Suggesting a Synergy between Self-Determination Theory and Person-Centred Care
Karin Weman Josefsson*
Halmstad University/ University of Gothenburg, Sweden
There seems to be interesting commonalities between self-determination theory (SDT) and person-centred care (PCC), especially when considering their respective value systems and foundations for practice. Both perspectives are based on the fundamental view of human beings as active and capable persons who will thrive if the social environment facilitates certain essential conditions. This short communication paper addresses potential synergy effects in combining these two perspectives in order to improve future applications and assessments of person-centred care. Opportunities for theoretical guidance, concept and measurement adoption along with practical implications are briefly discussed.
Keywords: Self-Determination Theory; Person-Centred Care; Autonomy; Health Care
SDT: Self-Determination Theory;
Self-determination theory (SDT) [1,2] is a recognized theory of motivation with broad evidential support for its application in health care  and health behaviour interventions (e.g. [4,5]). The core of SDT is an organismic value system, considering people to have innate motivational drives towards growth, health and wellbeing. It is proposed that this natural tendency is fuelled by fundamental psychological needs to feel autonomous, (e.g. experience volition and choice of actions), competent (e.g. feeling capable to handle life demands) and related (feeling connected to and cared for by other people), and that satisfaction of these basic psychological needs could be either facilitated or thwarted by the social environment . Main focus is put on the quality (not quantity) of motivation, that is, whether motivation is regulated by controlled (e.g. force, fear, guilt) or autonomous (e.g. enjoyment, curiosity, pleasure) forces. It is stipulated that if the basic psychological needs are satisfied (e.g. in a health care situation) using so called autonomy support , initially controlling regulations will become more autonomous through internalization, which in turn will lead to more sustainable behaviours and increased wellbeing [2,7].
Based on some interesting commonalities of the foundations of SDT and person-centred care (PCC); [8,9], this paper will address potential synergy effects from combining these two perspectives in health care. PCC is strongly advocated in international health care research and practice  and has growing empirical support (e.g. [11,12] also for recovery and rehabilitation . PCC is founded in the hermeneutics of Paul Riceur, the psychology of personhood  and the ethics of personalism . The application of PCC is therefore centring on treating patients like persons and thus differs from patient-centred care because patients are persons and partners in care, hence not solely defined by their illness . PCC should not be confused with personalized medicine (see Taegtmeyer,  for description), since the latter focus on genetic or phenotype distinctions  and pays little or no attention to philosophical matters and personal agency. The value system behind personalism can be associated to the organismic foundations of SDT as well as to the notions behind basic psychological needs. Both perspectives also focus on the person’s subjective experience, which in PCC is defined as person narrative where personal resources and possibilities can be identified, founding a mutual action plan labelled the working partnership, which is central to PCC practice  and tap the needs for autonomy and relatedness. Both perspectives also view the person as an active, intellectual and capable resource, which in PCC is based on the philosophical viewpoint of homo capax , signifying the needs for competence and autonomy respectively. The organismic assumption in SDT proposing humans to have innate drives towards well-being [2,7] will shape the social climate and interaction between clients and counsellors in the same way as when patients are considered to be capable persons and partners in PCC  and this will facilitate all three psychological needs. Volition and personal agency constitute a powerful and vital human resource in both SDT and PCC, which according to SDT tenets could be expected to stimulate a positive emotional experience where people feel autonomous and efficient [2,7]. Essentially, this signify that both perspectives would consider a decision not to change (or not to comply) to be fully acceptable and altogether this represents an important step away from traditional top-down approaches using control, persuasion and even regular threats in patient/care-giver interactions. Moreover, this is also in line with the addition of “Agree” to the 5As model , and this inclusion of patient autonomy represents a new paradigm compared to the prevailing patriarchal value systems employed within health care. The theoretical understanding of autonomy, along with the practical implications of autonomy support provided by SDT could surely serve as a useful resource in the implementation of these guidelines and could also serve as an ethical-philosophical compass of human capacity in policy-making. The support of personal autonomy and control has been identified as imperative ingredients of PCC  and it should be noted that within SDT, autonomy cannot be equated with independence. On the contrary, autonomy is closely related to the conceptions of volition and interest discussed by Smith . Furthermore, both perspectives emphasize the significance of the person and of social environmental relations. In SDT autonomy and well-being are thought to be facilitated through an autonomy supportive context [2,7] and the patient/care-giver relationship as well as the social setting is equally important in PCC  hence both have potential to satisfy the need for relatedness. To summarize, it is clear that both SDT and PCC inspired approaches - implicitly or explicitly - address satisfaction of the needs for autonomy, competence and relatedness respectively.
According to Price  person-centeredness might be understood as a counselling style or guiding philosophy/ethics. Within psychology, person-centeredness is typically based on the outlooks of existentialism and humanism and the work of Carl Rogers . When aiming to promote a person’s motivation and engagement towards healthy behaviours, personal involvement and empowerment are regarded as important keys to success . In contrast to the traditional top-down approach where an expert deliver advice to a receiver; SDT  and PCC [8,22] share essential bottom-up philosophical foundations in their attitudinal values for applied work, where clients/patients instead are supposed to be highly involved in the processes and decisions of the counselling situation. Both perspectives encourage collaborative discussion, planning, problem-solving and decision-making, which in PCC constitute the working partnership  and in SDT a part of autonomy support.
Considering the abovementioned commonalities with PCC fundaments, SDT in itself might be regarded as person-centred, and this might in turn entail interesting implications for PCC assessment. Although several instruments have been developed, there is no consensus or gold-standard in PCC measures  and development of PCC assessment across services and contexts has been called for [24,25]. Within the field of SDT, several reliable and valid measures of psychological need satisfaction and motivational regulations have been developed over the years, for example health care climate questionnaire (HCCQ);  and treatment self-regulation questionnaire (TSRQ);  and conceivably such conceptualizations could be a complementary way to operationalize and measure PCC efficacy as an outcome.
Adding the concept of autonomy might transform the traditional (and highly controlling) term compliance, which is typically applied in health care (see  for concept description), also within PCC [9, 29], more in line with PCC values.
Furthermore, a recent study of patients’ perceptions of PCC  concluded that some participants did not take active part in their own care according to PCC intentions and that a reason might be that care-givers lack adequate “pedagogic skills” to change traditional patriarchal (top-down) approaches to more empowering (bottom-up) strategies. Although the nature of the warranted pedagogic skills remains unclear, this is an important insight. There have been widespread calls in international research for basing interventions in adequate theory to increase the understanding of the mechanisms behind successful interventions and improving effective intervention tailoring [31-33]. The skills Alharbi and colleagues  call for are clearly tapping the basics of autonomy support, psychological need satisfaction and autonomous motivation in accordance with SDT. Considering the commonalities between SDT and PCC value systems, the application of a psychological lens of understanding might indeed serve these purposes well. Accordingly, educating PCC practitioners in autonomy support might create added value and improved PCC efficacy, a suggestion preliminary supported by a pilot intervention by Weman-Josefsson and colleagues  in the field of exercise promotion. In line with recommendations for SDT practice [e.g., 4, 6, 35, 36], the intervention conveyed structure and involvement through autonomy support, also encompassing vital elements of the working partnership (e.g. through person narrative, documentation, goal setting and follow-up; see Ekman et al.). In short, results showed that observed main effects in exercise level and intensity were mediated by motivation quality in accordance with SDT tenets. Such mechanisms might help explain intervention efficacy and active ingredients of intervention content, also in PCC contexts.
All in all, the commonalities of SDT and PCC in terms of value systems and practical implications might constitute, if not a happy marriage, at least a promising engagement. PCC would be likely to promote autonomy, and conversely autonomy support could be expected to promote person-centeredness. In the same way as Motivational Interviewing (MI) has been suggested to provide SDT with practical guidelines while SDT would provide MI with a theoretical framework [see 37-39], PCC could aid application of SDT in the specific contexts of health care while SDT contribute to PCC practice and evaluation with a firm theoretical foundation and valid measures.
Above all, SDT have potential to embody the spirit of PCC and contribute with explanations of the mechanisms responsible for observed effects in PCC research and practice.
Cite this article: Weman Josefsson. Suggesting a Synergy between Self-Determination Theory and Person-Centred Care. J J Physical Rehab Med. 2016, 2(2): 023.