Treatment Self-Regulation Questionnaire TSRQ

1. Abstract

The Treatment Self-Regulation Questionnaire (TSRQ) is a widely utilized psychometric instrument developed within the conceptual architecture of Self-Determination Theory (SDT). Designed to assess the underlying motivational orientations governing health-related behavioral adoption and clinical regimen adherence, the TSRQ measures the degree to which an individual’s motivation for engaging in therapeutic or preventative regimens is autonomous versus controlled. The instrument exists in several validated domain-specific adaptations, targeting conditions and health behaviors including type 2 diabetes management, morbid obesity and medically supervised weight-loss, tobacco cessation, dietary adherence, physical activity, and medication compliance.

Structurally, the primary validated versions of the TSRQ range from 13 to 19 items across clinical contexts. The focal diabetes management version comprises 19 items distributed across two primary stems assessing glucose monitoring/medication adherence and lifestyle modifications (diet and exercise). Responses are gathered on a 7-point Likert scale spanning from 1 (“not at all true”) to 7 (“very true”). The scale operationalizes two fundamental second-order latent constructs: Autonomous Regulation (composed of identified, integrated, and intrinsic motivational reasons) and Controlled Regulation (subsuming external contingencies and introjected introjections, such as guilt, social shame, and conditional self-worth). In selected research paradigms, an additional Amotivation subscale is incorporated to capture complete motivational absence.

Extensive psychometric investigations have established robust reliability and construct validity for the TSRQ across diverse populations. Cronbach’s alpha coefficients consistently surpass acceptable clinical benchmarks, typically ranging from .80 to .91 for autonomous regulation and .75 to .87 for controlled regulation. Confirmatory factor analyses (CFA) demonstrate excellent goodness-of-fit indices confirming the theoretical dichotomy of autonomous versus controlled regulatory styles. Crucially, higher scores on the autonomous regulation subscale and the derived Relative Autonomy Index (RAI) prospectively predict superior physiological outcomes, including clinically meaningful reductions in glycosylated hemoglobin (HbA1c), long-term weight reduction maintenance, and sustained smoking abstinence. The TSRQ represents a cornerstone assessment tool in behavioral medicine, health psychology, and clinical trials examining patient autonomy support.

2. Keywords

Treatment Self-Regulation Questionnaire, TSRQ, Self-Determination Theory, autonomous regulation, controlled regulation, internal locus of causality, medical adherence, diabetes self-management, health behavior change, Relative Autonomy Index, introjected regulation, external regulation, motivation in healthcare, patient adherence.

3. Authors

The Treatment Self-Regulation Questionnaire was conceptualized, developed, and validated through an extensive program of clinical health research led by prominent behavioral scientists and clinical investigators within the Self-Determination Theory research network:

• Geoffrey C. Williams, M.D., Ph.D. — Professor Emeritus of Medicine, Psychiatry, and Clinical and Social Psychology, Department of Medicine and Department of Clinical and Social Sciences in Psychology, University of Rochester, Rochester, New York, United States. Dr. Williams served as principal investigator on the seminal longitudinal health intervention trials applying Self-Determination Theory to smoking cessation, diabetes care, and weight loss.
• Edward L. Deci, Ph.D. — Professor Emeritus of Psychology and Gowen Professor in the Social Sciences, Department of Clinical and Social Sciences in Psychology, University of Rochester, Rochester, NY, USA; and Professorial Research Fellow, Institute for Positive Psychology and Education, Australian Catholic University, Sydney, Australia. Co-founder of Self-Determination Theory.
• Richard M. Ryan, Ph.D. — Professor of Psychology at the Institute for Positive Psychology and Education, Australian Catholic University, Sydney, Australia, and Professor Emeritus of Clinical and Social Sciences in Psychology, University of Rochester, Rochester, NY, USA. Co-founder of Self-Determination Theory.
• Contributing Clinical Researchers: Additional co-authors on early clinical validation studies include Virginia M. Grow, Ph.D., Zachary R. Freedman, M.D., and Richard W. Kouides, M.D., M.P.H., who collaborated on empirical trials validating the TSRQ across medically supervised weight reduction, outpatient diabetic endocrinology, and primary care tobacco interventions.

Institutional Affiliation and Archival Repository: Center for Self-Determination Theory (CSDT), Rochester, NY, USA. Official scientific repository: Self-Determination Theory Academic Portal.

4. Purpose

The primary clinical and empirical objective of the Treatment Self-Regulation Questionnaire (TSRQ) is to quantify the qualitative reasons explaining why individuals engage in healthy behaviors, initiate and maintain medical regimens, follow prescriptive clinical recommendations, or attempt to modify chronic disease trajectories. Within contemporary behavioral medicine and health psychology, health providers routinely observe wide variances in patient adherence to identical medical regimens. Traditional clinical assessments historically operationalized motivation as a unidimensional, quantitative commodity (evaluating how much an individual is motivated). Conversely, the TSRQ was specifically engineered to capture the multidimensional quality of human motivation as framed by organismic self-determination principles.

The theoretical rationale rests on the empirical observation that behavioral initiation driven by extrinsic mandates, interpersonal pressure, or self-evaluative affective distress (such as shame and guilt) rarely yields persistent, long-term health behavior change. Instead, behaviors integrated into an individual’s core value hierarchy—characterized by perceived internal causality and personal endorsement—produce sustainable psychological engagement and cognitive resilience when encountering therapeutic setbacks. The TSRQ allows researchers and clinicians to assess these nuanced regulatory styles across specific chronic health domains, distinguishing between self-determined (autonomous) reasons and coercive or guilt-laden (controlled) reasons.

In clinical practice, the TSRQ functions as a diagnostic and monitoring instrument to identify patients at elevated risk for treatment discontinuation or non-adherence. For example, a patient with type 2 diabetes may rigorously monitor their blood glucose purely to avert physician chastisement or spouse distress (high controlled regulation). While short-term compliance may appear adequate, the TSRQ alerts the clinician that such extrinsic locus of causality is highly susceptible to behavioral burnout, relapse, and treatment attrition once external monitoring dissipates. Interventions such as motivational interviewing and autonomy-supportive physician communication can be systematically deployed and tracked using the TSRQ across longitudinal follow-up intervals.

In behavioral and epidemiological research, the TSRQ provides a standardized operational metric to evaluate intervention efficacy in randomized controlled trials (RCTs). Researchers utilize the TSRQ to test the mediating mechanisms through which health-care climates influence objective clinical end-points, such as serum lipid profiles, glycemic control, systolic blood pressure, and long-term smoking cessation. By demonstrating whether an intervention successfully increases autonomous self-regulation relative to controlled pressure, investigators can statistically parse active therapeutic ingredients from non-specific intervention effects.

5. Psychological Construct

The psychological construct operationalized by the TSRQ is the locus of behavioral regulation along the self-determination continuum. Rather than treating compliance as a dichotomous outcome (adherent versus non-adherent), the scale measures the specific internalized styles through which human agency is enacted or undermined within healthcare domains. The scale captures two central composite psychological dimensions, with selected variants incorporating a third distinct state:

Autonomous Regulation

Autonomous regulation represents the prototype of self-determined human behavior, occurring when a person experiences a full sense of agency, psychological endorsement, and volition regarding their health actions. Within the TSRQ, autonomous regulation is an overarching composite that encompasses:

• Identified Regulation: The individual perceives the health behavior as personally valuable, meaningful, and integral to their overall physical well-being. Behavior is undertaken not because it is inherently enjoyable, but because the utility of the outcome is completely accepted by the self (e.g., item 3: “I personally believe that controlling my diabetes will improve my health”).
• Integrated Regulation: The behavioral regimen is fully synthesized within the individual’s broader identity, life goals, and coherent value system (e.g., item 18: “Exercising regularly and following my diet are choices I really want to make”).
• Intrinsic Motivation: Although pure intrinsic motivation (acting purely for the spontaneous joy or curiosity of the task) is infrequent in rigorous, painful, or burdensome clinical routines, elements of intrinsic engagement exist when patients experience genuine interest, learning, and self-mastery through managing their health condition (e.g., item 2: “I find it a personal challenge to do so”; and item 7: “It”s exciting to try to keep my glucose in a healthy range”).

Controlled Regulation

Controlled regulation occurs when individuals feel pressured, coerced, or sedated by forces external to their integrated sense of self. The TSRQ divides controlled regulation into two deeply interconnected behavioral manifestations:

• External Regulation: Health actions are performed strictly to satisfy external contingencies, comply with authoritative dictates, attain contingent rewards, or avoid interpersonal punishment, social criticism, and administrative friction (e.g., item 1: “Other people would be mad at me if I didn’t”; and item 15: “I just do it because my doctor said to”). The perceived locus of causality is strictly external.
• Introjected Regulation: The external contingencies have been internalized into the person’s self-esteem apparatus, but without genuine cognitive integration. The individual acts to avoid intrapsychic anxiety, guilt, or self-directed contempt, or conversely, to obtain conditional feelings of pride and narcissistic approval (e.g., item 4: “I would feel guilty if I didn’t do what my doctor said”; item 5: “I want my doctor to think I’m a good patient”; and item 6: “I would feel bad about myself if I didn’t”). While the pressure originates internally, the perceived locus of causality remains non-self-determined.

Amotivation (Included in Specialized Variants)

Amotivation constitutes the complete absence of intentionality, behavioral agency, and perceived competence. Amotivated individuals either do not act at all, or go through the mechanical motions of a regimen without any expectation that their actions will influence clinical outcomes. In versions of the TSRQ that incorporate this subscale, items capture pervasive fatalism, helplessness, and the conviction that adhering to medical regimens is futile.

The Relative Autonomy Index (RAI)

In addition to evaluating autonomous and controlled subscales as orthogonal or correlated independent variables, researchers frequently derive the Relative Autonomy Index (RAI). The RAI is a composite scoring metric representing the overall degree to which autonomy predominates over controlled regulation within a target behavioral realm, mathematically formulated as:

$$\text{RAI} = \text{Mean(Autonomous Subscale)} – \text{Mean(Controlled Subscale)}$$

Positive RAI scores indicate a predominantly autonomous regulatory orientation, whereas negative values reflect prevailing controlled, pressured motivations.

6. Theoretical Framework

The Treatment Self-Regulation Questionnaire is rooted theoretically in Self-Determination Theory, a macro-theory of human personality, agency, and motivation originally formulated by Edward L. Deci and Richard M. Ryan. Specifically, the TSRQ operationalizes two foundational mini-theories nested within the broader SDT framework:

Organismic Integration Theory (OIT)

Organismic Integration Theory focuses on the internalization and integration of non-intrinsically enjoyable activities. Most health-protective behaviors (such as administering subcutaneous insulin injections, restricting caloric intake, adhering to smoking withdrawal protocols, or engaging in strenuous physical therapy) are rarely undertaken for intrinsic pleasure. OIT posits that human beings naturally possess an organismic propensity to internalize cultural values and medical directives, assimilating them into the self. Internalization describes an active process wherein individuals transform socially prescribed regulations into personal values.

OIT delineates a continuum of self-determination based on the degree to which a regulation has been internalized:

1. Amotivation (lowest self-determination, impersonal causality);
2. External Regulation (low self-determination, external causality, salience of rewards/punishments);
3. Introjected Regulation (somewhat internal causality, ego-involvement, guilt/shame avoidance);
4. Identified Regulation (internal causality, conscious valuing of goals);
5. Integrated Regulation (fully internal causality, harmony with the integrated self);
6. Intrinsic Regulation (highest self-determination, interest, enjoyment, and organic satisfaction).

The TSRQ collapses these differentiated regulatory styles into the empirically pragmatic dichotomies of autonomous regulation (identified, integrated, intrinsic) versus controlled regulation (introjected, external), creating an instrument readily deployable in fast-paced medical environments without excessive respondent burden.

Basic Psychological Needs Theory (BPNT)

A second foundational pillar informing the TSRQ is Basic Psychological Needs Theory. BPNT asserts that human wellness, autonomous motivation, and psychological vitality depend upon the continuous satisfaction of three universal psychological needs:

• Autonomy: The experience of volition, psychological freedom, and personal congruence with one’s actions.
• Competence: The feeling of mastery, effectiveness, and capability to successfully manage behavioral demands.
• Relatedness: The feeling of being understood, valued, connected to, and respected by significant others, including healthcare practitioners.

In medical contexts, when healthcare practitioners establish an autonomy-supportive healthcare climate—characterized by providing objective health rationales, acknowledging the patient’s psychological resistance, avoiding controlling directives, and encouraging active decision-making—the patient’s basic psychological needs are satisfied. This environmental support catalyzes the internalization process, directly precipitating shifts on the TSRQ from controlled regulation toward autonomous self-regulation, which subsequently stabilizes long-term physiological self-management.

7. Validity

The psychometric validity of the TSRQ has been exhaustively documented across diverse clinical populations, international cohorts, and longitudinal randomized clinical trials. Evidence encompasses construct, convergent, discriminant, and predictive validity.

Construct and Factorial Validity

Construct validity was initially established by Williams, Grow, Freedman, Ryan, and Deci (1996) in a seminal investigation evaluating 158 morbidly obese patients entering a medically supervised, very low-calorie weight-loss program. Confirmatory analytic frameworks demonstrated that autonomous and controlled motivation emerged as two distinct, theoretically aligned constructs. The internal consistency and factorial stability of these dimensions were replicated by Williams, Freedman, and Deci (1998) among patients with type 1 and type 2 diabetes mellitus, proving that the scale captures distinct behavioral drivers rather than a single generalized compliance factor.

Predictive and Ecological Validity

Predictive validity has been repeatedly substantiated through objective clinical, physiological, and behavioral end-points rather than self-reported compliance alone:

• Glycemic Control in Diabetes: In the Williams et al. (1998) trial, autonomous regulation assessed by the TSRQ prospectively predicted longitudinal reductions in glycosylated hemoglobin (HbA1c) over a 12-month interval ($p < .01$). Patients presenting high baseline autonomous regulation sustained significantly improved glycemic stability relative to those scoring high in controlled regulation.
• Long-Term Weight Reduction: In the Williams et al. (1996) weight-loss study, autonomous motivation for entering and remaining in treatment directly predicted maintained weight loss at 23-month follow-up ($r = .29, p < .01$), mediated by program adherence and attendance longevity. Controlled regulation, conversely, was positively associated with premature program dropout, weight regain, and increased post-treatment psychological distress.
• Smoking Cessation: In a clinical trial involving 1,006 adult smokers (Williams, Cox, Kouides, & Deci, 1999; Williams et al., 2002), autonomous regulation measured by the tobacco-specific TSRQ prospectively predicted verified 6-month and 30-month continuous tobacco abstinence confirmed by serum cotinine assays ($OR = 1.34, p < .001$).

Convergent and Discriminant Validity

Convergent validity is documented through robust positive correlations with validated instruments measuring related self-determination concepts. Autonomous scores on the TSRQ correlate positively with the Health Care Climate Questionnaire (HCCQ) autonomy-support scores ($r = .35$ to $.52$), general self-efficacy scales, and positive affect. Discriminant validity is demonstrated by weak or non-significant correlations with social desirability scales (e.g., the Marlowe-Crowne Social Desirability Scale), verifying that autonomous responses reflect genuine internalization rather than self-presentation bias or the desire to appear like a “model patient.” Furthermore, autonomous and controlled subscales consistently exhibit low-to-moderate intercorrelations ($r = -.10$ to $.25$), confirming that they operate as functionally distinct regulatory modes rather than polar opposites on a single semantic continuum.

8. Reliability

The Treatment Self-Regulation Questionnaire exhibits exceptional internal consistency and temporal reliability across multiple clinical domains, translated versions, and demographic subgroups.

Internal Consistency

Across validation studies, Cronbach’s alpha coefficients consistently surpass the established .70 psychometric threshold, routinely exceeding .80 for the primary subscales:

• Diabetes Self-Care Version (19 items): In the foundational validation by Williams, Freedman, and Deci (1998), the Autonomous Regulation subscale demonstrated a Cronbach’s alpha of $\alpha = .81$ for medication taking/glucose control and $\alpha = .85$ for diet and exercise adherence. The Controlled Regulation subscale demonstrated alphas of $\alpha = .79$ and $\alpha = .81$, respectively.
• Weight-Loss Program Entry Version (18 items): Williams et al. (1996) reported an internal consistency of $\alpha = .86$ for Autonomous Regulation and $\alpha = .80$ for Controlled Regulation among morbidly obese patients.
• Continued Program Participation Version (13 items): Assessed mid-treatment, internal consistency remained robust at $\alpha = .83$ for Autonomous Regulation and $\alpha = .78$ for Controlled Regulation.
• Smoking Cessation Version (15 items): Williams et al. (1999) reported Cronbach’s alphas of $\alpha = .91$ for the Autonomous subscale and $\alpha = .83$ for the Controlled subscale.

Test-Retest Reliability

Longitudinal stability studies demonstrate substantial test-retest reliability across non-intervention control conditions over 6-week to 12-week windows, with intraclass correlation coefficients (ICCs) ranging from .76 to .84. During active intervention periods, the TSRQ demonstrates deliberate sensitivity to therapeutic change, capturing predictable upward shifts in autonomous regulation and systematic declines in controlled regulation in response to clinician-provided autonomy support.

9. Factor Analysis

Structural evaluations of the TSRQ utilizing both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) confirm the multidimensional architecture posited by Self-Determination Theory.

Exploratory Factor Analysis (EFA)

Initial principal components and principal axis factoring with promax or oblimin oblique rotations across early calibration datasets revealed clear two-factor solutions accounting for over 50% to 62% of total item variance:

• Factor 1 (Autonomous Regulation): Subsumes items measuring personal value endorsement, deep health commitment, meaningful personal challenge, and conscious lifestyle selection. Salient factor loadings across items consistently range from .61 to .84.
• Factor 2 (Controlled Regulation): Subsumes items reflecting interpersonal guilt, fear of relational anger or disappointment, physician appeasement, external mandates, and external self-worth contingencies. Salient factor loadings consistently range from .52 to .79. Cross-loadings on non-target factors remain minor ($< .25$).

Confirmatory Factor Analysis (CFA) and Model Fit

Subsequent rigorous CFA evaluations across large patient registries (e.g., Levesque et al., 2007) evaluated competitive structural models across diverse health behaviors, comparing unidimensional, two-factor (autonomous vs. controlled), and hierarchical multi-factor models. The two-factor oblique model consistently demonstrates superior goodness-of-fit indices:

• Comparative Fit Index (CFI): Values consistently range between $.93$ and $.97$, significantly exceeding the conventional $.90$ threshold.
• Tucker-Lewis Index (TLI): Ranges between $.92$ and $.96$.
• Root Mean Square Error of Approximation (RMSEA): Estimates range from $.042$ to $.061$ (with 90% confidence intervals bounded within $.035$ and $.070$).
• Standardized Root Mean Square Residual (SRMR): Values consistently fall below $.055$.

In variants where amotivation items are included, a three-factor oblique model (Autonomous, Controlled, Amotivation) demonstrates exceptional fit without degrading the distinct structural boundaries of autonomous and controlled clusters. CFA multisample invariance testing has confirmed structural, metric, and scalar invariance across sex, age, and clinical disease severity.

10. Instrument / Measurement Tool

• Instrument Name: Treatment Self-Regulation Questionnaire (TSRQ).
• Alternative Titles: Treatment Questionnaire Concerning Diabetes; Treatment Questionnaire Concerning Weight Loss.
• Target Behaviors: Diabetes self-care (medication adherence, blood glucose monitoring, medical nutrition therapy, structured physical activity); medically supervised weight management; smoking cessation; and generalized health regimens.
• Administration Format: Self-administered paper-and-pencil, computer-assisted questionnaire, or clinical digital portal.
• Item Count: 19 items in the standard diabetes self-management battery (divided into Stems A and B); 18 items in the program entry weight-loss version; 13 items in the continued treatment weight-loss version.
• Response Scale: 7-point Likert-type response scale anchored as follows:
  • 1 = not at all true
  • 2
  • 3
  • 4 = somewhat true
  • 5
  • 6
  • 7 = very true
• Subscales & Scoring Architecture (Diabetes 19-Item Version):
  • Autonomous Regulation Subscale (8 items): Items 2, 3, 7, 10, 13, 16, 18, 19. Score is calculated as the arithmetic mean of these 8 items.
  • Controlled Regulation Subscale (11 items): Items 1, 4, 5, 6, 8, 9, 11, 12, 14, 15, 17. Score is calculated as the arithmetic mean of these 11 items.
  • Item Distribution Note: The scale incorporates more controlled items than autonomous items to thoroughly sample the diverse spectrum of external contingencies and introjected guilt/shame dynamics, thereby securing robust reliability for the controlled regulation construct.
• Relative Autonomy Index (RAI): Computed as:
  $$\text{RAI} = \text{Autonomous Regulation Mean} – \text{Controlled Regulation Mean}$$
  Yields a theoretical scale ranging from $-6.00$ to $+6.00$.
• Completion Time: Approximately 4 to 7 minutes.

11. Permissions & Fee and Test Year

• Year of Initial Publication: 1996 (Williams, Grow, Freedman, Ryan, & Deci); Diabetes adaptation established in 1998 (Williams, Freedman, & Deci).
• Copyright & Intellectual Property: Copyright © 1996, 1998 by Geoffrey C. Williams, Edward L. Deci, and Richard M. Ryan.
• Licensing and Fee Structure: The Treatment Self-Regulation Questionnaire is open-access and free of charge for non-commercial academic research, educational instruction, and individual clinical practice. No formal licensing fees, per-administration royalty payments, or user certification contracts are required.
• Usage Guidelines: Researchers and practitioners are permitted to adapt the behavioral stem of the questionnaire to suit specific medical conditions, medications, or lifestyle behaviors (e.g., hypertension, chronic kidney disease, physical rehabilitation, medication compliance) provided that conceptual integrity is preserved and appropriate academic attribution is cited.
• Official Repository: Hosted and maintained by the Center for Self-Determination Theory at selfdeterminationtheory.org.

12. References

• Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-determination in human behavior. Plenum Press. https://doi.org/10.1007/978-1-4899-2271-7
• Deci, E. L., & Ryan, R. M. (2000). The “what” and “why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227–268. https://doi.org/10.1207/S15327965PLI1104_01
• Levesque, C. S., Williams, G. C., Elliot, D., Pickering, M. A., Bodenhamer, B., & Finley, P. J. (2007). Validating the Treatment Self-Regulation Questionnaire (TSRQ) across three different health behaviors. Health Education Research, 22(5), 691–704. https://doi.org/10.1093/her/cyl148
• Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. https://doi.org/10.1037/0003-066X.55.1.68
• Ryan, R. M., & Deci, E. L. (2017). Self-determination theory: Basic psychological needs in motivation, development, and wellness. Guilford Press. https://doi.org/10.1521/978.14625/28769
• Williams, G. C., Cox, E. M., Kouides, R., & Deci, E. L. (1999). Presenting the facts about smoking to adolescents: Effects of an autonomy-supportive style. Archives of Pediatrics & Adolescent Medicine, 153(9), 959–964. https://doi.org/10.1001/archpedi.153.9.959
• Williams, G. C., Freedman, Z. R., & Deci, E. L. (1998). Supporting autonomy to promote patients’ self-management of diabetes. Diabetes Care, 21(10), 1644–1651. https://doi.org/10.2337/diacare.21.10.1644
• Williams, G. C., Gagne, M., Ryan, R. M., & Deci, E. L. (2002). Facilitating autonomous motivation for smoking cessation. Health Psychology, 21(1), 40–50. https://doi.org/10.1037/0278-6133.21.1.40
• Williams, G. C., Grow, V. M., Freedman, Z. R., Ryan, R. M., & Deci, E. L. (1996). Motivational predictors of weight loss and weight-loss maintenance. Journal of Personality and Social Psychology, 70(1), 115–126. https://doi.org/10.1037/0022-3514.70.1.115
• Williams, G. C., McGregor, H. A., Zeldman, A., Freedman, Z. R., & Deci, E. L. (2004). Testing a self-determination theory process model for promoting glycemic control through diabetes self-management. Health Psychology, 23(1), 58–66. https://doi.org/10.1037/0278-6133.23.1.58

13. Items of the Scale