How Therapists Help Clients Change: A Self-Determination Theory Analysis of Effective Behaviors in Substance Use Disorder Treatment

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Author: Rosedale, Jacob PhD, LPC

Jacob Rosedale Therapy, Independent Clinical Practice, Ramat Beit Shemesh, Israel National University, Department of Psychology, San Diego, California, USA

Abstract

Substance use disorder (SUD) treatment continues to face challenges related to engagement, early dropout, and inconsistent long-term outcomes. Although the therapeutic alliance is one of the most reliable predictors of success across treatment modalities, far less is known about the specific therapist behaviors that generate the motivational conditions necessary for recovery. Self-Determination Theory (SDT) provides a useful empirical lens for understanding how therapists influence clients’ autonomy, competence, and relatedness—the basic psychological needs that underlie internalization, persistence, and meaningful behavior change. This article integrates SDT with contemporary alliance and addiction literature to articulate how autonomy supportive, competence-enhancing, and relatedness-building therapist behaviors function as mechanisms of motivational change throughout treatment. Particular attention is given to early session processes, which consistently predict retention and set the trajectory of the alliance. We also highlight ongoing motivational maintenance across the course of therapy and outline clinical implications for individual clinicians, supervisors, and treatment programs. An SDT-informed model offers a coherent framework for understanding how therapist behaviors influence engagement, internalization, and sustained recovery. This perspective extends beyond modality specific techniques and emphasizes the relational foundations through which therapeutic change occurs in SUD treatment.

Keywords: Self-Determination Theory; therapeutic alliance; substance use disorder; motivation; therapist behaviors; engagement; addiction treatment

Introduction

Substance use disorder (SUD) represents one of the most challenging and persistent conditions treated in behavioral health, with relapse, partial engagement, and treatment dropout continuing to undermine outcomes across modalities. Although pharmacological and psychosocial interventions have advanced considerably, decades of psychotherapy research consistently highlight a single factor that predicts outcomes across settings: the quality of the therapeutic alliance. Yet a persistent gap remains in the literature—the field knows that alliance matters, but far less is known about the specific therapist behaviors that create the conditions for strong alliance and sustained motivation, particularly during the critical early stages of SUD treatment. Self-Determination Theory (SDT), a widely researched model of human motivation, offers a compelling framework for addressing this gap. SDT posits that psychological growth and behavior change depend on the fulfillment of three basic psychological needs: autonomy, competence, and relatedness. When these needs are supported, individuals demonstrate higher quality motivation, better engagement, and more sustained behavior change. Conversely, when these needs are thwarted, motivation deteriorates and resistance increases—patterns commonly observed in addiction treatment. Integrating SDT with psychotherapy process research offers a pathway for identifying how therapist behaviors directly influence clients’ motivational states and treatment engagement. Despite SDT’s strong empirical foundation in health behavior change, the theory has been underutilized as an explanatory mechanism for how therapists help clients change within SUD treatment. Likewise, alliance research has traditionally emphasized alliance measurement rather than the specific relational behaviors that strengthen or weaken it. Emerging studies suggest that therapist behaviors—such as empathic attunement, collaborative agenda-setting, autonomy supportive communication, and structured competence-building—may serve as the mechanisms that connect relational processes with measurable treatment outcomes. However, these findings are dispersed across multiple bodies of literature, and no integrative framework currently synthesizes them within an SDT-based model. This article addresses these gaps by proposing a cohesive, SDT-informed conceptual model for understanding therapist behaviors as mechanisms of motivational change in SUD treatment. We examine how therapists support autonomy through choice, transparency, and collaboration; how they enhance competence through feedback and skill-building; and how they foster relatedness through warmth, consistency, and empathic connection. We also highlight the importance of early-session behaviors—critical predictors of retention—and outline how therapist behaviors can sustain motivation across the full course of treatment. By integrating SDT with alliance and SUD research, this article advances a theoretically grounded, practice-focused understanding of how therapists help clients change. The model not only clarifies mechanisms of action within existing therapeutic approaches but also offers practical guidance for clinicians, supervisors, and training programs seeking to strengthen treatment engagement and outcomes.

THEORETICAL FOUNDATIONS: SELF-DETERMINATION THEORY AND THE THERAPEUTIC ALLIANCE

Self-Determination Theory (SDT) provides a comprehensive empirical framework for understanding how interpersonal environments shape motivation, engagement, and well-being. Decades of research demonstrate that optimal functioning depends on the fulfillment of three basic psychological needs: autonomy, competence, and relatedness (Ryan & Deci, 2000, 2017; Vansteenkiste et al., 2020). When these needs are supported, individuals exhibit higher-quality motivation, greater persistence, deeper engagement, and improved long-term behavior change across health domains (Ng et al., 2012; Ntoumanis et al., 2021). Conversely, when these needs are thwarted—through coercion, criticism, or relational disconnection—motivation deteriorates and resistance increases, patterns frequently seen among clients entering substance use disorder (SUD) treatment.

A growing body of evidence shows that autonomy-supportive interpersonal behavior predicts better treatment adherence and outcomes in addiction-related contexts. For example, autonomy supportive counseling increases motivation and enhances treatment retention in individuals with SUD (Chan et al., 2023) and improves goal engagement among clients with severe mental illness (Jochems et al., 2016). Competence-supportive environments—including clear guidance, skill building, corrective feedback, and reinforcement of successes—strengthen clients’ sense of efficacy, a critical predictor of recovery outcomes (Mills et al., 2021). Relatedness support, conveyed through empathic attunement and genuine interpersonal presence, enhances engagement and predicts better therapeutic outcomes across diverse clinical populations, including those with trauma, eating disorders, and substance use disorders (Howard et al., 2021; Urbanoski et al., 2012).

Parallel to SDT, the therapeutic alliance is one of the most consistently validated predictors of treatment outcomes in psychotherapy. Meta-analyses repeatedly show a robust alliance–outcome correlation across modalities and diagnoses (Flückiger et al., 2018; Wampold & Flückiger, 2023). The alliance is defined by agreement on therapy goals, agreement on tasks, and the emotional bond between client and therapist (Bordin, 1979). Importantly, emerging research indicates that specific therapist behaviors—not just global relational ratings—drive alliance formation. Behaviors such as empathic attunement, shared agenda-setting, nonjudgmental stance, and collaborative transparency enhance early alliance quality and predict decreased dropout in SUD treatment (Del Río Olvera et al., 2022; Urbanoski et al., 2012). Likewise, therapist interpersonal skill predicts outcomes beyond treatment modality or specific techniques (Anderson et al., 2009; Schöttke et al., 2017).

Although SDT and alliance research stem from different intellectual traditions—motivational science and psychotherapy process research—they converge on a central principle: interpersonal environments shape internal motivational states. Yet SDT has been underutilized as a framework for articulating how therapist behaviors support the motivational processes that underlie alliance formation, engagement, and sustained behavior change in SUD treatment. This represents a significant gap, given that clients entering addiction services often report depleted autonomy, diminished self-efficacy, and relational ruptures (Love et al., 2020), rendering them highly sensitive to how therapists communicate, structure sessions, and respond to emotional experiences. An SDT-informed lens suggests that therapist behaviors serve as proximal mechanisms that support psychological needs and thereby strengthen the alliance. Autonomy-supportive behaviors—offering meaningful choices, validating perspectives, and minimizing coercive language—enhance volition and reduce defensiveness (Chan et al., 2023; Ng et al., 2012). Competence-supportive behaviors—structured guidance, skill development, and mastery-oriented feedback—support clients’ sense of capability, a predictor of change in both gambling and substance use contexts (Mills et al., 2021). Relatedness-supportive behaviors— empathy, attunement, warmth, and consistency—fulfill a fundamental need for interpersonal safety, which predicts stronger alliance and improved outcomes across clinical populations (Anderson et al., 2009; Howard et al., 2021; Urbanoski et al., 2012).

Together, SDT and alliance theory provide a theoretically rich and empirically grounded foundation for understanding how therapist behaviors function as motivational mechanisms in SUD treatment. When clinicians support autonomy, competence, and relatedness, clients experience greater motivational internalization and form stronger alliances—two factors consistently associated with reduced dropout and improved substance use outcomes (Flückiger et al., 2018; Wampold & Flückiger, 2023). This integrative perspective clarifies why certain therapist behaviors matter and how they influence recovery trajectories. By uniting SDT’s motivational science with alliance research, this framework offers clinicians, supervisors, and researchers a coherent model for strengthening engagement, deepening therapeutic work, and improving long-term outcomes in SUD treatment. The next section builds directly on this foundation by articulating the specific therapist behaviors that operate as mechanisms of motivational change.

THERAPIST BEHAVIORS AS MECHANISMS OF MOTIVATIONAL CHANGE

Therapist behaviors shape clients’ motivational experiences by influencing how the basic psychological needs proposed by Self-Determination Theory—autonomy, competence, and relatedness—are supported or frustrated throughout treatment. Although traditionally examined within specific modalities such as motivational interviewing or cognitive-behavioral therapy, these behaviors function as broader relational mechanisms that transcend therapeutic orientation. Empirical research consistently confirms that interpersonal qualities such as empathy, attunement, collaboration, and responsiveness predict both stronger therapeutic alliances and improved treatment outcomes across diverse clinical settings (Anderson et al., 2009; Flückiger et al., 2018; Schöttke et al., 2017).

Autonomy-Supportive Behaviors. Autonomy support refers to therapist behaviors that promote volition, minimize coercion, and validate the client’s perspective. In addiction treatment, where ambivalence is common and external pressure often precipitates entry into care, autonomy supportive communication plays a protective role. Behaviors such as offering meaningful choices, inviting client-generated goals, and using non-controlling language enhance intrinsic motivation and decrease defensiveness (Ng et al., 2012; Chan et al., 2023). Research in SUD treatment shows that clients who perceive higher levels of autonomy support demonstrate greater treatment engagement, more internalized motivation, and reduced dropout (Urbanoski et al., 2012).

Competence-Supportive Behaviors. Competence support involves structured guidance, feedback, and reinforcement practices that help clients develop mastery over new skills. For individuals with SUDs—many of whom struggle with decreased self-efficacy and repeated experiences of relapse—competence-enhancing interventions are essential. Studies show that therapy environments emphasizing skill acquisition (e.g., coping strategies, craving regulation, decision-making) foster a stronger sense of capability and predict more enduring behavior change (Mills et al., 2021; Dellazizzo et al., 2023). Therapists who highlight incremental progress and normalize setbacks strengthen clients’ belief in their capacity to recover.

Relatedness-Supportive Behaviors. Relatedness support centers on the therapist’s ability to convey warmth, empathy, emotional presence, and genuine interest. These behaviors fulfill clients’ need for connection and belonging, which is often undermined by stigma, isolation, and shame associated with addiction. Meta-analytic evidence demonstrates that therapist warmth, empathic accuracy, and attunement directly predict treatment outcomes beyond technique or modality (Flückiger et al., 2018; Wampold & Flückiger, 2023). Relatedness-building behaviors provide a corrective relational experience that fosters trust and sets the stage for client openness, engagement, and risk-taking within therapy.

Taken together, autonomy-, competence-, and relatedness-supportive therapist behaviors function as mechanisms of motivational change. Through these behaviors, therapists create interpersonal conditions that optimize engagement, strengthen alliance, and promote sustainable recovery. These mechanisms are especially consequential during the earliest phases of treatment, when clients’ willingness to stay in therapy is most vulnerable.

EARLY-SESSION PROCESSES AND THE FORMATION OF ALLIANCE IN SUD TREATMENT

Early session processes play a disproportionately powerful role in determining whether clients remain engaged in SUD treatment long enough to benefit from it. Research consistently shows that first-session alliance ratings predict treatment retention and outcomes across mental health and addiction settings (Del Río Olvera et al., 2022; Urbanoski et al., 2012). For many clients, the first encounter with a therapist establishes expectations regarding safety, trust, autonomy, and the therapist’s attunement to their lived experience.

Early-session behaviors that strengthen alliance generally fall into four domains:

1. Empathic Attunement and Emotional Presence. Therapists who demonstrate warmth, curiosity, and responsiveness help clients feel seen and understood—critical components of relatedness support. Empathic presence in the first session predicts lower dropout and stronger alliance trajectories across treatment (Anderson et al., 2009; Howard et al., 2021). For clients who anticipate judgment or moral condemnation due to substance use, early empathic behaviors reduce shame and facilitate engagement.

2. Collaborative Goal and Task Agreement. Alliance theory emphasizes the importance of shared agreement on therapy goals and the means to achieve them (Bordin, 1979). When therapists invite clients to articulate what they want from treatment, validate their perspectives, and collaboratively outline a treatment plan, clients experience greater autonomy support. Research shows that early agreement on goals and tasks predicts both adherence and improved outcomes in SUD and comorbid populations (Kan et al., 2014; Campbell et al., 2015).

3. Transparency, Role Clarification, and Avoidance of Coercion. Clients entering SUD treatment often arrive under external pressure from courts, employers, partners, or health systems. Therapists who explicitly acknowledge this context, clarify their role, and minimize controlling language enhance client autonomy and reduce resistance (Ng et al., 2012; Chan et al., 2023). First-session transparency—explaining expectations, confidentiality, and treatment structure—predicts improved alliance formation.

4. Early Competence Building and Hope Induction. Even in the first session, small opportunities for competence support—such as identifying strengths, highlighting adaptive efforts, or teaching a brief coping tool—can increase clients’ sense of capability. Competence building behaviors in early treatment predict motivation, confidence, and reduced early dropout (Mills et al., 2021; Dellazizzo et al., 2023). For clients who may feel demoralized by repeated relapse, early reinforcement of strengths can enhance hope and willingness to continue. Collectively, these early-session behaviors shape clients’ motivational orientation and determine whether the alliance becomes a stable foundation for ongoing treatment. In SUD settings, where dropout rates remain high, early therapist behavior serves as both a clinical intervention and a mechanism of motivational change.

MAINTAINING MOTIVATION IN ONGOING SUBSTANCE USE TREATMENT

While early-session processes determine initial engagement, maintaining motivation over the course of SUD treatment requires ongoing reinforcement of autonomy, competence, and relatedness. Clients often experience fluctuations in confidence, ambivalence, and external pressures throughout recovery. Therapist behaviors that continue to support SDT’s psychological needs can stabilize the alliance and promote sustained participation.

Sustaining Autonomy Through Shared Decision-Making.

As treatment progresses, clients benefit from increasing ownership of therapeutic direction. Ongoing collaborative agenda-setting, periodic goal review, and invitations for client feedback strengthen autonomy by ensuring treatment remains personally meaningful. Studies in health behavior change show that autonomy-supportive follow-up interactions predict adherence and internalization (Ng et al., 2012; Ntoumanis et al., 2021). In SUD treatment, transparent dialogue around setbacks, medication decisions, and behavioral strategies reduces shame and enhances volition (Del Río Olvera et al., 2022).

Building Competence Through Structured Skill Development.

Clients in SUD treatment require repeated opportunities to develop coping skills, regulate affect, navigate cravings, and manage interpersonal conflicts. Competence support becomes increasingly important as clients transition from crisis stabilization to long-term relapse prevention. Structured practice, guided rehearsal, problem-solving, and feedback—core elements of evidence-based treatments—reinforce a sense of mastery. Research demonstrates that competence-enhancing interventions predict improved self-efficacy and reductions in substance use over time (Mills et al., 2021; Dellazizzo et al., 2023). Therapists who highlight progress, normalize learning curves, and reinforce adaptive behaviors strengthen clients’ belief in their ability to maintain change.

Deepening Relatedness Through Consistent Attunement.

As therapy unfolds, therapists must remain vigilant to alliance ruptures, disengagement, or emotional withdrawal. Continued empathic attunement, validation of emotional experiences, and responsiveness to client concerns fulfill relatedness needs and prevent dropout (Howard et al., 2021; Wampold & Flückiger, 2023). Many clients with SUD histories have experienced relational instability; thus, consistent follow-through and emotional presence serve as corrective experiences that reinforce trust.

Longitudinal alliance research shows that stable, high-quality alliances over time predict better outcomes than strong early alliances alone (Flückiger et al., 2018). The maintenance phase of treatment is therefore not passive; it is an active relational process in which therapist behaviors continue to shape the motivational conditions necessary for recovery.

CLINICAL IMPLICATIONS FOR SDT-INFORMED PRACTICE IN SUD TREATMENT

The integration of SDT with psychotherapy process research offers actionable guidance for clinicians and treatment systems. Because therapist behaviors operate as mechanisms of motivational change, enhancing these behaviors can improve engagement, strengthen alliance, and promote long-term recovery.

Implications for Individual Clinicians.

Therapists can embed SDT principles into routine practice by adopting autonomy-supportive communication, emphasizing client choice, and avoiding controlling language. Competence support can be strengthened by offering clear rationale for interventions, using guided practice, scaffolding complex tasks, and highlighting moments of success. Relatedness is deepened through warmth, consistency, and empathic presence—skills shown to predict outcomes across modalities (Anderson et al., 2009; Flückiger et al., 2018).

Implications for Supervisors and Training Programs.

Supervision that models autonomy support leads to better clinician competence, stronger alliances, and reduced burnout. Training programs should incorporate SDT principles into curricula, helping therapists understand how their interpersonal style influences client motivation. Process-based training—focusing on moment-to-moment relational skills rather than solely on manualized techniques—can strengthen therapist effectiveness.

Implications for Treatment Programs and Systems of Care.

SUD programs frequently operate under external pressures (legal mandates, insurance constraints), which can inadvertently foster coercive climates. Creating organizational structures that promote patient choice, transparency, and collaborative decision-making may enhance treatment retention (Adeniran et al., 2023). Integrating SDT principles into program design— such as flexible goal pathways, client advisory boards, and strengths-based assessments—can improve engagement at the systemic level. Collectively, these implications highlight that SDT-informed practice is not a new modality but a relational orientation that enhances all evidence-based treatments by aligning clinical processes with fundamental human motivational needs.

CONCLUSION AND FUTURE DIRECTIONS

Therapists play a central role in shaping motivational processes that influence client engagement and recovery in substance use disorder treatment. By examining therapist behaviors through the lens of Self-Determination Theory and the therapeutic alliance, this article articulates how autonomy-, competence-, and relatedness-supportive behaviors function as mechanisms of motivational change. These behaviors strengthen the alliance, reduce dropout, and promote sustained engagement—findings supported across multiple areas of psychotherapy and health behavior research (Flückiger et al., 2018; Wampold & Flückiger, 2023; Ng et al., 2012).

Future research should empirically test the SDT-informed model proposed here, particularly the pathways by which therapist behaviors influence motivational internalization and long-term outcomes in SUD treatment. Microprocess coding, naturalistic observation studies, and longitudinal designs may help clarify which therapist behaviors exert the strongest motivational effects and how these processes unfold over time. Additionally, program-level research examining how organizational climate influences client autonomy and engagement will further strengthen the application of SDT principles in addiction treatment systems.

By integrating SDT with alliance theory, clinicians and researchers can deepen their understanding of how therapists help clients change. Ultimately, supporting clients’ basic psychological needs is not only a theoretical ideal—it is a practical framework for improving the relational environment in which recovery takes root.

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