analyses in the literature show that autonomy supportive care by health care practitioners really promotes the autonomous motivation of patients which in turn promotes good outcomes and I show you here just a an overview of 67 studies that were summarized by [inaudible] and his colleagues who show these strong effects of autonomy support versus control on patient motivation across very different kinds of health care problems. So we've developed a self-determination model for health and it really begins with the idea that you create an autonomy supportive indeed a need responsive environment in the health care climate. This leads to more patient satisfaction of basic psychological needs and this has been associated not only with better experience and satisfaction with treatment but also with better health outcomes. In fact, at this point, there's been successful randomized controlled trials and physical health domain in many different areas supporting SDT techniques. These have been done in the areas of smoking cessation, physical activity promotion, weight loss, diabetes management, medication adherence, engaging in a better diet, even dental hygiene varies and their colleagues in Norway recently did an intervention with dental hygienists. They trained them to be more autonomy supportive and explaining why we should be flossing and brushing and they found that autonomy supportive interventions of that sort led people to floss more frequently and that led to less gingivitis measurably different over the next period of time. So in both important activities that relate to health as well as things that we may not have put such importance on, I can really change if you are treated in autonomy supportive climate and that's the thrust of most of our interventions. So just to summarize are some implications for everybody who's a health care professional who wants to employ SDT, expect that autonomy Support will really advance outcomes but that involves that you really listen to your patients, understand their perspective, acknowledge the obstacles and sometimes the negative effect that they might experience in making change. You tried to provide them with as many options and choices as possible as pathways for change. When you have to give advice or you need to give direction, you have a rationale that the person can understand so that they can really take it on board on an autonomous way and most of all, of course, we avoid controlling communications and we remain not judgmental because we know how hard it is to really make sustained health care changes over time
