email page    print page

All Topic Reviews
101 Healing StoriesA Clinician's Guide to Legal Issues in PsychotherapyA Map of the MindA Primer for Beginning PsychotherapyACT With LoveActive Treatment of DepressionAffect Regulation, Mentalization, and the Development of SelfAlready FreeBad TherapyBecoming an Effective PsychotherapistBefore ForgivingBeing a Brain-Wise TherapistBetrayed as BoysBeyond Evidence-Based PsychotherapyBeyond MadnessBeyond PostmodernismBinge No MoreBiofeedback for the BrainBipolar DisorderBody PsychotherapyBoundaries and Boundary Violations in PsychoanalysisBrain Change TherapyBrain Science and Psychological DisordersBrain-Based Therapy with AdultsBrain-Based Therapy with Children and AdolescentsBrief Adolescent Therapy Homework PlannerBrief Child Therapy Homework PlannerBrief Therapy Homework PlannerBuffy the Vampire Slayer and PhilosophyBuilding on BionCare of the PsycheCase Studies in DepressionCaught in the NetChild and Adolescent Treatment for Social Work PracticeChoosing an Online TherapistChronic DepressionClinical Dilemmas in PsychotherapyClinical Handbook of Psychological DisordersClinical Intuition in PsychotherapyClinical Pearls of WisdomCo-Creating ChangeCognitive Therapy for Challenging ProblemsCompassionConfessions of a Former ChildConfidential RelationshipsConfidentiality and Mental HealthConfidingContemplative Psychotherapy EssentialsControlConversations About Psychology and Sexual OrientationCoping with BPDCouch FictionCounseling in GenderlandCounseling with Choice TheoryCouple SkillsCrazy for YouCreating a Life of Meaning and CompassionCreating HysteriaCritical Issues in PsychotherapyCrucial Choices, Crucial ChangesDeafness In MindDecoding the Ethics CodeDeconstructing PsychotherapyDeep Brain StimulationDemystifying TherapyDepression 101Depression in ContextDialogues on DifferenceDissociative ChildrenDo-It-Yourself Eye Movement Techniques for Emotional HealingE-TherapyEarly WarningEncountering the Sacred in PsychotherapyEnergy Psychology InteractiveErrant SelvesEssays on Philosophical CounselingEssentials of Wais-III AssessmentEthically Challenged ProfessionsEthics and Values in PsychotherapyEthics in Plain EnglishEthics in Psychotherapy and CounselingExpectationExploring the Self through PhotographyExpressing EmotionFacing Human SufferingFairbairn's Object Relations Theory in the Clinical SettingFamily TherapyFavorite Counseling and Therapy Homework AssignmentsFear of IntimacyFlourishingFolie a DeuxForms of Intersubjectivity in Infant Reasearch and Adult TreatmentFoundations of Ethical Practice, Research, and Teaching in PsychologyFreud and the Question of PseudoscienceFrom Morality to Mental HealthFundamentals of Psychoanalytic TechniqueGenes on the CouchGod & TherapyHalf Empty, Half FullHandbook of Clinical Psychopharmacology for TherapistsHandbook of Counseling and Psychotherapy with Lesbian, Gay, and Bisexual ClientsHandbook of Evidence-Based Therapies for Children and AdolescentsHealing the Heart and Mind with MindfulnessHeinz KohutHelping Children Cope With Disasters and TerrorismHigh RiskHistory of PsychotherapyHow Clients Make Therapy WorkHow Psychotherapists DevelopHow to Fail As a TherapistHow to Go to TherapyHypnosis for Inner Conflict ResolutionHypnosis for Smoking CessationI Never Promised You a Rose GardenIf Only I Had KnownIn Others' EyesIn SessionIn Therapy We TrustIn Treatment: Season 1Incorporating Spirituality in Counseling and PsychotherapyInside the SessionInside TherapyIs Long-Term Therapy Unethical?Issues in Philosophical CounselingIt's Not as Bad as It SeemsIt’s Your HourLearning from Our MistakesLearning Supportive PsychotherapyLetters to a Young TherapistLife CoachingLove's ExecutionerMadness and DemocracyMaking the Big LeapMan's Search for MeaningMetaphoria: Metaphor and Guided Metaphor for Psychotherapy and HealingMind GamesMindfulness and AcceptanceMindfulness-Based Cognitive Therapy for DepressionMindworks: An Introduction to NLPMockingbird YearsMoments of EngagementMomma and the Meaning of LifeMotivational Interviewing: Preparing People For ChangeMulticulturalism and the Therapeutic ProcessMultifamily Groups in the Treatment of Severe Psychiatric DisordersNarrative PracticeOn the CouchOne Nation Under TherapyOur Inner WorldOur Last Great IllusionOutsider ArtOvercoming Destructive Beliefs, Feelings, and BehaviorsOverexposedPathways to SpiritualityPersonality and PsychotherapyPhilosophical CounselingPhilosophical Counselling and the UnconsciousPhilosophical Issues in Counseling and PsychotherapyPhilosophical PracticePhilosophy and PsychotherapyPhilosophy for Counselling and PsychotherapyPhilosophy PracticePhilosophy's Role in Counseling and PsychotherapyPillar of SaltPlan BPlato, Not Prozac!Polarities of ExperiencesPower GamesPractical Psychoanalysis for Therapists and PatientsPrinciples and Practice of Sex TherapyPsychologists Defying the CrowdPsychology, Psychotherapy, Psychoanalysis, and the Politics of Human RelationshipsPsychosis in the FamilyPsychotherapyPsychotherapyPsychotherapy and ConfidentialityPsychotherapy As PraxisPsychotherapy for Children and AdolescentsPsychotherapy for Personality DisordersPsychotherapy Is Worth ItPsychotherapy Isn't What You ThinkPsychotherapy with Adolescent Girls and Young WomenPsychotherapy with Children and AdolescentsPsychotherapy without the SelfPsychotherapy, American Culture, and Social PolicyRapid Cognitive TherapyRational Emotive Behavior TherapyRational Emotive Behavior TherapyRationality and the Pursuit of HappinessRebuilding Shattered LivesReclaiming Our ChildrenRecovery OptionsRelationalityRent Two Films and Let's Talk in the MorningSaving the Modern SoulScience and Pseudoscience in Clinical PsychologySecond-order Change in PsychotherapySelf-Compassion in PsychotherapySelf-Determination Theory in the ClinicSelf-Disclosure in Psychotherapy and RecoverySerious ShoppingSex, Therapy, and KidsSexual Orientation and Psychodynamic PsychotherapySigns of SafetySoul Murder RevisitedStaring at the SunStraight to JesusStrangers to OurselvesSubjective Experience and the Logic of the OtherTaking America Off DrugsTales of PsychotherapyTales of UnknowingTalk is Not EnoughTalking Cures and Placebo EffectsTelling SecretsThe Behavioral Medicine Treatment PlannerThe Body in PsychotherapyThe Brief Couples Therapy Homework Planner with DiskThe Case Formulation Approach to Cognitive-Behavior TherapyThe Challenge for Psychoanalysis and PsychotherapyThe Child and Adolescent Psychotherapy Treatment PlannerThe Clinical Child Documentation SourcebookThe Clinical Documentation SourcebookThe Complete Adult Psychotherapy Treatment PlannerThe Couch and the TreeThe Couples Psychotherapy Treatment PlannerThe Crucible of ExperienceThe Cure of SoulsThe Death of PsychotherapyThe Education of Mrs. BemisThe Ethical Treatment of DepressionThe Ethics of PsychoanalysisThe Gay and Lesbian Psychotherapy Treatment PlannerThe Gift of TherapyThe Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work The Healing JourneyThe Heart & Soul of ChangeThe Heroic ClientThe Husbands and Wives ClubThe Love CureThe Making of a TherapistThe Mindful TherapistThe Mirror Crack'dThe Mummy at the Dining Room TableThe Neuroscience of PsychotherapyThe Neuroscience of Psychotherapy: Healing the Social BrainThe New Rational TherapyThe Older Adult Psychotherapy Treatment PlannerThe Other Side of DesireThe Pastoral Counseling Treatment PlannerThe Philosopher's Autobiography The Pornographer's GriefThe Portable CoachThe Portable Ethicist for Mental Health Professionals The Present Moment in Psychotherapy and Everyday LifeThe Problem of EvilThe Problem with Cognitive Behavioural TherapyThe Psychodynamics of Gender and Gender RoleThe Psychotherapy Documentation PrimerThe Psychotherapy Documentation PrimerThe Psychotherapy of HopeThe Real World Guide to Psychotherapy PracticeThe Schopenhauer CureThe Sex Lives of TeenagersThe Talking CureThe Therapeutic "Aha!"The Therapist's Guide to PsychopharmacologyThe Therapist's Guide to Psychopharmacology, Revised EditionThe Therapist's Ultimate Solution BookThe Trauma of Everyday LifeThe UnsayableThe Way of the JournalTheory and Practice of Brief TherapyTherapy with ChildrenTherapy's DelusionsTheraScribe 3.0 for WindowsTheraScribe 4.0Thinking about ThinkingThinking for CliniciansThinking for CliniciansThoughts Without a ThinkerThriveToward a Psychology of AwakeningTracking Mental Health OutcomesTrauma, Truth and ReconciliationTreating Attachment DisordersTreatment for Chronic DepressionTreatment Plans and Interventions for Depression and Anxiety DisordersUnderstanding Child MolestersUnspeakable Truths and Happy EndingsWhat the Buddha FeltWhat Works for Whom?What Works for Whom? Second EditionWhen the Body SpeaksWhispers from the EastWise TherapyWittgenstein and PsychotherapyWorking MindsWoulda, Coulda, ShouldaWriting About PatientsYoga Skills for Therapists:Yoga Therapy

Related Topics
Self-Determination Theory in the ClinicReview - Self-Determination Theory in the Clinic
Motivating Physical and Mental Health
by Kennon M Sheldon, Geoffrey Williams and Thomas Joiner
Yale University Press, 2003
Review by Roy Sugarman, Ph.D.
Sep 3rd 2004 (Volume 8, Issue 36)

It was William Miller in the 80's who began to investigate human motivation and ambivalence, the great leveler of motivated action.  In essence, human beings see where they are and know where they want to be, but the distance between the two may seem daunting, and saps our will.  Festinger's concept of cognitive dissonance applies here as well.  Giving up things, even when they are harmful, like drugs, involves sacrifice, and this may be hard. 

In illness, 'power' relationships involving complementary stances are common and endemic: doctor-patient, nurse-patient, doctor-nurse, medical and mental health settings are political hotbeds for personality dysfunctional patients, as well as those others who are ill. Larry Diller spoke of the patient's loss of sense of efficacy, loss of the sense that what THEY as person did, makes a difference to the outcome.

Consumer pressure, in the form of a 'recovery' revolving around a patient's return to wellness, even though technically still ill, has at its core the sense of personal efficacy in the journey towards recapturing the premorbid position in society, or at least, replicating it in the new world of mental disorder.  Patients became clients, then consumers, and now I am told, they just want to be known as service users, distinct from providers.

The health worker is thus being thrust from what David Manchester calls the 'sage on the stage position' to the 'guide on the side position', an empowered position in which the consumer dictates a series of needs around entitlements, and the provider accesses those and creates clinical competencies in the community to deal with the change in consumer status which has resulted in a loss of position and status in society.  Mental illness and more medical illness is thus not a specter without cure, cure is not possible but that is not a sine qua non for survival and happiness: empowerment, self-efficacy, recovery, self-esteem, these are the features of Anthony's work, and Deegan's laments about her care and wellness dilemmas.

The humanitarian stances of the recovery/rehabilitation groups have not been entirely integrated into mental health care.  Although the Meyerian, Boston, Rochester, and other biopsychosocial model philosophies have begun to dominate the psychiatric world, empirical science or sometimes pseudoscience still prevails against the more humanitarian, non-medical, non-linear, seemingly unproven and unscientific methods of care.  Along the way, Laing, Szasz and others have seemed too radical and hippie to be of value.  Here, the authors of this book are doing the same for medicine in the mainstream, but avoiding the radical stance.

Sheldon, Williams and Joiner have set out to address the above historical issues by applying a more humanist and general-systems informed approach, which also has the benefit of an evidence base, within mainstream clinical medicine:

Unfortunately, the products of humanistic research were often unimpressive, sometimes presenting laborious descriptive analyses of trivial personal experiences, and other times seeming to make hopelessly naïve assumptions about the inherent "goodness" of human nature…..There was also a general shying away from causal analysis, as if scientific explanation itself were taboo….By seeking to reform both theoretical and methodological psychology simultaneously, the humanists overextended themselves and diluted their message.  Further, their attack on empirical methodology was wrong, and it undermined their credibility.  Research methods are, after all, only tools, not ideologies, and like all tools, they can be applied more or less thoughtfully (pages 8-9).

This is what the authors set out to do, integrating humanism with cognitive science, in creating a basis for self-determinism theory in a thoughtful, scientific way (SDT).

They begin with examining self-determination theory's supportive research base, heavily reliant on Edward Deci's and Richard Ryan's works.  Concepts of mastery or 'effectance' in efficacy are taken from Robert White's work in the late 50's in combating social withdrawal and disengagement. Obviously if one is to recover one's premorbid social position, one has to engage with the environment in an effective way, and may need help to do so.  Volition is, after all, problematic to achieve with severe mental illness dominating, and surrogate frontal and executive scaffolding seems called for.  As with ambivalence, issues of intrinsic motivation are important to, as exemplified in Deci and Ryan's work which overturned much of the behaviourist approach by demonstrating that people will often choose internal rewards rather than external, and seek their own satisfaction choosing their own poison so to speak, punished by reward rather than the other way round.  Following on Plato, James, Piaget, Dewey, SDT is thus an 'organismic' perspective (page 15).  It assumes that we are naturally curious and often seek challenge above other rewards.  In this way too, we are complicators of our lives, 'entropyreducing systems' in other sort-of words – I shall avoid describing the concepts of entropy and enthalpy and autopoesis and other thermodynamic/constructivist notions, which cloud the issue here.  The stance is that we seek to create, and evolutionary trends in the brain have driven this organ to thrive on increasingly complex and creative situations, not shrink or die off when stressed in this way.  We are thus engagers in creative complexity on different levels, and facilitating and integrative process with this complex entity to empower movement out of pathological stasis is a goal of healing.

This is presented as a dialectic: thesis and antithesis interact to form a gestalt-like greater whole, a synthesis, of inner and outer selves, and we seek to master our internal and external environs, drives and impulses, a dialectic that evolves around the synergic of the cognitive approach and the humanism that this approach has lost so much of, sliding backward into the mechanistic reductionism that characterized the early behaviourists.  In essence, we are either pawns or autonomous in the potentially alienating contexts of work and play, or of wellness or illness.  Hegel still has Marx on his head, with a bit of Rousseauian romanticism showing itself in the lineage of the arguments put forward here, and in the arguments reminiscent of dialectic versus scientific materialism.  SDT thus has a humanistic orientation supported by quantitative and experimental research, makes positive assumptions about human nature, whilst still accepting how the bad stuff can accrue anyway, assumes that there are three human needs that constitute wellness, namely autonomy, competence, and relatedness, focuses on people's need for ownership and mastery of motivated behavior towards wellness, and the target of this thin book is to show how those at the upper end of the complementary loop can best motivate the one-down sick people so that they internalize suggested behaviors and self regulate them (see page 22).

As they put it, SDT begins with the concept of intrinsic motivation, viewing it as the basis of the prototype of the self-organized state, and in this way we are epitomized as doing things in the interface of the environment for the challenge of it, not the external reward, but for the satisfaction that mastery of the self and other brings.  We all need to find what our intrinsic motivators are, so we can follow them, and not master things that are not reinforced internally, but merely supported by the environment: it's a kind of leaving home, leaving mum and dad's view of the world, and following our own view, if we know what that is.  In this way, psychosocial competency and maturity means we can also do what is aversive to us, mastering the external boundaries of the self, and relating therefore to other selves which are critical to the sense of relatedness above.

Such latter changes are thus unpleasant, and require abandonment of unhealthy in favor of healthy, changed behavior, and this book is about how we facilitate that in the use of our services.  Or rather, how we promote ownership of not-so-enjoyable behaviors, and how we get people to acquire motivation which is not intrinsically reinforced, not immediately gratifying anyway, lets say.

In the unequal, complementary situation, a power structure, supporting autonomy is thus the key, again a Deci and Ryan concept. In, this is often a meta-complementary stance, providing help.  The first challenge is to stay with what the user of service sees as illness perspective, letting them decide what to do, the most difficult part for any service provider to play in Anthony's recovery model anyway.  Providing of choice wherever possible is vital too, and finally, providing a meaningful rationale when choice is not offered, is a necessary part of the support game too.

Concepts of client resistance come into play here, some are less dutiful than others in following the clinicians prescriptions. Ownership of recommended behavior is the goal here.

From chapter four, SDT is applied to medical practice and physical health.  Here, the concept of motivation is examined closely with some clinical research, and chapter five becomes more specific with regard to tobacco dependence

Following on Prochaska and DiClementi, as did William Miller with MI and MET, time frames are allowed to extend, relapse is expected and accepted, each failure doing more to guarantee a better outcome next time, rather than worse, and relating this process to many health related behaviors. Case studies are used, as they are in the next chapter, where compliance in the face of ambivalence in diabetes mellitus is supported.

As expected, mental health has its turn here, and so they seek a unified psychology, of science and clinical work coming together.  The authors make good use of the controversy that emerged around the Temple University finding on the outcomes in child abuse, and the social pressure that arose rapidly when a survivor, rather than a victim perspective was adopted, in positive psychology frames.  Rind and colleagues were pilloried, after peer review and acceptance, to boot, as were Herrnstein and Murray when they published The Bell Curve, condemning the averaged sum of some to the lower, middle or upper ranks in a deterministic fashion, but with careful science to back them up.  Again, the public often confuse the statistical person with a real one.  One of course cannot divide 10 000 results by 10 000 to get one, one does not have the results of statistical averaging to create perfection, or regression to the mean.

Neither technical skill nor motivational abilities are enough, both are necessary and neither is sufficient (see page 113). The human condition is such that in the interaction, both expertise, and the capacity to sell that in such a way as to promote ownership, is the challenge of clinical work.  We knew that, and thanks to these authors, in some part, we learn how to better achieve that end: wellness, empowerment and recovery in medical settings.

Their final chapters look at substance abuse (predictable), and finally, and acceptably, motivational interviewing gets its time in the spotlight.  Anxiety and eating disorders also get attention, OCD, PTSD, bulimia gets a page or so, that is all.  Mood and personality are focused on in chapter 10, and here, the Cognitive Behavioral Analysis System rises to the fore, as does interpersonal therapy for depression, both focusing on manageable specificity.

They conclude:

What matters is not weaving a spell of inspired speech, but, rather, creating an interpersonal context and relationship in which clients can encounter their own resolve….There is a huge gap between clients' intended and actual behavior (page 185).

The book is more than mere philosophy, yet not enough.  It is more than hocus-pocus, but the evidence base is a tad thin.  I think however they are really where they need to be in providing a brief and somewhat scholarly, very readable and concise guide to becoming a better person, and more importantly, to quote Jack Nicholson, in his OCD laden compliment to Helen Hunt, they make me want to be a better person. 


© 2004 Roy Sugarman


Roy Sugarman, PhD, Clinical Director: Clinical Therapies Programme, Principal Psychologist: South West Sydney Area Health Service, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia.


Welcome to MHN's unique book review site Metapsychology. We feature over 7600 in-depth reviews of a wide range of books and DVDs written by our reviewers from many backgrounds and perspectives. We update our front page weekly and add more than thirty new reviews each month. Our editor is Christian Perring, PhD. To contact him, use one of the forms available here.

Can't remember our URL? Access our reviews directly via ''

Metapsychology Online reviewers normally receive gratis review copies of the items they review.
Metapsychology Online receives a commission from for purchases through this site, which helps us send review copies to reviewers. Please support us by making your purchases through our Amazon links. We thank you for your support!

Join our e-mail list!: Metapsychology New Review Announcements: Sent out monthly, these announcements list our recent reviews. To subscribe, click here.

Interested in becoming a book reviewer for Metapsychology? Currently, we especially need thoughtful reviewers for books in fiction, self-help and popular psychology. To apply, write to our editor.

Metapsychology Online Reviews

Promote your Page too

Metapsychology Online Reviews
ISSN 1931-5716