Are your patients out of control?

This post and other science related content has moved to a new home at The Science PT website.

Photo Credit: Faramarz Hashemi

Photo Credit: Faramarz Hashemi

In psychology, a lot of things are described as a continuum: Introvert vs extrovert, optimist vs pessimist, etc. Nobody is purely one or the other, but everyone falls somewhere on the continuum. Also, many of these can be combined to describe an overall global tendency. Those of you with a Dungeons & Dragons background understand ethical and moral alignment of a character (I am chaotic good in case you were wondering). So what does this have to do with physical therapy?

An often overlooked continuum of personality is locus of control. It has to do with the person’s view of how they interact with the world (not to be confused with a person’s narrative, that’s a whole other post). Whether or not your patient has an internal or an external locus of control can have a huge affect on how they respond to your interaction with them. It can also explain why some patients self-discharge after a visit or two, whereas you just can’t get rid of others. Confused? Read on…

Locus of Control

Locus of control refers to the way a person perceives the causes of change in their life. Some people perceive situations in their own lives to be controlled by external forces. For example, “That rock shifted when I stepped on it which is why I fell,” or “That jerk punched me!” This is known as an external locus of control. Others perceive situations in their own lives to be controlled by internal forces. Same example, “I trusted that rock without testing it first which is why I fell,” or “I called that guy an idiot and shoved him which is why he punched me.” This is known as an internal locus of control.

Now, we all have experience with the extremes of these two types. People with a strong internal locus of control will take ownership of their difficulties and are committed to their home program. You will rarely hear them place blame anywhere but themselves. Athletes are typical of this group. That is not to say that these are perfect patients. In the first place, it is hard to get them to seek any medical care. It is typical for them to ignore an injury for quite some time. When they do come in, they just want you to show them what to do for themselves and be on their way. I love these patients. They almost always do well. To be fair, they probably won’t tell you if they weren’t doing well, they would just disappear.

It should be obvious that people with a tendency of an external locus of control can be more problematic. Some things you may hear from these patients:

  • “I need you to fix me.”
  • “If my first doctor would have diagnosed me correctly earlier, I wouldn’t be in this mess.”
  • “My boss keeps making me do more work than I should be doing which is keeping me from getting better.”
  • “I just need surgery.”
  • “No one can figure out what is wrong with me.”

You can see the trend here. The extreme case looks like a helpless victim. That is not to say that these statements are all wrong – they may all be legitimately true and require assistance. The issue is that the person with a strong external locus of control will get stuck on these issues and continuously look for a “savior”. They can be difficult to discharge because they believe that you are “fixing” them. In their view, they can’t succeed without you. An external locus of control is also common in people with depression.

Workman’s compensation and auto accident patients are typical of this group. Inherent to these cases is a placement of blame – the injury is the accepted fault of someone else. Think about all the auto accident patients that you may have seen (and can’t seem to discharge) that were injured by another driver in a minor accident. But when was the last time you had an auto accident patient who clearly caused the  minor accident? Almost never. Why is that? Wouldn’t they be injured to a similar extent?

We as physical therapists can have an effect on someone’s locus of control. Sadly, there are providers who actively encourage an external locus of control as a way to make the patient dependent on them for routine “maintenance” of their problem and maximal profits (I hate profit driven medicine). The technical term for these practitioners would be “evil shit-heads” (or “evil shits-head” – not sure where the plural goes with technical jargon). The goal of an ethical provider, however, would be to encourage an internal locus of control.

Encouraging an Internal Locus of Control

  • Focus on home program with equipment that they have access to
  • Instruct patients on self care techniques like self-mobilizations, self-PROM, etc
  • Reinforce to the patient that they are the ultimate decision maker, the provider is not – Educate where necessary and then treat the patient like an informed and valuable part of the decision process
  • Have the patient come in less often so you can check the progress that they have made on their own
  • Minimize passive treatments like electrical stimulation, ultrasound, massage, and manual therapy as these can reinforce the “victim/healer” archetypes
  • Help the patient to focus on what good they can do for themselves now, instead of what harm others have done to them in the past

Now what if you strongly believe that your patient needs a passive treatment like manual therapy? Well, the research says that in the cases in which manual therapy is effective (for whatever reason) it only requires a session or two of the treatment. Even the much criticized clinical prediction rule for manipulation for low back pain showed that only two sessions were needed to be effective. If on the initial evaluation, you decide that they would benefit from a passive treatment, set a limit up front. Maybe 2 or 3 sessions. If you just keep on doing it for ever and ever, good luck ever discharging that patient! Specialized passive treatments feel GOOD and it reinforces the idea that you, the provider, are the one fixing their problem. They will leave each session feeling great, only to return later for you to “fix” them again. The best thing that you could do is to teach them how to do it to themselves on the first visit and never touch them in the first place.

Performing passive treatments on people with a strongly internal locus of control won’t cause any harm and may cause some actual benefit. At worst, they will feel that you are wasting their time. If they are polite, they will let you keep doing it, especially if it feels good. But if you don’t do anything else, they will disappear. If you reinforce their independence, however, they will vigorously agree with you and are more likely to comply with your plan of care.

Medicine inherently encourages a normal external locus of control (something is wrong and they do need help). Sometimes the provider can inadvertently encourage it more because a patient expressing a strong external locus of control can make the provider feel like a special healer – “You are my savior with your magic hands!” If during your initial evaluation you start picking up that the patient has a strong external locus of control, you may need to take that into consideration when you develop your treatment plan. Reinforcing that mindset, even unintentionally, may not be ultimately the best plan of care for the patient.

This was an overview of this concept as it applies to medicine and rehabilitation. If you would like to learn more about all of the impacts of locus of control, Wikipedia has a great in-depth article on it that I would highly recommend.

This post and other science related content has moved to a new home at The Science PT website.

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