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The objective of this essay is to discuss the relationship between a patient’s rights to refuse certain treatments, or investigations, and how this non-compliance relates to the concept of learned helplessness in individuals, particularly in a hospital setting.
The concept of learned helplessness was first suggested by M. Seligman an animal psychologist, in 1975. During a series of experiments involving rats and dogs, he discovered that the animals which had some control over their environment (in being able to prevent a series of electric shocks) would always try to avoid the undesirable stimulus; whereas the animals which had previously had no control over their environment (and so were unable to prevent the shocks) eventually became apathetic and would not try to escape the stimulus, even if it was possible to do so.
It was found that “Because these animals have learned that nothing they did worked, they did nothing.” [Page 237] (Brannon & Feist, 1992)
The animals concerned had therefore learned to be helpless, but had also learned to apply this helplessness to other situations, where there was no perceived controllability.
The concept of learned helplessness has been criticised, however. Skevington (1995) notes three studies that criticise learned helplessness, namely Dent & Teasdale (1988), Lewinsohn et al. (1981) and Skevington (1993). Skevington (1995) states “All three studies showed little support for the learned helplessness antecedent hypothesis that depressive attributions precede depression.” [Page 147] (Skevington, 1995)
With particular regard to the duration of arthritis, Skevington (1995) maintains that learned helplessness is not a significant feature, a position she also maintains for chronic low back pain sufferers.
However Skevington (1995) does accept the presence of the concept of Universal Helplessness as having a wider theoretical basis than learned helplessness.
This leads us to the concept of the locus of control, as hypothesised by Rotter (1966). In this theory he stated that there are personality types who have and external locus of control, and try to hold external factors such as fate, luck, or other people as being responsible for many aspects of their lives. Those with an internal locus of control tend to believe that they have control over their own actions, and any events that happen to them during their lives, are a result of their own actions.
Whether one accepts learned helplessness or not, one of the most stressful occurrences which can occur in an individual’s life is an admission to hospital due to an acute or chronic illness. It is a time when the individual’s personal independence and privacy are all but destroyed, and everyday activities such as using the toilet, bathing, sleeping, eating and relaxing become part of an alien regime over which the individual has little or no control.
Some people cease their normal behaviour patterns and adopt the role of the patient, as can be seen very often in hospitals, when they immediately change into their night clothes and get into bed. Generally these patients tend to be passive, place very few demands on the ward staff, are generally co-operative with their treatment program, and seldom ask questions. The ward staff react to these “good patients” favourably, as it makes the duties of nurses and other medical staff much easier. Other patients are not as easily dealt with and may act in rebellion at their perceived loss of control.
Taylor (1979) argues that the different reactions from patients who are “good” and “bad” are a response to the depersonalisation of hospitalisation, and the perceived loss of control which accompanies it, and that the reaction is dependent on the individual differences, and past experiences of each patient. She argues that patients who are “good” are actually suffering from learned helplessness, and their passivity, while making the role of the hospital staff easier, is not conducive to their recovery. The passivity they express is not merely a conformity to the regime in which they find themselves, but can also extend beyond this, and even mean withholding their relevant medical history or any symptoms they are experiencing, which could have a bearing on their treatment. These good patients also have a tendency to become depressed while in hospital, and after their discharge, find it difficult to resume a normal pattern of life. This is supported by Abramson et al. (1980) and Alloy & Abramson (1980) who have suggested that “…Depression is a result of Learned Helplessness” (Page 237] (Brannon & Feist, 1992)
Taylor (1979) also argues that “bad “patients who have developed a more rebellious stance toward their treatment, are in fact attempting to regain control in an environment where they have lost their personal freedom and identity. This has been supported by Gross (1992) who suggests that “When our freedom is threatened, we tend to react by reasserting our freedom.” [Page 140] (Gross, R 1992)
This is a reaction which Brehm (1966) a social learning theorist, had described as being psychological reactance.
These “Bad” patients generally only engage in what could be considered minor “violations” of hospital procedures, such as drinking and smoking against advice which they may have been given by health care professionals, and wandering around the ward or even the hospital, in cases where it is inadvisable for them to do so. They can even refuse to comply with their treatment regimes, refuse surgery or abscond from the hospital altogether. Although these forms of non-compliance may pose a risk to the patient’s health, as the acute or chronic illness they have been admitted with has not been effectively treated or resolved, the minor “violations” of procedure are not really more than an inconvenience as far as staff are concerned, and may actually help the patient develop coping skills to deal with their hospital and/or illness experience. It could be argued that these “violations” by hospital patients are simply a reflection of their rejection of the role of learned helplessness and a positive coping strategy for dealing with a changed mode of existence, and therefore can be assumed not to be suffering from learned helplessness.
Rarely the refusal to co-operate can take a more serious form when the patient is refusing to undergo emergency treatment which may save his or her life. This can cause a serious dilemma for the ward staff who may feel that they are failing to act in the patients best interests. This places nursing staff in the predicament of a conflict situation. Does the nurse represent the doctor, or is the nurse to be a patient advocate?
Nichols (1984) notes that, in effect, nurses are told what to do by medical practitioners, even though there is a hierarchy of nursing management.
One example of this may be the refusal of a patient to have a Naso-gastric tube passed in order to remove gastric contents where an obstruction may be suspected by the medical practitioner. Everyone will agree that having a tube passed through your nose is an unpleasant experience, but without this procedure there is a serious risk to the patients life. However, as much as the nursing and medical staff may want to pass the tube, without the consent of the patient it is illegal to do so, and can constitute an assault on the individual. This has been highlighted by Hinchliff et al. (1993) who state that “The patient has the legal right to decide whether or not to accept treatment – to informed consent” [Page 259]
There is a contrast between those with an internal locus of control, where they pursue their own course of living, and those who have an external locus of control, who are more likely to suffer from learned helplessness in a hospital situation, as they feel that the hospital staff know more about their illness than they do, and will know how to deal with it effectively. This learned helplessness is further reinforced by the power of the medical staff, as noted above, who, ostensibly believing they are acting in the patient’s best interests, will attempt to persuade the patient into undergoing treatment or surgery without considering any questions or resistance the patient may feel. This has been supported by Chadwick and Tadd (1992) who, supporting the view, noted above, that nurses act at the behest of medical practitioners, state: “The patient has little control of the situation as he cannot withdraw and, therefore the nurse occupies a powerful position in relation to the patient, who is vulnerable to both coercion and persuasion” (Page 21]
Weinman (1995) points out that levels of non-compliance, or as he terms it “non-adherence”, varies across a range of treatments and treatment settings. In some clinical areas some 40 – 50% of patients do not adhere to medical treatment or advice.
“The lowest rates of adherence are found in patients with chronic conditions and in those taking medication for preventative purposes. In contrast, patients receiving such treatments as chemotherapy for cancer generally show very high levels of adherence, even thought the treatments may produce unpleasant side effects.” [Page 85] (Weinman, 1995)
Weinman also stresses that patient adherence is partly dependent upon the effectiveness with which information is given by health care professionals. Effective communication enhances levels of patient adherence. In the same way, it could be argued that effective communication would increase the possibility of a patient signing a consent form prior to pre-medication, without which the surgery cannot be performed. If the patient has been fully informed of the likely outcome of non-adherence, and still decides not to have the procedure performed, then we, as health care professionals, cannot go against their wishes since the patient is making an effective response to information that has been conveyed. Hinchliff et al. (1993) indicated however, that there are two special cases where consent is not required. These are if the person has a notifiable disease, such as cholera, diphtheria, encephalitis or plague, where isolation and treatment are required, or if the person has been detained (sectioned) under the Mental Health Act (1983).
In the case of the notifiable disease, it could be argued that the isolation and treatment of these people, even if it is against their wishes, has the best interests of the general populace at heart, in the prevention of the spread of the infection. The case for those detained under the mental health act is that these people are already mentally ill, and that their refusal to undergo medical or surgical treatment is a symptom of their pre-existing mental illness.
In conclusion it can be argued that those patients who are passive and adhere to their treatment regime or medical advice without questions or resistance to even the most unpleasant procedure, are therefore adopting the role of role of learned helplessness. By contrast, those patients who refuse to follow every instruction to the word, and attempt to retain some control over their mode of living, cannot be suffering from learned helplessness, as they are actively resisting the demands placed upon them by both the illness, and the medical practitioners. This is similar to the coping skill which most psychoanalysts like to term “denial” (Reich, 1975). As noted earlier, the relative degree of nonadherence to treatment depends upon the severity of the illness, and that the greater the risk to life and limb, the lesser the degree of non-adherence. However, it is important to remember that Seligman’s theory is one which has been adopted/adapted from animal psychology. Human psychology, although related, has further factors to consider, such as those relating to cultural, educational, social, and religious differences. It could also be argued that patients who refuse to comply to treatment on religious and cultural grounds, such as Jehovah’s Witnesses refusing to accept blood products, cannot be experiencing learned helplessness. It is clear that, while the adoption of learned helplessness is beneficial to the medical staff who have to treat the patients, it can be damaging to the long term mental state which the patient experiences, and should not be encouraged. Depression and apathy can begin on the hospital ward, and can lengthen the time it takes for a patient to re-adapt to normal life once (if) the condition is resolved. It could be possible for us as nurses, to encourage those we perceive to suffer from learned helplessness, to take control of some aspects of their lives in hospital, such as washing and dressing. This should facilitate the transition from full care to self care when they are finally discharged. Similarly, effective communication with patients who do not adhere to their treatment plans, may lessen patient resistance and facilitate their recovery without making them give up their independence and freedom of choice.
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