Personal autonomy is highly valued across the field of healthcare.
Increasingly, patients are encouraged to make autonomous decisions regarding their goals and treatment plans (Entwistle, Carter, Cribb, & McCaffery, 2010).
Within counseling and therapy, research recognizes that “client’s autonomy should be respected and collaborative engagement fostered” to encourage the therapeutic alliance and improve treatment outcomes (Ryan, Lynch, Vansteenkiste, & Deci, 2011, p. 193).
Autonomy is crucial and one of the five principles that form the cornerstone of ethical guidelines for mental health practitioners (Forester-Miller & Davis, 2016).
This article examines the importance of autonomy in counseling and considers ways to promote it and strengthen the therapeutic relationship.
Before you continue, we thought you might like to download our three Strengths Exercises for free. These detailed, science-based exercises will help your clients realize their unique potential and create a life that feels energizing and authentic.
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What Is Client Autonomy in Counseling?
“Counseling and psychotherapy involve mobilizing forces or energy within the client in the direction of healing or change” (Ryan et al., 2011, p. 196). Counseling is mainly voluntary and requires client engagement.
Failure to attend sessions and client attrition are serious factors hampering treatment success. Therefore, the client must be initially motivated to attend their first appointment and maintain their drive to avoid dropping out (Ryan et al., 2011, p. 196).
While motivation is crucial – as it provides the energy and direction for change – so too is autonomy. Indeed, along with relatedness and competence, autonomy is one of three key factors in Ryan and Deci’s (2018) self-determination theory (SDT) of motivation.
“Supporting autonomy and competence is supporting the fundamental human capabilities for living a full life” (Ryan & Deci, 2018, p. 453).
Indeed, when treatment is personally relevant, clients experience a greater sense of autonomy, feeling less pressured or controlled to perform, and a higher degree of intrinsic motivation (Ryan & Deci, 2018).
SDT suggests that maintaining intrinsic motivation and internalizing extrinsic motivation can be facilitated by the degree of autonomy support provided in therapy. Crucially, this occurs when healthcare professionals and others “take the perspective of the target individual, support their choice, and minimize pressure and control” (Ryan et al., 2011, p. 203).
In a white paper written for the American Counseling Association, Holly Forester-Miller and Thomas Davis (2016, p. 1) suggest that autonomy in counseling “addresses respect for independence, and self-determination […] allowing an individual the freedom of choice and action.” Therefore, the counselor should encourage the client to take ownership of their decisions and act according to their values.
However, there are two points to consider when encouraging autonomy (Forester-Miller & Davis, 2016):
- Clients may need support to understand how their decisions and values impact others, including how they affect their rights.
- Consideration must be given to whether or not the client can make sound and rational decisions.
Next, we look at research and cases that support the idea that autonomy underpins clients’ willingness to engage in their treatment, leading to more positive outcomes.
6 Examples & Cases of Patient Autonomy
Successful treatment outcomes in counseling and therapy are helped by creating supportive, positive, and facilitative environments (Ryan & Deci, 2018).
Ideally, the setting of the intervention should support autonomy, encouraging treatment effectiveness, client retention, and the maintenance or persistence of change (Ryan & Deci, 2018).
Ongoing research confirms the importance of individual autonomy in the therapeutic alliance and treatments, both in attendance and outcome:
- Autonomy across therapy approaches
A series of studies investigated autonomy and autonomy support using multiple theoretical approaches, including Cognitive-Behavioral Therapy (CBT), Interpersonal Therapy, and pharmacotherapy with clinical management (Zuroff et al., 2007; Ryan & Deci, 2018).
The findings suggested that the degree of autonomy predicts the client’s motivation for treatment, improvement in symptoms of depression, and the success of the therapeutic alliance. Indeed, it appears that autonomous motivation is better at predicting treatment outcomes than the therapeutic alliance.
- Autonomy and treating depression
A further study tested clients being treated for episodes of depression. Results confirmed that increasing autonomous motivation in therapy is linked to reduced symptoms of depression following treatment (Zuroff, Koestner, Moskowitz, McBride, & Bagby, 2012; Ryan & Deci, 2018).
- Autonomy in group therapy
Dwyer, Hornsey, Smith, Oei, and Dingle (2011) explored the effect of autonomy in a CBT group treatment for adults lasting four weeks. The individuals who experienced a higher degree of autonomy showed greater improvements in their self-reported anxiety and depression (Ryan & Deci, 2018).
- Autonomy and drug treatment
The importance of autonomy has been studied in individuals receiving help for drug addiction. Findings showed that those higher in autonomous motivation attended more group and individual sessions and recorded fewer positive drug tests (Zeldman, Ryan, & Fiscella, 2004; Ryan & Deci, 2018).
Case studies of therapy promoting autonomy support report similar successes:
- Using logical consequences
Soon after seeking help with their marriage, ‘Amy’ discovered ‘Richard’ was having an affair (Smith, 2009). She continued with the therapy alone to consider her options.
The counselor supported her in taking back control of her life and achieving her own goals through role-play and providing specific feedback about her situation (Smith, 2009).
- Acceptance and letting go
‘Elizabeth’ arrived at counseling angry and with a sense that she was not coping with her life (Laemmle, 2009). She saw a professional counselor for five months and received CBT and Solution-Focused Therapy.
Part of her treatment involved visualization. Using an image of her present life gave her the freedom to vent her anger and understand how her partner controlled her. She used a subsequent visualization to picture a potential new life and help her regain control of her future (Laemmle, 2009).
Why Is Autonomy Important in Counseling?
As a therapist or counselor, “your purpose is to understand the life before you, to see the world through this person’s eyes rather than superimposing your own vision” (Miller & Rollnick, 2002, p. 16).
Forming such a relationship requires a partnership between the mental health professional and the client. Acceptance is paramount. The counselor may not agree with or approve of their client’s behavior but must accept it. Their “irrevocable right and capacity of self-direction” – their autonomy – must be respected (Miller & Rollnick, 2002, p. 16).
A client-centered approach to therapy suggests that if given the necessary therapeutic conditions, along with the positive effect of human nature, people will naturally proceed and grow positively (Miller & Rollnick, 2002).
Attempts to force, control, or coerce people into particular behavior often fail because, ultimately, the individual has a choice. Acknowledging that person’s right and capacity to do as they wish can facilitate and drive lasting change (Miller & Rollnick, 2002).
One of SDT’s aims in psychotherapy is to encourage client awareness and mindfulness of what is happening in their lives and therapy. Improving self-awareness enables clients to examine their inner lives, strengthen their sense of autonomy, and ultimately gain greater resilience to stress (Ryan & Deci, 2018).
As a facilitator of change, the therapist may or may not be an expert, with information necessary for the client to resolve their issues. However, the aim is neither to pressure nor direct transformation, but to provide the skills and knowledge required for the individual to make authentic choices appropriate to their values (Ryan & Deci, 2018).
Client autonomy is the ultimate clinical goal rather than the achievement of specific behavioral outcomes (Ryan & Deci, 2018). After all, therapy’s aim should be to facilitate “people’s ability to make informed and reflective choices about how to live their lives and then engage the challenges, often unpredictable, that will ensue” (Ryan & Deci, 2018, p. 453).
For that very reason, psychotherapy has, at times, been seen as subversive. When successful, individuals reevaluate their lives and values without the proximal pressures of their culture, family, and friends. Because of the autonomy gained, all phenomena (internal and external) are treated with an equal degree of curiosity, interest, and compassion (Ryan & Deci, 2018).
How to Promote Client Autonomy 101
“Creating sustained change in the direction of wellness or more effective functioning poses unique challenges for both clients and practitioners” (Ryan & Deci, 2018, p. 423).
Ryan and Deci (2018) advocate that therapists and counselors provide support for autonomy, and warn that it is not easy. Promoting client autonomy must be approached carefully, with the therapist working toward the following:
- Being sensitive and responsive to the basic psychological needs of the client: relatedness, autonomy, and competence. In their absence, the client will suffer harm to their growth and wellbeing.
- Providing unconditional positive regard, including ignoring personal biases, ego involvement, and personal agendas regarding the outcome of therapy.
- Ignoring outcome pressures that result from the healthcare environment in which the treatment takes place. Becoming too outcome focused can lead to a more controlling tone.
- Maintaining awareness regarding the therapist’s own goals and taking care not to bring them into the therapeutic relationship with the client.
According to Ryan and Deci (2018), several autonomy-supportive techniques embrace the perspective of the client to promote client autonomy, including:
- Taking the internal frame of reference
Taking the client’s internal frame of reference involves listening carefully and with empathy to the clients’ viewpoints (including motivations and values) and gaining a fuller understanding of their experiences.
The therapist can reduce the client’s defensiveness and foster autonomy through the following techniques:
- Showing openness and acceptance
- Being interested in what the client has to say
- Using nonjudgmental communication and interactions
- Displaying compassion and empathy.
- Emotional focus
Through attending to and uncovering important feelings, the therapist can unearth significant experiences and events that may interfere with the move toward greater autonomy and need satisfaction.
By being curious, accepting, and nonjudgmental, it is possible to understand and overcome resistance to change.
- Provide a rationale for treatment strategies and activities
For many, therapy can be an unknown and possibly daunting process. Explaining the meaning and value of activities can provide “clear and legitimate reasons to act” (Ryan & Deci, 2018, p. 444).
Creating an environment where questions and doubts can be raised and discussed leads to respect and a stronger sense of autonomy.
- Acknowledge resistance
Resistance is a common and expected aspect of therapy. Counselors must adopt a mindful, self-regulated outlook that embraces resistance and invites a collaborative counseling approach to overcome obstacles.
- Offering choice and inviting valuable input
Giving the client a sense of choice regarding what they are doing encourages autonomy. Collaboratively working as part of the therapeutic alliance ensures the client has the opportunity to provide meaningful input while establishing valuable goals.
- Mindfulness for autonomy
Fostering awareness and cultivating mindfulness are helpful therapeutic tools, promoting autonomy and healthy self-regulation. Mindfulness enables people to understand better what is happening internally and externally, in therapy and in life.
Encouraging the client’s interest in their internal processes also promotes autonomy, interest taking, and curiosity, and heightens the available energy and vitality.
Ethical Considerations: Respecting Patients’ Autonomy
The American Counseling Association provides guidance to help therapists and counselors maintain compliance with the counseling profession’s ethical standards.
According to the American Counseling Association’s (2014, n.d.) Code of Ethics, the core principles of professional, ethical behavior are as follows:
Foster the right to control the direction of one’s own (the client’s) life.
Avoid actions that cause harm.
Work for the good of the individual and society, promoting mental health and wellbeing.
Treat individuals equitably, fostering fairness and equality.
Honor commitments and keep promises, including fulfilling one’s responsibilities of trust in professional relationships.
Deal truthfully with individuals with whom they come into professional contact.
The code states that counselors must respect their clients’ diversity and avoid imposing their own “values, attitudes, beliefs, and behaviors,” particularly when they are at odds with the counselor’s goals (American Counseling Association, 2014, p. 5.).
Helpful Resources From PositivePsychology.com
We have many resources as part of our Toolkit, an online resource of positive psychology tools, that can help identify and improve psychological factors influencing autonomy, including:
- The Acceptance or Avoidance Route
The goal of Acceptance and Commitment Therapy is to help clients live (autonomously) according to their values. Once we accept rather than avoid emotions, we can overcome self-limiting emotions, such as fear. This worksheet is instrumental in making clients aware of their choices.
- The Ryff Scales of Psychological Wellbeing
This tool is a widely used and scientifically grounded instrument that measures multiple psychological wellbeing factors, including autonomy.
- Initiating Physical Activity
Physical activity helps people flourish. This worksheet is useful for creating an action plan to integrate physical activity – a vital source of autonomy – into your life.
- Self-Directed Speech Worksheet
Changing behavior is not easy. This exercise utilizes your inner voice to motivate you and captures what you could do when faced with obstacles.
- Basic Needs Satisfaction in General Scale
This scale, containing 21 questions answered on a scale of one to seven, indicate if your basic needs of autonomy, relatedness, and competence are being met.
- Building New Habits
Habits can be incredibly powerful, and they are more manageable when we understand how they work. This exercise can help you find the motivation to persevere and make lasting changes.
- 17 Strength-Finding Exercises
If you’re looking for more science-based ways to help others develop their strengths, this collection contains 17 strength-finding tools for practitioners. Use them to help others better understand and harness their strengths in life-enhancing ways.
A Take-Home Message
Therapists are facilitators of change. On occasion, they can be experts in the subject area, providing helpful information for the client to resolve their issues, but they should not be controlling.
Changing specific behaviors is essential, yet limited, unless accompanied by new skills enabling the individual to “make informed and reflective choices about how to live their lives” (Ryan & Deci, 2018, p. 453).
Rather than pressuring the client to behave in a certain way, the counselor should inform and enhance their ability to make authentic choices. Autonomy-supportive therapy improves the client’s wellness and enables the satisfaction of their basic needs as they pursue what matters most to them (Ryan & Deci, 2018).
Client autonomy must remain a vital goal for those seeking treatment. Through creating a positive therapeutic alliance and a safe and supportive environment for therapy, therapists can offer clients a sense of control over both the treatment and their lives.
Central to acceptance in therapy is the idea of “honoring and respecting each person’s autonomy, their irrevocable right and capacity of self-direction” (Miller & Rollnick, 2002, p. 18). Such autonomy provides the client with the opportunity to grow authentically and positively in the direction they choose.
A well-trained counselor will show empathy and respect for their client, building an autonomy-supportive, collaborative alliance, fostering motivation to initiate and maintain long-lasting change.
We hope you enjoyed reading this article. Don’t forget to download our three Strengths Exercises for free.
- American Counseling Association. (n.d.). Ethics. Retrieved June 21, 2021, from https://www.counseling.org/knowledge-center/ethics
- American Counseling Association. (2014). ACA code of ethics. Retrieved June 21, 2021, from https://www.counseling.org/docs/default-source/default-document-library/2014-code-of-ethics-finaladdress.pdf?sfvrsn=96b532c_2
- Dwyer, L. A., Hornsey, M. J., Smith, L. G., Oei, T. P., & Dingle, G. A. (2011). Participant autonomy in cognitive behavioral group therapy: An integration of self-determination and cognitive behavioral theories. Journal of Social and Clinical Psychology, 30(1), 24–46.
- Entwistle, V. A., Carter, S. M., Cribb, A., & McCaffery, K. (2010). Supporting patient autonomy: The importance of clinician-patient relationships. Journal of General Internal Medicine, 25(7), 741–745.
- Forester-Miller, H., & Davis, T. E. (2016). Practitioner’s guide to ethical decision making (rev. ed.). American Counseling Association. Retrieved June 21, 2021, from https://www.counseling.org/docs/default-source/ethics/practioner-39-s-guide-to-ethical-decision-making.pdf?sfvrsn=f9e5482c_10
- Laemmle, K. (2009). A case of acceptance and letting go. Australian Institute of Professional Counsellors. Retrieved June 22, 2021, from https://www.aipc.net.au/articles/a-case-of-acceptance-and-letting-go/
- Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. Guilford Press.
- Ryan, R. M., Lynch, M. F., Vansteenkiste, M., & Deci, E. L. (2011). Motivation and autonomy in counseling, psychotherapy, and behavior change: A look at theory and practice. The Counseling Psychologist, 39(2), 193–260.
- Ryan, R. M., & Deci, E. L. (2018). Self-determination theory: Basic psychological needs in motivation, development, and wellness. Guilford Press.
- Smith, G. (2009). A case of using logical consequences. Australian Institute of Professional Counsellors. Retrieved June 22, 2021, from https://www.aipc.net.au/articles/a-case-of-using-logical-consequences/
- Zeldman, A., Ryan, R. M., & Fiscella, K. (2004). Motivation, autonomy support, and entity beliefs: Their role in methadone maintenance treatment. Journal of Social and Clinical Psychology, 23(5), 675–696.
- Zuroff, D. C., Koestner, R., Moskowitz, D. S., McBride, C., Marshall, M., & Bagby, M. R. (2007). Autonomous motivation for therapy: A new common factor in brief treatments for depression. Psychotherapy Research, 17(2), 137–147.
- Zuroff, D. C., Koestner, R., Moskowitz, D. S., McBride, C., & Bagby, R. M. (2012). Therapist’s autonomy support and patient’s self-criticism predict motivation during brief treatments for depression. Journal of Social and Clinical Psychology, 31(9), 903–932.