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The experiences of patients who elope from psychiatric units : a qualitative study McIndoe, Katherine Isobel 1983

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THE EXPERIENCES OF PATIENTS WHO ELOPE FROM PSYCHIATRIC UNITS: A QUALITATIVE STUDY By KATHERINE ISOBEL McINDOE B.S.N., The University of B r i t i s h Columbia, 1977 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (The School of Nursing) We accept th i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1983 © Katherine Isobel Mclndoe, 1983 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of h l U T t b l ' ^  The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 DE -6 A b s t r a c t T h i s study was designed to i n v e s t i g a t e how p s y c h i a t r i c p a t i e n t s e x p l a i n t h e i r elopements from h o s p i t a l . A l i m i t e d amount i s known about elopement and the a v a i l a b l e l i t e r a t u r e i s w r i t t e n from the p e r s p e c t i v e o f the c a r e t a k e r . The study was q u a l i t a t i v e i n de s i g n . Indepth i n t e r v i e w s were conducted w i t h f i v e p a t i e n t s when they r e t u r n e d t o the h o s p i t a l f o l l o w i n g t h e i r elopements. The data from these i n t e r v i e w s were analyzed u s i n g content a n a l y s i s and from t h i s a n a l y s i s , conceptual themes were c o n s t r u c t e d . The con-cept o f a l i e n a t i o n was u t i l i z e d by the r e s e a r c h e r to e x p l a i n the accounts of the p a t i e n t s . The p a t i e n t s i n the study experienced a l o s s o f c o n t r o l over t h e i r e n t r y i n t o h o s p i t a l , over t h e i r treatment and programme, and over events d i r e c t l y l i n k e d t o t h e i r elopements. The programmes and treatments were f r e q u e n t l y viewed as meaningless or not making sense. Elopement was viewed as a p o s i t i v e event by each of the p a t i e n t s because i t pr o v i d e d an o p p o r t u n i t y f o r some c o n t r o l and some freedom. The interdependence between the p a t i e n t s ' s u b j e c t i v e e x periences and the o b j e c t i v e o r g a n i z a t i o n o f the h o s p i t a l was examined. I t was e x p l a i n e d t h a t due to t h e i r placement i n the h i e r a r c h y o f the h o s p i t a l , p a t i e n t s o f t e n f e e l power-l e s s to a f f e c t what i s o c c u r r i n g . Moreover, the p a t i e n t s i n t h i s study f e l t they were not informed about the r a t i o n a l e s f o r the d e c i s i o n s t h a t were made about them. I t was argued t h a t while nurses b e l i e v e they are a d d r e s s i n g the concerns of p a t i e n t s , t h i s d i d not occur f o r the people i n t h i s study. I m p l i c a t i o n s f o r n u r s i n g p r a c t i c e , e d u c a t i o n and r e s e a r c h concluded t h i s study. i v Table of Contents Page Abstract i i Table of Contents i v Acknowledgements v i i Chapter One: Introduction to the Problem and Purposes 1 Conceptual Framework 5 Statement of the Problem 8 Purposes of the Study 9 Theoretical and Methodological Perspective of the Study 9 Assumptions of the Study 11 Limitations of the Study 11 Summary 12 Chapter Two: Methodology 13 Selection of Participants 13 C r i t e r i a for selection 13 Selection procedure 14 Description of the participants 14 Data C o l l e c t i o n 15 Construction of the accounts 16 Data Analysis 17 E t h i c a l Considerations 18 Summary 19 Chapter Three: The Process of the Analysis of the Data 2 0 Introduction to the Theme 20 Relationship of Alienation to Kleinman's Conceptual Framework 22 Implications for This Study 24 Summary 25 Chapter Four: Alienation 26 Literature Concerning Subjective Alienation . . . 26 Seeman's conceptualization of subjective a l i e n a t i o n 27 Writings r e f l e c t i n g Seeman's work 27 Conceptual frameworks for subjective alienation 2 9 Application of the concept to the therapeutic milieu 31 Literature Concerning Objective Alienation. . . . 32 Writings r e l a t i n g objective a l i e n a t i o n and the health care system 34 Summary of the l i t e r a t u r e on objective a l i e n a t i o n 38 Presentation and Discussion of the Accounts of the Participants 39 Powerlessness 41 Meaninglessness and i s o l a t i o n 52 Normlessness 59 Self-estrangement 6 3 Subjective Alienation Within an Objective Context 64 Summary 6 4 Chapter Five: Summary, Conclusions, and Implica-tions for Nursing 66 Summary and Conclusions 6 6 Implications for Nursing Practice 69 v i Implications for Nursing Education 72 Implications for Nursing Research 73 References 75 Appendix A 81 Appendix B 83 v i i Acknowledgements The w r i t i n g o f t h i s t h e s i s r e q u i r e d the combined e f f o r t s o f many people. In p a r t i c u l a r , I would l i k e to acknowledge the f o l l o w i n g f o r t h e i r i n v a l u a b l e a s s i s t a n c e . Dr. Joan Anderson, c h a i r p e r s o n of my committee, con-s i s t e n t l y p r o v i d e d support, e x p e r t i s e , and c r i t i c a l i n s i g h t . Dr. M a r i l y n Willman's o b j e c t i v i t y and i n c i s i v e comments were i n s t r u m e n t a l i n the completion of t h i s t h e s i s . I would l i k e t o thank the p a t i e n t s f o r t h e i r c a n d i d response and t h e i r time. The s t a f f i n the agencies must a l s o be acknowledged f o r a l l o w i n g and f a c i l i t a t i n g access to the p a t i e n t s . The support o f my f a m i l y and f r i e n d s was c r u c i a l through-out t h i s p r o c e s s . F i n a l l y , I must thank my husband Brendan f o r making l e a d b a l l o o n s f l y . Chapter One I n t r o d u c t i o n to the Problem and Purposes People make i n f e r e n c e s about the minds of o t h e r s by ob-s e r v i n g t h e i r behaviour ( C u r t i n , 197 9). In p s y c h i a t r i c / m e n -t a l h e a l t h p r a c t i c e , one o f t e n hears the statement, " A l l behaviour has meaning." T h i s same d e c l a r a t i o n i s seen i n the l i t e r a t u r e (Kyes & H o f l i n g , 1980; Robinson, 1972). Unfor-t u n a t e l y , the understanding of human behaviour remains i n a p r i m i t i v e s t a t e ( C l a r e , 1976). One behaviour which o c c a s i o n -a l l y occurs on a p s y c h i a t r i c u n i t i s the elopement of a p a t i e n t . Elopement i s the departure of a p a t i e n t , without s t a f f s a n c t i o n , from the p h y s i c a l boundaries of the h o s p i t a l i n which the p a t i e n t i s c u r r e n t l y h o s p i t a l i z e d . When t h i s behaviour o c c u r s , much time and energy are t y p i c a l l y ^ i n v e s t e d i n r e t u r n i n g the p a t i e n t who has e l o p e d . The nurse c a r i n g f o r the p a t i e n t , the nurse i n charge of the u n i t , the nurs-i n g s u p e r v i s o r , the primary t h e r a p i s t , the p o l i c e , and the r e l a t i v e s o f the p a t i e n t who eloped are t y p i c a l l y i n v o l v e d a t some l e v e l . Time and energy are a l s o i n v e s t e d i n the w r i t i n g of an i n c i d e n t r e p o r t and i n the w r i t i n g on the c h a r t . Despite the number of people i n v o l v e d and d e s p i t e the documentation, one element seems to be m i s s i n g : the p a t i e n t ' s p e r c e p t i o n of the events r e l a t e d to the elopement. 1 2 The behaviour of elopement p e r t a i n s t o the p r a c t i c e of nurses. Nurses are the p r o f e s s i o n a l s most f r e q u e n t l y i n -v o l v e d i n the d a i l y l i f e o f the p a t i e n t (Schrock, 1980) and p s y c h i a t r i c nurses are o f t e n i n v o l v e d i n the r e t u r n or attempted r e t u r n o f the p a t i e n t who e l o p e s . As w i t h other members o f the h e a l t h care team, the r o l e of the p s y c h i a t r i c nurse i s to support p a t i e n t s i n the h e a l t h y aspects of t h e i r behaviour and to provide the s e t t i n g i n which they can l e a r n more e f f e c t i v e behaviours to r e p l a c e the ones which are mal-adaptive (Robinson, 1972). Peplau (1980) r e i n f o r c e s t h i s stance by s t a t i n g nurses should "promote h e a l t h conducive behavior, and...aid the r e l e a s e and development of the c l i e n t ' s p o t e n t i a l " (p. 131). Thus, whether elopement i s viewed as a p o s i t i v e or a negative behaviour, the nurse has a mandate to be i n v o l v e d . Other reasons a l s o e x i s t as to why nurses should know about t h i s behaviour. Nurses o f t e n f e e l a sense of g u i l t or p e r s o n a l f a i l u r e when a p a t i e n t e l o p e s . A f r e q u e n t l y asked q u e s t i o n i s , "Why d i d n ' t I know t h i s was going to happen?" Another concern r e l a t e s t o the l e g a l l i a b i l i t y o f the nurse i f something does happen to the p a t i e n t . L i t i g a t i o n a g a i n s t h e a l t h p r o f e s s i o n a l s i s becom-i n g more common. Whether elopement i s a p o s i t i v e or a negative behaviour i s open to debate. Two opposing p o i n t s of view w i l l be b r i e f l y o u t l i n e d to i n d i c a t e how the behaviour has i m p l i c a -t i o n s f o r the p r o f e s s i o n o f n u r s i n g . P a t i e n t s who have eloped may or may not be committed. 3 I f they are committed, they can be d e t a i n e d i n the h o s p i t a l without g i v i n g t h e i r p e r m i s s i o n . The p a t i e n t s are c o n s i d e r e d a danger e i t h e r t o themselves or to o t h e r s . I f they are not committed, they have chosen to leave a s e t t i n g which they t e c h n i c a l l y have the r i g h t to do. The c o n t r a v e n t i o n of the wish to leave may be seen as an i n f r i n g e m e n t on the " p r o t e c -t i o n of l i b e r t y and of p e r s o n a l r i g h t s of p a t i e n t s admitted to p s y c h i a t r i c u n i t s " ( M e l l o r , 1977, p. 21). There i s c u r -r e n t l y a g r e a t value p l a c e d on the r i g h t to be an i n d i v i d u a l , t o express o n e s e l f as one sees f i t . How much then, and i n what manner, should people i n f l u e n c e one another? ( C u r t i n , 1979). Nurses cannot j u s t i n t e r v e n e f o r the purpose of i n -t e r f e r i n g (Matheney & T o p a l i s , 1974). They must have l o g i c a l and r a t i o n a l grounds to j u s t i f y the aims of t h e i r a c t i o n s as w e l l as the methods used to reach t h e i r goals ( M e l l o r , 1977) . As w e l l , i n t h i s age of the growing expense o f h e a l t h c a r e , nurses are accountable " f o r the best use of t h e i r time, and the economical use o f r e s o u r c e s " (Peplau, 1980, p. 132). Does the behaviour of elopement a u t o m a t i c a l l y warrant the e x t e n s i v e r e s o u r c e s t h a t are c u r r e n t l y m o b i l i z e d ? The more common and more t r a d i t i o n a l approach to e l o p e -ment views the behaviour as a p o t e n t i a l t h r e a t to the p a t i e n t . C e r t a i n p s y c h i a t r i c problems are c h a r a c t e r i z e d by impaired judgement and d e f e c t i v e p e r c e p t i o n (Kyes & H o f l i n g , 1980). Nurses are drawn i n t o a p r o t e c t i v e r o l e when c a r i n g f o r a v a r i e t y of p a t i e n t s (Darcy, 1978). I f a p a t i e n t i s known to be h i g h l y s u i c i d a l , s t a f f are concerned about the p a t i e n t 4 who has disappeared. As Darcy states: The p s y c h i a t r i c nurse has developed s k i l l s which may be seen as custodial....When r e s t r i c t i o n s are c a l l e d for, the nurse must be prepared to refute the accusation that she i s custodial or over-pro-tective simply because she i s protecting patients or s t a f f from harm. (p. 31) There i s l i t t l e written information on the patient who elopes. In a Registered Nurses' Association of B r i t i s h Columbia document, elopement i s l i s t e d as a p o s s i b i l i t y un-der the behavioural concept of depression. The nurse i s instructed to assess the patient's p o t e n t i a l for ''self-mutilating and s u i c i d a l acts" — the behaviour under discus-sion i s given as an example (Bastable, Gordon, M i l l e r , & Tregunna, 1977, p. 29). Another book associates elopement with the patient who uses projection or the patient who abuses alcohol and becomes "re b e l l i o u s " (Matheney & Topalis, 1974, pp. 253, 358). Though r e b e l l i o n can be viewed as either p o s i t i v e or negative behaviour depending on one's conceptual framework (Peplau, 1978) , when elopement i s mentioned i t tends to be categorized as a negative event. The author of a "problem i behavior report sheet" l i s t s elopement as a "high defiance" problem behaviour which "deviates from the s t a f f desired, standing patterns of behavior" (Bailey, 1979, pp. 488-494). Another behaviour inventory which states i t measures "the severity of psychopathological disturbance i n the ward be-haviors of adult p s y c h i a t r i c patients" also l i s t s elopement (Burdock & Hardesty, 1979, p. 221). One behavioural check-5 l i s t c l a s s i f i e s elopement i n the same category as sexual act-ing out, assaultive or threatening behaviour, and destruction of property (Moran, 1979). Of the l i t e r a t u r e reviewed, only three authors who mention elopement consider examining the reason for the be-haviour. ^Krall (1976) simply states there must be a cause for the behaviour and t h i s must be considered when planning the patient's treatment. Matheney and Topalis (1974) write that patients who are suspicious believe they are correct i n t h e i r concerns and that h o s p i t a l i z a t i o n i s therefore unneces-sary. As a r e s u l t , they leave the hospital without permis-sion. In an anecdotal account of a patient who eloped, Vousden (1979) writes that i f the patient had been warned a group of people would be v i s i t i n g , the patient might not have l e f t the unit. In summary, despite the concern nurses have when a patient elopes from a p s y c h i a t r i c unit, there i s only a lim i t e d amount known about the behaviour. When elopement i s considered i n the l i t e r a t u r e , i t tends to be viewed as a nega-tive event though there i s l i t t l e j u s t i f i c a t i o n for t h i s . How the patient perceives the behaviour i s not known. Conceptual Framework Whether elopement i s a posi t i v e or a negative behaviour, nurses should have an understanding of the experiences of the patient. Since nurses are accountable to patients, they should work with them to resolve issues i n ways that are most 6 b e n e f i c i a l f o r them (Peplau, 1980). In t h i s i n s t a n c e , the needs o f the p a t i e n t might be met through some means other than elopement. Nu r s i n g has acknowledged the need to understand the p a t i e n t as an i n d i v i d u a l who i s d i f f e r e n t from o t h e r people. C u r t i n (197 9) s t r e s s e s t h a t each person i s unique and thus " f i l t e r s . . . e x p e r i e n c e s through h i s or her own p e r c e p t i o n s " (p. 106). To best help the i n d i v i d u a l , nurses must have some knowledge o f the p a t i e n t ' s p e r s p e c t i v e . A v a r i e t y of authors r e i t e r a t e t h i s p o i n t ( A l t s c h u l , 1977; Kyes & H o f l i n g , 1980; Matheney & T o p a l i s , 1974; Schrock, 1980). Wilson and K n e i s l (1979) address the i s s u e i n t h i s manner: The n o t i o n t h a t people a c t i n a s i t u a t i o n based on the unique meaning t h a t s i t u a t i o n has f o r them i s a l l but i g n o r e d i n many approaches to p s y c h i a t r i c n u r s i n g . Instead, human conduct i s t r e a t e d as the product of v a r i o u s f a c t o r s t h a t p l a y on p a s s i v e human beings.. . . the meaning of experiences for, the p a r t i c u -l a r person i s e i t h e r bypassed or swallowed by the o t h e r f a c t o r s t h a t are used to account f o r the p a t -i e n t ' s b e h a v i o r . T h i s . . . n e g l e c t s the r o l e of meaning i n the formation of human behav i o r . . . . the p s y c h i a t r i c nurse must be wary o f i n t e r v e n t i o n s t h a t convey an i n v a l i d a t i o n of the. meaning of an experience to the c l i e n t i n f a v o r of the nurse's d e f i n i t i o n of the s i t -u a t i o n . A c o r o l l a r y i s the need f o r nurses to develop s k i l l i n o b s e r v i n g , i n t e r p r e t i n g and responding to the meanings w i t h i n the c l i e n t ' s frame o f r e f e r e n c e i n the hope of a r r i v i n g a t a common ground of n e g o t i -ated meanings. (p. 6) Smith (1975), a Canadian s o c i o l o g i s t , d i s c u s s e s the im-portance of examining the everyday world of the i n d i v i d u a l . She a l s o emphasizes the importance o f l o c a t i n g the i n d i v i d -u a l ' s experience w i t h i n the broader s o c i o c u l t u r a l c o n t e x t : [The study of the i n d i v i d u a l ] i s not l e f t d a n g l i n g t h e r e f o r e . I t becomes an e s s e n t i a l p a r t of the work 7 of understanding a t o t a l process. The micro-socio-l o g i c a l l e v e l of study of the everyday world and the macro-sociological inquiry... are pulled into a r e l a -t i o n of necessary interdependence .... The experienced world, the worlds i n which people are actually located and which organize t h e i r experience, are viewed as generated i n t h e i r v a r i e t i e s by an organization of s o c i a l and material relations because that i s indeed how they are related. (p. 375) Kleinman (1978) has constructed a conceptual framework of the health care system which acknowledges the importance of the patient's perception and which also locates the patient's experience within the broader s o c i o c u l t u r a l context. The health care system as a c u l t u r a l system involves the a r t i -culation of the health, i l l n e s s , and health care aspects of s o c i e t i e s . Kleinman's framework has provided the d i r e c t i o n for t h i s study. A state of nonhealth has three dimensions: disease, i l l n e s s , and sickness. Sickness i s a complex phenomenon which has b i o l o g i c a l , psychological, and s o c i o c u l t u r a l aspects (Kleinman, Eisenberg, & Good, 1978). Kleinman states sickness can be experienced i n three d i f f e r e n t s t r u c t u r a l domains of the health care system: the professional sector which includes s c i e n t i f i c medicine; the folk sector which includes non-professional healers; and the popular sector which includes the i n d i v i d u a l , the family, and the s o c i a l network. Each structural domain has i t s own c l i n i c a l r e a l -i t y which includes b e l i e f s , expectations, roles, and r e l a t i o n -ships (Kleinman, 1978). For the same sickness episode, the d i f f e r e n t domains would have d i f f e r e n t explanatory models to describe "what i s wrong with the patient and what should 8 be done" (Kleinman e t a l . , 1978, p. 254). When people from d i f f e r e n t s e c t o r s i n t e r a c t , the incorigruent e x p l a n a t o r y models can l e a d to c o n f l i c t i n g e x p e c t a t i o n s . The concept of d i s e a s e i s commonly a s s o c i a t e d w i t h the p r o f e s s i o n a l s e c t o r . Disease i s viewed as a d i s r u p t i o n i n the b i o l o g i c a l or p s y c h o l o g i c a l p r o c e s s e s . The concept of i l l n e s s i s commonly a s s o c i a t e d w i t h the popular s e c t o r . I l l n e s s i s viewed as the p e r s o n a l or i n t e r p e r s o n a l response to d i s e a s e : " I l l n e s s . . . i s most f r e q u e n t l y a r t i c u l a t e d i n a h i g h l y p e r s o n a l , n o n - t e c h n i c a l , concrete idiom concerned w i t h the l i f e problems t h a t r e s u l t from s i c k n e s s " (Kleinman, 1978, p. 88). The p a t i e n t ' s r e -sponse to s i c k n e s s i s a f f e c t e d by such i n f l u e n c e s as e t h n i c group, s o c i a l c l a s s , or f a m i l y -- t h i s i s e q u a l l y t r u e f o r those i n the p r o f e s s i o n a l s e c t o r (Kleinman e t a l . , 1978). People's s u b j e c t i v e e xperiences are l o c a t e d w i t h i n s o c i a l , c u l t u r a l , t e c h n i c a l , economic, and h i s t o r i c a l s e t t i n g s which i n f l u e n c e p e r s o n a l experience (Kleinman, 1978). As Kleinman s t a t e s : "[Models]...must be able to examine both i n d i v i d u a l as w e l l as s o c i a l dimensions o f h e a l t h care b e l i e f s and a c t i o n s . N e i t h e r alone g i v e s a s a t i s f a c t o r y a n a l y s i s of s i c k n e s s and h e a l i n g " (p. 89). Statement o f the Problem T h i s study i s designed to gain an understanding of how p a t i e n t s view t h e i r own elopements. T h i s understanding or s u b j e c t i v e r e c o l l e c t i o n encompasses reasons f o r the behaviour and the e xperiences d u r i n g the elopement. These s u b j e c t i v e 9 rec o l l e c t i o n s are then analyzed within the broader context of the so c i o c u l t u r a l structures which influence the experi-ences of the patients. Purposes of the Study The purposes of the study are: 1. to describe patients' perceptions of what led to t h e i r elopements; 2. to describe how patients view t h e i r experiences of the elopements; 3. to describe what purpose patients f e e l the elopements served for them; and 4. to analyze the subjective experiences of patients with-in the broader s o c i o c u l t u r a l context. Theoretical and Methodological Perspective of the Study Phenomenology, which i s a philosophy, an approach, and a method, describes human experience as i t i s l i v e d (Oiler, 1982). This approach was chosen as appropriate for meeting the purposes of t h i s study because i t emphasizes the under-standing of behaviour from the patient's own perspective (Rist, 1979). As Davis (1978) states: "human actions are highly s i t u a t i o n a l and human actors act i n .accord with t h e i r constructions of meaning for the concrete situations they face" (p. 194). The phenomenological approach thus allows for a greater depth of understanding than i s usual i n the more t r a d i t i o n a l methods of investigation (Rist, 1979). 10 Using t h i s approach also melds with the philosophy of the nursing profession: "emphasizing a reverence for c l i e n t s ' experiences" and advocating "the i n d i v i d u a l as author of his own world; definer of his own r e a l i t y " (Oiler, 1982, p. 178). Data c o l l e c t i o n and data analysis d i f f e r from the ap-proaches used i n the more common quantitative investigations. In the phenomenological approach, participants are chosen be-cause they " f i t " what i s being studied. One begins with the subjective perceptions of these pa r t i c i p a n t s . "As descrip-tions are compared and contrasted recurring elements are noticed. This allows i d e n t i f i c a t i o n of the ingredients of the phenomenon and the way the ingredients relate to each other" (Oiler, 1982, p. 180). It i s the r e s p o n s i b i l i t y of the researcher to c l e a r l y interpret the data and to show how the interpretation was made by r e f e r r i n g to the information c o l l e c t e d . In t h i s way, the reader can determine i f the researcher's interpretation i s v a l i d (Cicourel, 1968). The relationship between pa r t i c i p a n t and researcher i s viewed i n a very d i f f e r e n t manner than i n more orthodox forms of research. Schutz (1970) describes the concept of i n t e r -s u b j e c t i v i t y which ex i s t s between two people who are i n t e r -acting: This world i s not only mine but also my fellow men's environment; moreover these fellow men are elements of my s i t u a t i o n , as I am of t h e i r s . Act-ing upon the others and acted upon by them I know of t h i s mutual re l a t i o n s h i p . (p. 164) Each i n d i v i d u a l comes to a s i t u a t i o n with a unique background or knowledge, but through a verbal interaction of questioning 11 and c l a r i f i c a t i o n one can gain an understanding of the other (Schutz, 1970). Therefore, the role of the researcher i s an i n t e g r a l part of phenomenological research -- the major i n -strument for the c o l l e c t i o n of data i s the investigator (Ragucci, 1972). Bias of the researcher cannot be eliminated, but i t can be recognized and incorporated into the study (Davis, 197 8). Kleinman's (1978) conceptual framework i s complemented by the phenomenological approach to research. Each i s con-cerned with the understanding of the perspective of the i n d i -v i d u a l . The phenomenological approach provides the vehicle for exploring the c l i n i c a l r e a l i t y of those i n the popular sector of the health care system. Using Kleinman's concep-tua l framework, the researcher i s then able to relate these data to the surrounding so c i o c u l t u r a l context. Assumptions of the Study This study i s based on three assumptions: elopement has meaning for the person who engages i n i t ; t h i s meaning can be relayed to others so they can better evaluate care; and the patient who elopes w i l l speak t r u t h f u l l y about the experience. Limitations of the Study There are two main l i m i t a t i o n s i h t h i s study. The primary l i m i t a t i o n i s the l i k e l i h o o d that subjects may not have always been f u l l y open i n the interviews as some f e l t 12 uncomfortable i n d i v u l g i n g requested data. At times, p a r t i c i -pants r e f u s e d to answer or c o n t i n u a l l y evaded c e r t a i n ques-t i o n s . In a d d i t i o n , due to time c o n s t r a i n t s , the r i c h n e s s of the data may not have been as f u l l y e x p l o r e d as might have been p o s s i b l e . Summary T h i s chapter has d e s c r i b e d the problem under study and has presented a survey of the l i t e r a t u r e on the p s y c h i a t r i c p a t i e n t who elopes from h o s p i t a l . I t has shown t h a t a l i m i t e d amount i s known about t h i s behaviour and t h a t the w r i t i n g s which do e x i s t are formulated from the p e r s p e c t i v e of the c a r e t a k e r s r a t h e r than the p a t i e n t . The need f o r the nurse to e x p l o r e the p a t i e n t ' s understanding of elopement and the need to p l a c e t h i s understanding i n t o the l a r g e r s o c i o c u l -t u r a l c ontext were shown. Chapter Two Methodology This chapter describes the methodological perspective for t h i s study. Four major areas w i l l be discussed: the selection of the participants for the study, data c o l l e c t i o n , data analysis, and the e t h i c a l considerations involving the par t i c i p a n t s . Selection of Participants C r i t e r i a for selec t i o n . Five c r i t e r i a were u t i l i z e d i n s e l e c t i n g participants for t h i s study: 1. The patients returned to the unit from which they had eloped. This return could be of the patients' choice or i t could be i n spite of t h e i r choice. This c r i t e r i o n was employed so the researcher would be able to make contact with the participants through an agency. 2. The patients gave consent for the f i r s t interview with the researcher within 7 2 hours of returning from t h e i r elopements. This time period was established so the p a r t i c i -pants' experiences would s t i l l be v i v i d and clear i n t h e i r memories. 3. The patients were fluent i n English. This c r i t e r i o n was important because the interviews needed for t h i s type of study required indepth discussions. 14 4. The patients were 18 years or older. This was due. to the researcher's i n t e r e s t i n the experiences of adults. 5. The patients were competent to give informed consent for the interviews. Selection procedure. This study was conducted on the psych i a t r i c units of three general hospitals i n the Vancouver area. Depending on the preference of the i n s t i t u t i o n involved, two methods were used to a l e r t the researcher when a patient had returned from an elopement: the s t a f f on a unit contacted the researcher or the researcher routinely contacted the hospital every second day. After consulting with a s t a f f member to v e r i f y that the patient was capable of giving informed consent, the researcher made the i n i t i a l contact with the patient who had eloped. The study was explained to the patient, and, i f the patient expressed an in t e r e s t i n p a r t i c i p a t i n g , he or she was shown the consent form (see Appendix A). If the consent form was signed by the patient, the f i r s t interview then began. Description of the par t i c i p a n t s . There were three female and two male participants i n t h i s study. The oldest was 33 years old and the others were under the age of 25. A l l the participants were Caucasian. One of the patients was married, two were single, and two were involved i n hetero-sexual rela t i o n s h i p s . P r i o r to h o s p i t a l i z a t i o n , three of the partici p a n t s had l i v e d with t h e i r families of o r i g i n , one had l i v e d with his spouse and children, and one had l i v e d 15 with a f r i e n d . Four o f the f i v e p a r t i c i p a n t s had been un-employed f o r the s i x months p r i o r to h o s p i t a l i z a t i o n . The diagnoses of the p a r t i c i p a n t s were broadly c a t e -g o r i z e d as e i t h e r a f f e c t i v e or thought d i s o r d e r s . The l e n g t h o f time the p a t i e n t s had been i n h o s p i t a l ranged from three days to two months. The l e n g t h of the a c t u a l e l o p e -ments ranged from a few hours t o three days. Three of the p a r t i c i p a n t s were c o n s i d e r e d v o l u n t a r y admissions i n t h a t they had signed consent forms f o r h o s p i -t a l i z a t i o n . Two of the p a r t i c i p a n t s were on committal papers. T h i s meant two d o c t o r s and another i n d i v i d u a l who knew the p a t i e n t s f e l t they should be i n h o s p i t a l though they d i d not want to be t h e r e . Such p a t i e n t s are con-s i d e r e d to be p o t e n t i a l l y harmful e i t h e r t o themselves or to someone e l s e . Approximately ten people who met the r e s e a r c h e r ' s c r i -t e r i a were not i n c l u d e d i n the study. Most of them were h e s i t a n t to d i s c u s s t h e i r s i t u a t i o n . Despite the r e s e a r c h e r ' s reassurance o f c o n f i d e n t i a l i t y , they expressed concern some of the s t a f f might have access t o the data. Most of the people who r e f u s e d to t a l k with the r e s e a r c h e r were over the age o f 35. How t h i s age demarcation " f i t s " w i t h the d e c i s i o n r e g a r d i n g p a r t i c i p a t i o n i s not known, but i t d i d appear t o be a f a c t o r . Data C o l l e c t i o n Data were c o l l e c t e d i n audiotaped i n t e r v i e w s which were 16 conducted i n the h o s p i t a l . Two interviews were held with four of the p a r t i c i p a n t s . One patient refused a second i n -terview stating he was "too sick." The length of the i n t e r -views ranged from 30 to 90 minutes. The f i r s t interview was to occur within a maximum of 72 hours a f t e r patients had returned to the hospital from t h e i r elopements. Four of the i n i t i a l interviews were, i n fact, completed within 4 8 hours of the participant's return. The concerns of the participants were the f o c i and open ended questions were used extensively. However, the interviews were structured i n the sense that the researcher covered ce r t a i n broad areas which were suggested by the purposes of the study (see Appendix B). The second interview was conducted six to eight days af t e r the f i r s t . In the time intervening, the f i r s t tape was transcribed and analyzed. The second interview served two main purposes: to c l a r i f y any questions which arose a f t e r l i s t e n i n g to the previous tape; and to ascertain i f the participant's perception of the experience had altered in the intervening week. Construction of the accounts. In Chapter One, i t was explained that the researcher would describe how the p a r t i -cipants viewed t h e i r own elopements. Interviews were held between each pa r t i c i p a n t and the researcher to gather the data. The process by which the researcher gathered the i n -formation was the construction of the accounts. This con-str u c t i o n was affected by both the individuals involved as 17 each came to the i n t e r a c t i o n w i t h t h e i r own exp e r i e n c e s and t h e i r own e x p e c t a t i o n s . The r e s e a r c h e r had worked and had taught i n the c l i n i c a l area of p s y c h i a t r y -- she t r i e d to i d e n t i f y her own prec o n c e i v e d assumptions about p a t i e n t s who eloped . The p a r t i c i p a n t s acknowledged they, too, had c e r t a i n i d e a s about the i n t e r a c t i o n . Two of the p a r t i c i p a n t s r e f e r r e d to the r e s e a r c h e r as "doctor" -- both f e l t nurses d i d n ot engage i n r e s e a r c h . One o f the p a r t i c i p a n t s asked i f t h ere was anything " s p e c i a l " the r e s e a r c h e r would l i k e her t o say — she wanted the r e s e a r c h e r to o b t a i n the " r i g h t " r e s u l t s . A l l o f the p a r t i c i p a n t s viewed the i n t e r v i e w s as an o p p o r t u n i t y to make a statement about t h e i r d i f f i c u l t i e s . To ensure the p a r t i c i p a n t and the r e s e a r c h e r were con-gruent i n t h e i r understanding o f events o r words, the r e -sear c h e r f r e q u e n t l y sought c l a r i f i c a t i o n o r f u r t h e r data from the p a r t i c i p a n t . Even with t h i s approach, i t i s l i k e l y t h a t misunderstandings c o u l d have o c c u r r e d . Data A n a l y s i s A f t e r each i n t e r v i e w , the r e s e a r c h e r t r a n s c r i b e d the audiotape. The r e s e a r c h e r then examined each t r a n s c r i p t , n o t i n g emerging trends o r themes. These were then examined i n r e l a t i o n to the l i t e r a t u r e . Based on constant comparative a n a l y s i s o f the data and the i n v e s t i g a t i o n o f the l i t e r a t u r e , the r e s e a r c h e r adapted f u t u r e i n t e r v i e w s with p a r t i c i p a n t s . The major theme which was c o n s t r u c t e d from the a n a l y s i s of the data was the concept which the r e s e a r c h e r f e l t was the 18 most c o n s i s t e n t and the most u n i f y i n g f o r each p a r t i c i p a n t . E t h i c a l C o n s i d e r a t i o n s E t h i c a l c o n s i d e r a t i o n s were addressed i n a v a r i e t y o f ways. Before c o n t a c t i n g the p a t i e n t , the r e s e a r c h e r d i s -cussed w i t h a s t a f f member the competency o f the p a t i e n t to give an informed consent and then p e r s o n a l l y assessed t h i s competency. A f t e r the r e s e a r c h e r had c l a r i f i e d her r o l e , the study was e x p l a i n e d t o the p a t i e n t . T h i s same-information was r e i t e r a t e d i n the consent form. I t was s t a t e d t h a t the p a t i e n t had the r i g h t t o r e f u s e t o p a r t i c i p a t e i n the study and t h a t such a r e f u s a l would not a f f e c t the care r e c e i v e d . P a t i e n t s were assured t h a t the i n t e r v i e w m a t e r i a l s would be kept c o n f i d e n t i a l except i n cases o f l i f e t h r e a t e n i n g i n f o r -mation. They were t o l d t h e i r names would not appear on the tapes o r i n the t h e s i s . I t was a l s o e x p l a i n e d t h a t the tapes would be erased a f t e r the t h e s i s was w r i t t e n . The p a t i e n t s were informed there was no expected r i s k i f they p a r t i c i p a t e d i n the study. I t was e x p l a i n e d t h a t , w h i l e there may be no known b e n e f i t f o r them other than having the o p p o r t u n i t y to t a l k about the experience, the study might be bf b e n e f i t to o t h e r s i n the f u t u r e . They were a l s o informed they had the r i g h t t o withdraw from the study a t any p o i n t i n time. For those who were i n t e r e s t e d , a summary o f the r e s u l t s o f the study was o f f e r e d . 19 Summary T h i s chapter has d e s c r i b e d the methodology used to ex-p l o r e the p e r c e p t i o n s o f p a t i e n t s who have eloped from a p s y c h i a t r i c u n i t . The r e s e a r c h e r ' s c r i t e r i a and r a t i o n a l e f o r the s e l e c t i o n o f the p a r t i c i p a n t s were d e s c r i b e d as were the s e l e c t i o n procedure and the p a r t i c i p a n t s themselves. The c o n c u r r e n t processes o f data c o l l e c t i o n and data a n a l y s i s were d i s c u s s e d . A d i s c u s s i o n o f e t h i c a l c o n s i d e r a t i o n s f o r the study completed the chapter. Chapter Three The Process o f A n a l y s i s of the Data T h i s chapter has two purposes: to b r i e f l y i n t r o d u c e the reader to the major theme which was c o n s t r u c t e d from the a n a l y s i s of the data and to r e l a t e t h i s theme to Kleinman 1s (1978) conceptual framework. T h i s i n f o r m a t i o n w i l l enable the reader to understand the i n t e r p r e t a t i o n of the data which i s presented i n the f o l l o w i n g chapter. I n t r o d u c t i o n t o the Theme When the w r i t e r began the r e s e a r c h , she entered the process w i t h as few preconceived i d e a s as p o s s i b l e . A f t e r i n t e r v i e w s with the f i r s t two p a r t i c i p a n t s , however, i t was noted t h a t both i n d i v i d u a l s i d e n t i f i e d a sense of a l o s s of c o n t r o l over t h e i r l i v e s and a sense they d i d not " f i t " i n the h o s p i t a l . The r e s e a r c h e r began an i n v e s t i g a t i o n of the r e l a t e d l i t e r a t u r e a t t h i s p o i n t . As f u r t h e r i n t e r v i e w s o c c u r r e d and as the r e s e a r c h e r began to focus on these per-c e p t i o n s o f the p a r t i c i p a n t s , the trends p e r s i s t e d and strengthened. For the r e s e a r c h e r , one concept, t h a t of a l i e n a t i o n , c l e a r l y p r o v i d e d an e x p l a n a t o r y framework which "made sense" o f the data. The f o l l o w i n g chapter w i l l demon-s t r a t e how the theme melds wi t h the data. 20 21 The term alienation was used by the ancient Greeks and Romans to denote the transfer of property or the sale of goods. The Romans also used the word in describing one's mental capacity (Ludz, 1981). I t can thus be seen al i e n a -t i o n i s not simply a c h a r a c t e r i s t i c of our modern age. The term has recently been used i n a variety of d i s c i p l i n e s : theology, philosophy, history, psychiatry, psychology, s o c i -ology, anthropology, ethnography, economics, and education (F. Johnson, 1973b). Despite i t s history and frequent use, alienation i s not a c l e a r l y defined concept. It has been, and s t i l l i s , interpreted i n a myriad of ways: The p r o l i f e r a t i o n of alienation concepts, terms, and synonyms which has occurred i n recent years has produced a corresponding i n t e r e s t i n f i n d -ing a core theme, common denominator, or unifying multidimensional concept under which a l l v a r i e t i e s of alienation can be subsumed. The suggestion i s that alienation i s a "syndrome" of diverse forms which display a certain unity, and there i s a com-mon meaning which extends beyond some general notion of separation. Whether t h i s suggestion i s pla u s i b l e , or whether i t i s even worthwhile to pursue, i s a matter for debate. (Geyer & Schweitzer, 1976, p. x x i i i ) Hays (1976), who uses a psycholinguistic approach to analyze e x i s t i n g theories of al i e n a t i o n , expresses r e l i e f at only having to transcribe theories rather than decide which i s the "right" one. Overall, however, alienation i s viewed as a lack of a bond between an in d i v i d u a l and something or someone el s e . Although usually viewed as a negative occurrence (F. Johnson, 1973a), alienation i s also sometimes viewed as being either 22 of p o s i t i v e or of neutral value. Schweitzer (1982) states that perception of alienation can benefit both the i n d i v i d u a l and society; Ludz (1981) states that alienation can aid the creative i n d i v i d u a l . Two major categories of alienation are delineated by most writers i n the f i e l d : subjective and objective a l i e n a t i o n . In subjective a l i e n a t i o n : Attention i s focussed upon psychological s t a t e s — upon people's perceptions of, feelings about and attitudes toward the situations and relationships i n which they f i n d themselves. The forms of d i s -cord encountered here might thus be termed "experi-e n t i a l . " (Schachi;, 1976, p. 136) In objective a l i e n a t i o n : Attention i s focussed upon s o c i a l r e l a t i o n s — u p o n the [lack of] integration or "mutual f i t " of the behavior and a c t i v i t i e s of individuals with the conventions and expectations of groups and with the laws and i n s t i t u t i o n s of the s o c i o - p o l i t i c o -economic order i n which they l i v e . The forms of discord here might thus be termed " s o c i a l struc-t u r a l . " (Schacht, 1976, p. 136) Thus, one category relates to the psychological s i t u a t i o n while the other relates to the s o c i o l o g i c a l s i t u a t i o n . In examining the two categories of a l i e n a t i o n , there i s a cer-t a i n amount of overlapping of ideas. Usually a dominance of one or the other i s apparent and the researcher has separated the readings on t h i s basis. Relationship of Alienation to Kleinman's Conceptual Framework As stated i n Chapter One, i n Kleinman's model the patient i s a member of the popular domain of the health care system. As such, the i n d i v i d u a l has certain b e l i e f s , expecta-tions, and explanatory models. The perceptions, feelings, 23 and attitudes which e x i s t i n subjective alienation can be located within t h i s sphere of Kleinman 1s model. Interacting with the popular domain are the professional and folk sectors of the health care system and the external factors which a f f e c t the health care system as a whole. The r e a l i t y of the s i t u a t i o n which surrounds the patient can be seen as a potent i a l source of objective a l i e n a t i o n . In recent years, emphasis has been placed on the concept of subjective a l i e n a t i o n . As a r e s u l t , problems i n the so c i a l structure have been ignored. Geyer and Schweitzer (1976) state that even when alienation i s seen as a subjec-t i v e experience, the objective circumstances surrounding the experience should be examined. This would allow the re-searcher to make a judgement about the soci o c u l t u r a l context surrounding the individual's feelings: What i s at stake here i s a choice not so much between objective and subjective d e f i n i t i o n s of alie n a t i o n , but between competing epistemologies and departure points e x p l i c i t l y associated with these d i s t i n c t conceptualizations of alienat i o n . The choice between objective and subjective concepts, with t h e i r con-comitant points of departure, determines not only the way questions and answers are formulated, but also the methodologies, strategies, and remedies for change, action, and de-alienation. (Schweitzer, 1982, p. 69) Twaddle (1982) reinforces the need for an examination of the indiv i d u a l ' s feelings and the surrounding context. He describes a movement from medical sociology to a sociology of health. In the past, emphasis has been placed on the b i o l o g i c a l , psychological, and s o c i a l dimensions of an i n d i -vidual i n poor health. Now, emphasis i s being placed "on 24 a l l kinds of events, structures, etc. that l i m i t freedom of choice and/or reduce personal effectiveness" (p. 349). While some c r i t i c s have stated that a movement toward examining larger s o c i a l units w i l l lead to dehumanization, others be-lie v e that certain events can only be accurately understood by examination at a higher l e v e l than the i n d i v i d u a l (Twaddle, 1982). Twaddle (1982) makes an eloquent plea for both lev e l s of examination: I am very disturbed by the stance of some of my colleagues that understanding macrosystemic pro-cesses and structures i s both necessary and suf-f i c i e n t . Equally necessary, and equally i n s u f f i c -ient, are the microsystemic structures and processes: p e r s o n a l i t i e s , r o l e , i n t e r a c t i o n , i d e n t i t i e s , group dynamics, and the l i k e . We need to be aware of both the atomistic and the ecolo g i c a l f a l l a c i e s . There i s a c r i t i c a l need for maintaining a d i a l e c t a l con-sciousness of the fact that soci e t i e s are simul-taneously made of structures and people. (p. 356) Implications for This Study Influenced by the writings of Twaddle (1982), and Geyer and Schweitzer (1976), t h i s study addresses both subjective and objective a l i e n a t i o n . The phenomenological approach promotes the understanding of the subjective experiences of the par t i c i p a n t s . Kleinman's conceptual framework pro-motes the analysis of these experiences within the broader so c i o c u l t u r a l context. The researcher has presented the findings of t h i s study i n the following format. Chapter Four addresses the l i t e r a -ture on both subjective and objective a l i e n a t i o n . The pre-sentation and discussion of the participants' accounts are 25 then interwoven w i t h an examination o f the h e a l t h care system. Summary In t h i s chapter, the c o n s t r u c t i o n o f the concept o f a l i e n a t i o n from the a n a l y s i s o f the data has been d e s c r i b e d . The two major c a t e g o r i e s o f a l i e n a t i o n have been r e l a t e d to Kleinman's conceptual framework and to the phenomenological approach to r e s e a r c h . Chapter Four Alienation In t h i s chapter, some of the l i t e r a t u r e on both subjec-tive and.objective a l i e n a t i o n i s presented and examined. Because of the s p e c i f i c theme which emerged from the analysis of the data and because most of the information on t h i s topic i s i n the f i e l d of sociology, the l i t e r a t u r e review i s largely based on writings i n sociology. This review lays the foundation f o r understanding the feelings and per-ceptions of the participants i n t h i s study. These experi-ences w i l l be shown to be a r e f l e c t i o n of the larger socio-c u l t u r a l context i n which they took place. The presentation and discussion of the accounts of the participants are organized according to Seeman1s (1959/1972) conception and the concept of objective a l i e n a t i o n . By so doing, d i f f e r e n t aspects of a l i e n a t i o n can be highlighted. Literature Concerning Subjective Alienation Before embarking on the actual review of the l i t e r a t u r e , the researcher feels obligated to enter a caveat to the reader: This p r o l i f e r a t i o n [of d e f i n i t i o n s of alienation] has c e r t a i n l y not resulted i n a Maoist flower garden, nor has the extreme d i v e r s i t y brought about a great leap forward. The advantages of d i v e r s i t y disappear when nearly everyone conceptualizes alienation i n a 26 27 s l i g h t l y d i f f e r e n t way, without bothering to specify the differences and the s i m i l a r i t i e s with the al i e n a -t i o n concepts used by others. Research re s u l t s are consequently d i f f i c u l t to compare, l e t alone to accumu-la t e . These d i f f i c u l t i e s , i n turn, impede e f f e c t i v e theory building. (Geyer, 1976, p. 189) Seeman's conceptualization of subjective a l i e n a t i o n . Seeman's 195 9 piece, "On the Meaning of Alienation," i s con-sidered a c l a s s i c work on subjective a l i e n a t i o n . His a r t i c l e , which appears to be the catalyst for much of the renewed in t e r e s t i n t h i s f i e l d , i s s t i l l a basis for discussion (Geyer, 1976; Ludz, 1976; Schweitzer, 1982). While he l a t e r expanded the number of categories to six, Seeman (1959/1972) i n i t i a l l y v i s u a l i z e d f i v e ways i n which the theme of aliena-t i o n was expressed. The o r i g i n a l five categories of power-lessness, meaninglessness, normlessness, i s o l a t i o n , and self-estrangement dealt primarily with "the ideas of expecta-tion and value" (p. 46). He acknowledged the need for re-search to determine what s o c i a l conditions caused the various types of al i e n a t i o n just as he acknowledged that the be-havioural consequences of alienation must be investigated. Seeman thus saw his work as an attempt to organize a common language for those i n the f i e l d -- he did not see i t as an answer to a l l questions about the concept. Writings r e f l e c t i n g Seeman's work. Blauner's (1964/ 1972) work discussing modern industry was actually a hybrid of subjective and objective a l i e n a t i o n : Alienation i s viewed as a qua l i t y of personal exper-ience which re s u l t s from s p e c i f i c kinds of s o c i a l arrangements...Alienation i s a general syndrome made 28 up of d i f f e r e n t objective conditions and subjec-t i v e feeling-states which emerge from certain relationships between workers and the sociotech-n i c a l settings of employment. (p. 110) What i s p a r t i c u l a r l y noteworthy about Blauner's work i s his conceptualization of a l i e n a t i o n : his four subcategories of subjective-objective a l i e n a t i o n can be d i r e c t l y linked to Seeman's subcategories of subjective a l i e n a t i o n . Geyer (1976) u t i l i z e d a general systems theory approach in analyzing a l i e n a t i o n . Individuals were viewed as systems in i n t e r a c t i o n with t h e i r environments. Because only human beings have poten t i a l awareness of t h e i r state, only they as indi v i d u a l s can be seen as alienated. Seeman's fi v e types of alienation were seen as various problems which could arise i n the information processing by the system. Thus, powerless-ness, or the expectancy held by individuals that they cannot determine the outcome they seek, was related to a d i f f i c u l t y i n the system's output. Geyer's work d i f f e r s from Seeman's in two important ways: i t i s at a d i f f e r e n t a n a l y t i c a l l e v e l and i t also relates the causes of alienation to the system. Bloch (1978), who u t i l i z e d Seeman's five categories of a l i e n a t i o n , traced i t s causes to either s o c i a l or psycho-l o g i c a l factors. While she did not develop her own theory of a l i e n a t i o n , she c i t e d a series of studies which related the concept to the health care f i e l d . Her work i s p a r t i c u -l a r l y relevant because she stated how nurses can intervene i n alienation and she u t i l i z e d c l i n i c a l examples as i l l u s -29 t r a t i o n s . D. Johnson (1967) , who discussed powerlessness as a var i a t i o n of Seeman's conception of alienation, described i t as a more or less permanent personality t r a i t . This i s in contradiction to Seeman1s (1959/1972) own viewpoint. Linking the subtheme with Rotter's s o c i a l learning theory, she stated that i f powerlessness was high, learning was adversely affected. This would obviously influence the teaching nurses did with patients. If a nurse recognized the powerlessness of a patient who was extremely dependent, the nurse might be better able to cope with the s i t u a t i o n . Johnson thus applied the concept d i r e c t l y to nursing prac-t i c e though, l i k e Bloch (1978), she did not formulate her own d e f i n i t i o n of the concept. Roberts (1978) , l i k e D. Johnson (1967) , addressed powerlessness as a va r i a t i o n of Seeman's conception of alienation and described two causes: a lack of knowledge or a loss of psychological, physical, or environmental con-t r o l . Due to the feelings of powerlessness experienced by a patient, his or her behaviour may be altered. One of the behavioural p o s s i b i l i t i e s described was "acting out" and elopement was i d e n t i f i e d as acting out by some of the authors quoted i n Chapter One. Roberts' work i s useful due to her suggestions on how the nurse can help the patient reduce the experience of ali e n a t i o n . Conceptual frameworks for subjective a l i e n a t i o n . Keniston (1972) has attempted to define subjective alienation 30 on the basis of four facets: focus, replacement, mode, and agent. Focus asks from what i s the person alienated; re-placement asks what replaces the old relationship; mode asks how i s the alienation shown; and agent asks who or what decided on t h i s f e e l i n g . Keniston used alienation to refer only to those situations which the ind i v i d u a l has chosen to rej e c t . His use of the term thus excluded such situations as a person being rejected by an i n s t i t u t i o n or another i n -d i v i d u a l . This i s a s i g n i f i c a n t departure from some of the d e f i n i t i o n s . Manderscheid (1981) formulated a biopsychosocial model which viewed alienation as a method of coping with stress. This model i s being discussed under the heading of subjective a l i e n a t i o n as i t allowed f o r i n d i v i d u a l v a r i a t i o n i n psycho-l o g i c a l and physiobiochemical reactions to stress: Alienation was conceptualized as an intervening variable contingent on the dynamics of s o c i a l structure and antecedent to perceptual s t y l e . . . and alienation was viewed as a successful form of coping with stress. (p. 178) This model i s noteworthy for four reasons: i t acknowledges both subjective and objective alienation; i t addresses both overt and covert responses to stress; i t states that i n d i -viduals need not be aware of th e i r stress; and i t views ali e n a t i o n as p o s i t i v e . Shoham (1976) viewed subjective a l i e n a t i o n within an ontological framework. In his personality theory, people were inevitably alienated due to the three developmental stages of b i r t h , the formation of an ego boundary, and the 31 s o c i a l i z a t i o n process: After these [developmental stages] the i n d i v i d u a l i s on h i s own, o n t o l o g i c a l l y lonely and try i n g desperately to regain the togetherness of his l o s t f o l d . In t h i s u p h i l l climb, the i n d i v i d u a l may choose either legitimate or i l l e g i t i m a t e paths, either s t r i c t l y acceptable or deviant avenues, (p. 106) In t h i s conceptualization, then, people are alienated and they cannot a l t e r t h i s f a c t . Application of the concept to the therapeutic milieu. F. Johnson (1976) employed a phenomenological approach i n his psychotherapy with schizoidal patients. These severely withdrawn individuals were viewed as experiencing a s e l f -a l i enation with ontological concerns at the crux of t h e i r experiences. As well as f e e l i n g a sense of being overwhelmed by a l l about them, they f e l t a purposelessness in t h e i r actions. By emphasizing the d i r e c t i o n given by phenomenology, Johnson focussed on in t e r a c t i v e techniques such as examining the meaning of the experience for the patient and using empathy and closeness i n his treatment. Johnson thus re-lated alienation to patients with a p a r t i c u l a r p s y c h i a t r i c diagnosis and he used himself as the major therapeutic t o o l . Carser and Doona (1978) addressed alienation as a p r i -marily subjective experience which can be e i t h e r p o s i t i v e or negative for the i n d i v i d u a l . The concept was used by the authors to help t h e i r nursing students to become more aware of alienation as i t affected themselves and t h e i r patients. 32 In a very b r i e f vignette, Aspy (1972) described the experience of an i n d i v i d u a l who was admitted to hospital for cataract surgery. A sense of bewilderment and a loss of con-t r o l were c l e a r l y outlined as a r e l a t i v e l y healthy person was processed into the role of a patient. Literature Concerning Objective Alienation Schaff (1980) wrote that to define both subjective and objective a l i e n a t i o n by using the same noun creates a d i f f i -c u lty because the two concepts are quite d i f f e r e n t . He suggested that a d i f f e r e n t term for each would help to c l a r i f y the s i t u a t i o n . He viewed a connection between the two, though, as subjective alienation was seen as a derivative of objective a l i e n a t i o n . To Schaff, dealing only with subjec-tive alienation did not convey a true understanding of a s i t u a t i o n : "Objective alienation i s always primary, the process of change starts with i t , which l a t e r leads to v a r i -ous forms of subjective a l i e n a t i o n " (p. 66). The writings of Marx ( F i n i f t e r , 1972) are considered the c l a s s i c works on objective a l i e n a t i o n . Because his writ-ings focussed on the work force, many of the current a r t i c l e s continue to r e f l e c t t h i s influence. Due to the fact that the researcher i s interested i n objective alienation as i t re-lates to patients, t h i s aspect of the concept w i l l not be emphasized. There are, however, two c r u c i a l points: 1) there i s inequality i n the d i s t r i b u t i o n of valuable resources (Nowakowska, 1981); 2) because of the v e r t i c a l hierarchy i n 33 most bureaucracies, with control held by only a few i n d i -viduals, people who are at the bottom of an organization are often powerless to a f f e c t what occurs (Cherns, 1981; Olsen, 1976). "Alienation.means a s o c i a l s ituation which i s beyond the control of the actor, and hence, unresponsive to his basic human needs" (Etzioni, 1968, p. 879). E t z i o n i stated that a certain degree of alienation was in e v i t a b l e : i n meet-ing one need, another need might be thwarted. He also saw, however, that most forms of alienation were reducible. Alienation could usually be decreased through the r e d i s t r i b u -t i o n of power or through the development of soc i o c u l t u r a l patterns which would be more responsive to human needs. E t z i o n i ' s viewpoint again demonstrates the idea that some external force i s negatively a f f e c t i n g the degree of control held by an i n d i v i d u a l . E t z i o n i (1968) also addressed the way in which the structures of organizations a f f e c t people. An authentic s o c i a l condition was one which appeared to be, and struc-t u r a l l y was, responsive to human needs. Some structures were seen as being inauthentic: while they gave the appear-ance of being responsive to needs, the underlying structure did not permit t h i s . An important point i s being made i n t h i s work. While groups may say one thing, t h e i r actions may not be congruent with t h e i r stated philosophies. A highly a l i e n a t i n g s i t u a t i o n can then r e s u l t . F. Johnson (1973c) devised a table for r e l a t i n g the 34 l e v e l of s o c i a l relationships or associations to the exper-iences of a l i e n a t i o n . The t h i r d l e v e l of t h i s f i v e t i e r e d table dealt with i n s t i t u t i o n a l relationships and described the association between an i n d i v i d u a l and an organization to which he or she belonged. An i n d i v i d u a l was seen as i n -fluenced by parts of an organization which the person never dealt with d i r e c t l y . To a certain extent, alienation was seen as i n e v i t a b l e i n a s o c i a l organization, but: This basic and inevitable estrangement i s either ampli-f i e d or minimized by the degree to which the i n d i v i d u a l p a r t i c i p a t e s i n and i d e n t i f i e s (at a symbolical level) with the o v e r a l l purposes, ethi c s , and norms of the larger organization. If one's status and i d e n t i f i c a t i o n within the i n s t i t u t i o n are agreeable, then the exper-ience of both s o c i a l and psychological alienation would be minimized. Conversely, i f one's status i s f e l t to be i n s i g n i f i c a n t , or i f one i s c o n f l i c t e d about the goals of the i n s t i t u t i o n (or finds such goals meaningless), the sense of alienation would be high. (p. 375) As i n E t z i o n i ' s viewpoint, al i e n a t i o n i s i n e v i t a b l e , but the degree of alienation can vary with the organization and the i n d i v i d u a l ' s " f i t " with that organiqation. In summary, objective a l i e n a t i o n can be viewed as a "lack of f i t " between an i n d i v i d u a l and some structure to which he or she belongs. This lack usually involves a valu-able resource such as control, of which there i s only a limited amount. Writings r e l a t i n g objective alienation and the health care system. Geiger (1975) described his experience when he was hospitalized on the unit on which he was an intern: At one moment I was a physician: e l i t e , t e c h n i c a l l y s k i l l e d , vested with authority, wielding power over 35 others, a f f e c t i v e l y neutral. The next moment I was a patient: dependent, anxious, sanctioned i n an i l l -ness only i f I was cooperative. A protected depen-dency and the promise of e f f e c t i v e technical help were mine--if I accepted a considerable degree of psychological and s o c i a l servitude.... If I had to choose between having my i l l n e s s accurately diag-nosed and competently treated or having my emotional needs as a patient f i l l e d , I would choose the former every time. (pp. 13-15) Geiger's writing i s important for a number of reasons. In describing his subjective f e e l i n g state when his role changed, he openly acknowledged his former power which was stripped when he became a patient. He also i n d i r e c t l y i n d i -cated that the primary purpose of the health care system was to deal with the immediate problem. The psychological i n t e g r i t y of the patient, while a pleasant nicety, was a secondary requirement. Geiger (1975) viewed four sources of humanizing or de-humanizing elements i n health care: sources i n the s o c i a l order or general society; sources i n our r a t i o n a l , s c i e n t i f i c approach to the world; sources i n the subculture of the health professions; and sources i n p o l i t i c a l movements t r y -ing to a f f e c t health care. He, too, l i n k s the experience of the patient to the larger s o c i a l order just as the authors describing objective a l i e n a t i o n linked a person's experience to the larger s o c i a l order. Howard's (1975) approach was generally consistent with that of Geiger. She saw the dehumanization i n health care not as an individual's problem, but as a r e f l e c t i o n of the organization of medical work and the process of sickness. 36 Torrance (1981) described the growth of hospitals i n Canada "from small, simple organizations to large, bureau-cratized, technologically complex industries" (p. 254). Coburn, D'Arcy, New, and Torrance (1981) saw the Canadian health care system as oriented to cure, rather than the physical, mental, and s o c i a l well being of the i n d i v i d u a l : There i s l i t t l e attempt to view health as related to the l i f e experiences of d i f f e r e n t s o c i a l classes, as deeply indicated i n issues of health i n the work-place, with income inequality, or as related to broad s o c i e t a l goals and s o c i a l policy generally....The health sector has been changing from a "cottage" i n -dustry to a complex, technologically sophisticated, bureaucratic industry, with a highly r a t i o n a l i z e d d i v i s i o n of labour. The system i s s t i l l i n the midst of these processes of reorganization, r a t i o n a l i z a t i o n , and bureaucratization. The h o s p i t a l , the central health-care i n s t i t u t i o n , more and more resembles other i n d u s t r i a l , service, and welfare bureaucracies, as the technocrats seek to apply the c u l t of e f f i c i e n c y to the care and cure of the sick. (p. 439) Two important elements are noted i n t h i s a r t i c l e : the health care system was viewed as a bureaucracy with an emphasis on e f f i c i e n c y and the primary goal of the health care system was again seen as the cure of the immediate problem. Though Kaluzny, Warner, Warren, and Zelman (1982) are describing the American system, they r e i t e r a t e the viewpoint of Coburn et a l . (1981). As health services have to prove managerial accountability, p a r t i c u l a r l y i n f i n a n c i a l matters, s t a f f and patients may be adversely affected. They fear that health care workers may face an increased chance of "burnout" and that patients w i l l increasingly face a r b i t r a r y and fixed rules. These authors address the p o t e n t i a l l y harm-f u l e f f e c t s of bureaucracy on both patients and s t a f f . 37 While the general consensus i s that the health care system holds the greatest amount of power, Numerof (1982) wrote that some of t h i s control may now be s h i f t i n g to the patient, at l e a s t i n the United States. People are expect-ing more of health care, s o c i a l i n s t i t u t i o n s i n general are being c r i t i c i z e d , and consumers are increasingly expressing t h e i r displeasure through such actions as lawsuits. Con-sumers are thus making a more concerted e f f o r t to have t h e i r needs met. Twaddle's (1982) work has shown a strong connection be-tween alienation and the health care system: Alienation and autonomy are linked by the central issue of resource c o n t r o l . The more any group gains control over an important set of resources (e.g. the means of production), the more any other group i s barred from meaningful decision making (e.g. the more that group i s alienated). This r e f e r s , of course, to objective a l i e n a t i o n . (p. 336) Twaddle saw that i n four d i s t i n c t areas where physicians had a high degree of professional autonomy, patients had a correspondingly high degree of a l i e n a t i o n . Two of the four areas are p a r t i c u a r l y relevant to t h i s discussion and are t y p i c a l of the health care system i n general. The two are c l i n i c a l c o n t r o l / a l i e n a t i o n and organizational c o n t r o l / a l i e n a t i o n . The element of c l i n i c a l control cannot be eliminated or underestimated. Professionals i n the health care f i e l d have a specialized knowledge which patients do not have. In t h i s sense, the professionals have a monopoly. While the sense of a l i e n a t i o n due to c l i n i c a l control can be reduced, 38 i t i s i n e v i t a b l e : Any i n s t i t u t i o n s , which serve to promote the a t t a i n -ment of a wide range of human values, e s s e n t i a l l y involve an inequitable d i s t r i b u t i o n of powers, re-serving forms of influence and control to some while denying them to others. And by seizing upon the existence of avoidable forms of powerlessness i n such cases, while neglecting to consider the contexts i n which they occur, the significance of the i n s t i t u -tions of which they are features i s only too e a s i l y misunderstood. (Schacht, 1978, p. 433) The above i s c r u c i a l to t h i s study. Because the professionals i n the health care f i e l d do have a specialized knowledge, they may make decisions about patients which do not make sense or have meaning for them. The safety and the care of the patient must be maintained, thus c l i n i c a l control can be shared, but only to a certain degree. However, c l i n i c a l decisions can and should be explained and discussed with the patients so care does have more meaning and the p o t e n t i a l for a l i e n a t i o n may be decreased. Organizational control refers to the settings i n which health care i s provided. Most care i s now provided i n the formal health care setting rather than the patient's home. As such, the patient i s in someone else's t e r r i t o r y and automatically has decreased control as a r e s u l t : "Proce-dures are set for the convenience of the s t a f f , which often maximize inconvenience to the patients" (Twaddle, 1979, p. 168). I t i s i n t h i s realm where more adjustments might be made to accommodate patients. Summary of the l i t e r a t u r e on objective a l i e n a t i o n . Objective a l i e n a t i o n i s due to conditions i n the sociocul-39 t u r a l s e t t i n g . I t appears i n many o r g a n i z a t i o n s due to the v e r t i c a l h i e r a r c h y which allows a small number of people to have a d i s p r o p o r t i o n a t e amount of c o n t r o l . A c e r t a i n amount of a l i e n a t i o n i s i n e v i t a b l e , however. The primary g o a l o f the . h o s p i t a l i s s t i l l the management of the immediate problem o f the p a t i e n t . To provide e f f e c -t i v e c are, the members of the h e a l t h care team r e t a i n c l i n i -c a l c o n t r o l . Because the h o s p i t a l has become a l a r g e bureau-c r a c y w i t h an emphasis on e f f i c i e n c y , r e c o g n i t i o n of the needs of the p a t i e n t has assumed a low p r i o r i t y . In areas such as o r g a n i z a t i o n a l c o n t r o l which c o u l d be shared the p a t i e n t has l i t t l e i n p u t . P r e s e n t a t i o n and D i s c u s s i o n o f the Accounts of the P a r t i c i p a n t s T h i s s e c t i o n of the chapter d e s c r i b e s how the p a r t i c i -pants i n the study viewed t h e i r own elopements. While the focus was i n i t i a l l y on the behaviour being i n v e s t i g a t e d , other i n f o r m a t i o n r e l a t e d t o t h e i r h o s p i t a l i z a t i o n and to t h e i r p e r s o n a l l i v e s emerged. These data have been woven i n t o the accounts and the d i s c u s s i o n o f the accounts because they help to c l a r i f y the purposes of t h i s study: to de-s c r i b e the p a t i e n t s ' p e r c e p t i o n s of what l e d to t h e i r e l o p e -ments; t o d e s c r i b e how p a t i e n t s view t h e i r e xperiences of the elopements; to d e s c r i b e what purpose p a t i e n t s f e e l the elopements served f o r them; and to analyze the s u b j e c t i v e experiences of p a t i e n t s w i t h i n the broader s o c i o c u l t u r a l c o n t e x t . The purposes are r e l a t e d to Seeman's f i v e c a t e -40 gorizations of subjective a l i e n a t i o n . These categories have been u t i l i z e d to "make sense" of the experience of elopement. The researcher chose Seeman's work as a framework for the discussion of the p a r t i c i p a n t s ' accounts for three s p e c i f i c reasons: i t i s considered a c l a s s i c work and i s thus f a m i l i a r to a great number of people; i t made no pretences to the absolute answer on the topic; and i t can be readily u t i l i z e d and understood. As one i l l u s t r a t i o n of how the subjective experiences of the participants can be linked to the objective surround-ing conditions, Goffman's writing w i l l be used. In h i s c l a s s i c work, Asylums, Goffman (1961) defined a t o t a l i n s t i t u t i o n as "a place of residence and work where a large number of l i k e - s i t u a t e d i n d i v i d u a l s , cut o f f from the wider society for an appreciable period of time, together lead an enclosed, formally administered round of l i f e " (p. x i i i ) . He saw that "The handling of many human needs by the bureaucratic organization of whole blocks of people... i s the key fact of t o t a l i n s t i t u t i o n s " (p. 6). Many of the features of a t o t a l i n s t i t u t i o n , as defined by Goffman, were described by the participants i n t h i s study: Features of a t o t a l i n s t i t u t i o n Comments of the participants Staff and patients see each other i n stereotypes, with s t a f f t y p i c a l l y seen as superior, and with patients t y p i c a l l y seen as i n f e r i o r . Decisions are usually made about the patients without t h e i r input. "Who i s h e l p f u l here? The cleaners at l e a s t talk to you. That's better than most people here." "They changed my room. I was happy where I was, but I had to go." 41 Features o f a t o t a l i n s t i t u t i o n Comments o f the p a r t i c i p a n t s P a t i e n t s are p l a c e d i n the p o s i t i o n of having to ask f o r everyday t h i n g s . P a t i e n t s see themselves as un-able to e x e r t autonomy. A p r i v i l e g e system o f r u l e s encourages co n f o r m i t y . To be r e l e a s e d from the i n -s t i t u t i o n , one must be "good." A s p e c i a l language i s o f t e n a s s o c i a t e d with the i n s t i t u -t i o n . "Messing up," or doing some-t h i n g which i s f o r b i d d e n , can be a means of p u r p o s e f u l l y p r o l o n g i n g a stay i n the i n s t i t u t i o n . A t h e r a p e u t i c stance o f t e n e x i s t s t h a t f o r the p a t i e n t s to become b e t t e r , they must adopt a new way o f behaving. "Um, no, I asked p e r m i s s i o n to leave to go shopping." "I j u s t l i s t e n to what I'm t o l d and t h a t ' s i t . " " [ S i n c e my elopement], they won't change my phase, they won't even c o n s i d e r i t . " " I t pays not to complain." "I've asked f o r a change i n my phase." "I took o f f from here because I had my p r i v i l e g e s and e v e r y t h i n g and they were going to r e l e a s e me." " I t seems to me they wanted me to change my whole l i f e . They gave me a whole page of problems." Obvio u s l y , many o f the f a c e t s o f Goffman's d e s c r i p t i o n of a t o t a l i n s t i t u t i o n are r e l a t e d to the p a r t i c i p a n t s ' exper-i e n c e s i n the h o s p i t a l . There i s a s t r o n g l i n k a g e of the s u b j e c t i v e f e e l i n g s to the o b j e c t i v e s t r u c t u r e of the h e a l t h care system. Other w r i t e r s have a l s o d e s c r i b e d t h i s phenome-non as w i l l be i n d i c a t e d i n the d i s c u s s i o n s which f o l l o w . Powerlessness. Seeman (1959/1972) d e s c r i b e d powerless-ness as probably being the most common form of a l i e n a t i o n . Defined as "the expectancy or p r o b a b i l i t y h e l d by an i n d i -v i d u a l t h a t h i s own behaviour cannot determine the occurrence of the outcomes, o r r e i n f o r c e m e n t s , he seeks" (p. 4 6 ) , 42 powerlessness does not r e f l e c t the value o f the c o n t r o l f o r the person. Seeman saw powerlessness i n terms o f man's r e -l a t i o n s h i p to the l a r g e r s o c i a l o rder. In- t h i s study, i t has been i n t e r p r e t e d i n r e l a t i o n s h i p t o any events surround-i n g the person. Powerlessness was the most f r e q u e n t l y o c c u r r i n g v a r i a -t i o n of a l i e n a t i o n i n t h i s study. Instances were r e a d i l y apparent with each of the p a r t i c i p a n t s and these i n s t a n c e s w i l l be d e s c r i b e d i n three c l u s t e r s : s i t u a t i o n s surrounding the p a t i e n t ' s admission to the h o s p i t a l ; s i t u a t i o n s d i r e c t l y l i n k e d t o the elopement; and s i t u a t i o n s surrounding the treatment and management of the p a t i e n t . Four o f the p a r t i c i p a n t s saw someone other than them-s e l v e s as being i n s t r u m e n t a l i n t h e i r admission to h o s p i t a l . Doctors, w e l f a r e workers, and s i g n i f i c a n t o t h e r s were a l l c i t e d a t l e a s t twice as c o n t r i b u t i n g to the h o s p i t a l i z a t i o n of the p a t i e n t s . Only one person had f r e e l y chosen to e n t e r h o s p i t a l , and she had the o p p o s i t e problem: " I t took me two years to get the help I need." Of the f o u r p a r t i c i p a n t s who were r e l u c t a n t , three acknowledged they were having p r o -blems, but they a l s o f e l t these problems d i d not warrant admission. One p a r t i c i p a n t denied he was having any problem, and he o b v i o u s l y thought he should not have been h o s p i t a l i z e d . The f o u r p a t i e n t s f e l t they had i n some way been coerced i n t o h o s p i t a l i z a t i o n by e i t h e r the t h r e a t of withdrawn f i n a n c i a l support or the t h r e a t of withdrawn l i v i n g q u a r t e r s : P ( a r t i c i p a n t ) : W e l l , I knew, I knew I'd have to come here u n t i l I, the government s o r t of f o r c e s me to 43 come here because I can't go anywhere e l s e . I can't get w e l f a r e , wh-, when welfar e wants me to be i n the h o s p i t a l , r i g h t ? So how am I going to do f i n a n c i a l l y , I'm n-, I'm not w e l l enough to go to work r i g h t now. I have no p l a c e to say, s t u f f l i k e t h a t . R ( e s e a r c h e r ) : Sounds l i k e you were f e e l i n g some p r e s -sure then, you saw i t as being --P: — a b o u t the o n l y p l a c e I c o u l d go. Thus, f o u r o f the p a r t i c i p a n t s f e l t they d i d not even have c o n t r o l over t h e i r admission t o h o s p i t a l . D e c i s i o n s by ot h e r s and p e r c e i v e d t h r e a t s p l a c e d them i n a s i t u a t i o n i n which they d i d not want t o be. Both i n t e r a c t i o n s w i t h s t a f f and events which o c c u r r e d i n the h o s p i t a l were l i n k e d w i t h s i t u a t i o n s which caused f e e l i n g s o f powerlessness i n the p a r t i c i p a n t s . With two of the p a r t i c i p a n t s , a s p e c i f i c i n c i d e n t which c o u l d be i n t e r -p r e t e d as r e l a t i n g t o the p a t i e n t ' s f e e l i n g s of powerlessness sparked t h e i r elopements. In two other cases, f e e l i n g s of powerlessness r e l a t e d to the care or treatment being r e c e i v e d l e d t o the unsanctioned l e a v i n g o f the h o s p i t a l . One p a t i e n t l e f t the h o s p i t a l a f t e r h i s request f o r d i s -charge had been denied by the d o c t o r . Since the committal papers had been signed by h i s w i f e , he f e l t she should be able t o d i s c o n t i n u e them and thus f r e e him: P: She [ h i s w i f e ] d i d n ' t want... she d i d n ' t want... to h elp out... R: And when she d i d n ' t want to help out, how d i d t h a t make you f e e l ? P: P r e t t y bad. R: P r e t t y bad. 44 P: Angry I R: Okay, so you got angry t h a t she wouldn't stand up f o r you — P: She knows t h a t I'm committed, r i g h t ? She knows t h a t I can't j u s t walk out. She c o u l d j u s t t e a r up the papers l i k e I wanted her t o . She signed me i n , and I s a i d she cou l d j u s t s i g n me out! In t h i s i n s t a n c e , the p a t i e n t was very aware o f h i s i n v o l u n -t a r y s t a t u s as he was admitted "on papers." Having been r e -fused d i s c h a r g e by h i s d o c t o r h i s " l a s t hope" was to e n l i s t the a i d o f h i s w i f e . With her r e f u s a l to h e l p him, he ran o f f the u n i t . He was powerless to take charge o f h i s own l i f e and he had been powerless i n h i s attempts to sway her. Another dramatic i n c i d e n t surrounds the case o f a young woman who eloped a f t e r another p a t i e n t t r i e d to p h y s i c a l l y harm her: R: What happened t h a t made you decide to leave h o s p i t a l ? P: When I got i n t o her room she grabbed me by the t h r o a t w i t h one hand and squeezed hard. I got r e a l l y scared and h i t her and ran back to my room ....The nurses came and asked what was wrong. I t o l d them and they d i d n ' t b e l i e v e me. They s a i d t h a t ' s not t r u e , she's not v i o l e n t . I got r e a l l y upset and thought why am I here i f nobody b e l i e v e s me. Thus, the p a t i e n t was suddenly c o n f r o n t e d w i t h a s i t u a t i o n over which she had no c o n t r o l . When she sought the support of the s t a f f , they compounded her f e e l i n g s o f powerlessness by not t a k i n g her concerns s e r i o u s l y . As a r e s u l t , the p a t i e n t ' s p e r c e p t i o n o f the n u r s i n g s t a f f was n e g a t i v e l y a f f e c t e d : 45 P: I was r e a l l y angry when I took o f f . I had a headache t h a t j u s t throbbed. I f they'd t r i e d to stop me, I'd have taken o f f again as soon as I had the chance. R: Who were you angry a t when you l e f t ? P: The nurses and [ p a t i e n t who t r i e d to harm h e r ] , but mainly the nurses. She has a problem, t h a t ' s why she's here, but supposedly the s t a f f has i t together. Two other p a t i e n t s , w h ile not having such dramatic events which sparked t h e i r d e parture, d e s c r i b e d f e e l i n g s of powerlessness over t h e i r treatment which d i r e c t l y c o n t r i b u t e d t o t h e i r elopement. One p a t i e n t , who had a parent who was c o n t i n u a l l y being admitted to h o s p i t a l f o r p s y c h i a t r i c c a r e , was very preoccupied w i t h the medications she was r e c e i v i n g . She wondered about the s i d e - e f f e c t s , the p o s s i b i l i t y o f a d d i c t i o n , how long she would be t a k i n g the drugs, and the e f f e c t o f the medications on her l i f e when she was di s c h a r g e d . She s t r o n g l y f e l t drug treatment was i n a p p r o p r i a t e f o r her, and t h a t what she r e a l l y r e q u i r e d was c o u n s e l l i n g as she wasn't " s i c k enough" to warrant h o s p i t a l i z a t i o n : R: Okay. Had you t o l d t h i s t o people here, had you t o l d t h i s to the doct o r t h a t you're working with, or the nurses t h a t you're working with? P: Umm, yeah, but they don't, they j u s t don't, they t h i n k I'm a hapychondriac ( s i c ) . Even when the p a t i e n t attempted t o n e g o t i a t e treatment with the s t a f f , she f e l t she had no impact. She l e f t the i n t e r -a c t i o n w i t h the sense she d i d not have c o n t r o l over what was being done to t r e a t her. Another p a t i e n t l e f t h o s p i t a l because of her p e r c e i v e d 46 i n a b i l i t y to i n f l u e n c e her l e n g t h of s t a y i n the i n s t i t u t i o n . She knew i f she was di s c h a r g e d , she would r e t u r n home: P: I took o f f from here because I had my p r i v i l e g e s and e v e r y t h i n g and they were going to r e l e a s e me t o the o u t s i d e world and I wasn't ready f o r i t . R: So they were gonna l e t you go and you d i d n ' t want t o go. P: Yeah. I t was too e a r l y . No p l a c e to go but home, and look at i t . I t ' s f u l l o f headaches, p a i n , and sorrow. But i f you're i n a home-like boarding home, it' 1 1 be n i c e . R: What headaches and sorrow? P: My dad i s mean—he beat me up l a s t week. Bad news bears, r i g h t ? He s t a r t e d s l u g g i n g me which i s why I was black and blue when you saw me. My dad's an a l c o h o l i c and my mum's a p i l l f r e a k . The p a t i e n t , who was powerless t o d e a l w i t h the s i t u a t i o n at home and powerless to extend her stay i n the h o s p i t a l , ran away. In the f o u r i n s t a n c e s c i t e d , a sense of powerlessness over the events i n the h o s p i t a l l e d to the elopement of the p a t i e n t . In each case, though other concerns were a l s o p r e -sent, none were as paramount as the events a l r e a d y d i s c u s s e d . An i n a b i l i t y to n e g o t i a t e w i t h s t a f f was d e s c r i b e d i n each s i t u a t i o n , though t h i s i n a b i l i t y was not n e c e s s a r i l y the p r e c i p i t a t i n g f a c t o r . In each i n s t a n c e , the p a t i e n t s t a t e d she t r i e d t o e x p l a i n the concern to a t l e a s t one s t a f f member. R: Had you asked them b e f o r e you took o f f about s t a y i n g here? P: Yuh. R: What d i d they say? P: No way, Jose. 47 A s e r i e s o f i n c i d e n t s which c o u l d be i n t e r p r e t e d as i n -v o l v i n g powerlessness were r e l a t e d to the treatment and the management o f the p a r t i c i p a n t s while i n the h o s p i t a l . Some of the i n c i d e n t s were p e r c e i v e d by the p a t i e n t s as being more c r u c i a l than o t h e r s and these c r i t i c a l occurrences tended to be those i n v o l v i n g o t h e r people. I t was annoying to have a n o i s y environment; i t was b o r i n g to have a l a c k o f a c t i v i t i e s ; and i t was f r u s t r a t i n g t o have one's c l o t h e s l o s t i n another h o s p i t a l , but i t c r e a t e d f e e l i n g s of power-l e s s n e s s when one c o u l d not o b t a i n the reinforcement one sought from o t h e r s . P a t i e n t s f e l t the wards were run i n such a way t h a t , while they were t o l d they had i n p u t i n t o decision-making, t h e i r a c t u a l c o n t r o l was v e r y l i m i t e d . Two p a r t i c i p a n t s d e s c r i b e d t h i s as being more f r u s t r a t i n g than being t o l d they had no power: " I f they're honest, I can l i v e w i t h t h a t . I t ' s when they pretend, you know." The p a t i e n t then de-s c r i b e d how she was t o l d her medications wouldn't be a l t e r e d u n l e s s she was informed -- and then her dosage of h a l o p e r i d o l was i n c r e a s e d . Comments r e f l e c t i n g powerlessness i n t h e i r everyday l i v e s on the ward were frequent: " I f I get too upset, they j u s t g ive me a shot;" "I'm t i r e d o f the l i t t l e baby s t a f f — they don't l i s t e n ; " "What can you do? Sweet no t h i n g . They've got you;" "They want a break, so they s t i c k me i n my room;" "Doctors got the a u t h o r i t y and nurses don't. The nurses get p i s s e d o f f and f r u s t r a t e d and take i t out on us. We're the bottom l i n e ; " and "The student nurses 48 are.-here now. They're always w r i t i n g s t u f f down, r i g h t i n f r o n t o f me. Where does t h a t s t u f f go?" T h i s sense of r o u t i n e l a c k o f c o n t r o l i s w e l l i l l u s t r a t e d i n the f o l l o w i n g example. A p a t i e n t d e s c r i b e d how she r e -quested a change i n her p r i v i l e g e l e v e l a f t e r she eloped. She f o l l o w e d the p r o t o c o l as o u t l i n e d , but her request was not brought up a t the a p p r o p r i a t e meeting. When the s t a f f was questioned, an e x p l a n a t i o n was giv e n , "but they should have t o l d me beforehand, not j u s t i g n o r e d my request." The p a t i e n t s f r e q u e n t l y d i s a g r e e d w i t h the nature o f t h e i r treatments, e s p e c i a l l y when medications were i n v o l v e d . The amount and types o f medications were f r e q u e n t l y l i s t e d as i s s u e s where the p a t i e n t s had u n s u c c e s s f u l l y t r i e d to ga i n c o n t r o l . J u s t as the p a t i e n t s p e r c e i v e d a l a c k of c o n t r o l over t h e i r treatment, they a l s o p e r c e i v e d a l a c k o f c o n t r o l over the i n f o r m a t i o n which r e l a t e d t o them. One p a t i e n t s t a t e d he d i s a g r e e d w i t h h i s d i a g n o s i s , but he knew he c o u l d not change i t ; another p a r t i c i p a n t s t a t e d t h a t " t h i n g s " put on a r e p o r t c o u l d i n f l u e n c e h i s l e n g t h o f st a y i n h o s p i t a l , but t h a t he h i m s e l f d i d not have i n p u t i n t o the r e p o r t . In two d i f f e r e n t s i t u a t i o n s , s t a f f members made e r r o r s which r e s u l t e d i n the p a t i e n t s having to d e a l with the con-sequences. In one i n c i d e n t , a p a t i e n t ' s s l e e p i n g medica-t i o n was d i s c o n t i n u e d f o r three or four n i g h t s . She doggedly pursued the i s s u e , and indeed t h e r e had been an e r r o r . Her f r u s t r a t i o n l a y i n the f a c t she had to co n t a c t three s t a f f 49 members before someone r e c t i f i e d the s i t u a t i o n : " A l l they had to do was check my c h a r t p r o p e r l y . " In another s i t u a t i o n , the p a t i e n t who had been p h y s i -c a l l y abused by her f a t h e r had requested no v i s i t o r s : P: I t o l d , s t r i c t l y t o l d the nurses t h a t I d i d not want to see my f a m i l y . He [Dad] came up with . I was r e a l l y upset about t h a t because I t o l d the nurses I d i d not want any con-t a c t w i t h the f a m i l y . I f e e l i t was t h e i r r e -s p o n s i b i l i t y . They had i t i n t h e i r c h a r t s t h a t I have no v i s i t o r s . So I don't t h i n k i t was f a i r a t a l l . I thought, " S h i t , i s he going to h i t me, or what?" In both i n s t a n c e s , s t a f f d i d not f u l f i l l the s a f e g u a r d i n g r o l e which the p a t i e n t s expected. Two of the f i v e p a r t i c i p a n t s were r e t u r n e d to the h o s p i -t a l on committal papers. Of the three o t h e r s , o n l y one per-son, the i n d i v i d u a l who had v o l u n t a r i l y e n t e r e d the h o s p i t a l , f e l t p o s i t i v e about her d e c i s i o n to r e t u r n : "I wanted to get help i f they'd have me back." The other two p a r t i c i p a n t s r e t u r n e d because they had nowhere e l s e to go. T h i s i n t e r -a c t i o n concluded the second i n t e r v i e w with one o f these two: R: Ok, have you thought about l e a v i n g here i n the pa s t week? P: Yeah. R: Uh - huh. And d i d you a c t u a l l y leave? P: No. R: What stopped you from going? P: Nothing. R: Nothing? You must have stopped y o u r s e l f i n some way. Why d i d you decide not to go? P: Uh, because I had no p l a c e to go and I s t i l l have no p l a c e to go u n t i l the end of the month. 5 0> One has the sense the p a r t i c i p a n t has completed a c i r c l e : he was powerless over h i s coming i n t o h o s p i t a l and he was powerless over h i s l e a v i n g . So f a r i n t h i s d i s c u s s i o n o f powerlessness, one i n c i d e n t of t h i s v a r i a t i o n o f a l i e n a t i o n has f o l l o w e d another. The theme o f powerlessness has been shown throughout the hos-p i t a l e x perience. How does t h i s theme blend with the a c t u a l elopements of the p a t i e n t s ? T h i s w i l l be the focus of the c o n c l u s i o n o f the d i s c u s s i o n . The p a r t i c i p a n t s i n t h i s study p e r c e i v e d themselves as powerless to a f f e c t what was happening i n t h e i r environment. I f the s o c i o c u l t u r a l s e t t i n g o f the p a t i e n t s i s examined, t h i s p e r c e p t i o n e x i s t e d because i t was true to a c e r t a i n ex-t e n t . The h o s p i t a l i s a h i e r a r c h y and i n a h i e r a r c h y people have d i f f e r e n t l e v e l s o f c o n t r o l . The p a t i e n t i s at the bottom o f the h o s p i t a l ' s h i e r a r c h y , and thus has l i m i t e d i n -put i n t o the system. The p a r t i c i p a n t s i n t h i s study, then, were simply aware o f t h e i r s i t u a t i o n . "We're [the p a t i e n t s ] the bottom l i n e . " Thus, as Twaddle (1979) has argued, i f some people have g r e a t e r access to a d e s i r e d resource such as c o n t r o l , those who have l e s s o f the resource may s t r u g g l e to o b t a i n a g r e a t e r p o r t i o n . The elopements of the p a r t i c i -pants were the v e h i c l e s to r e g a i n some c o n t r o l i n t h e i r l i v e s . A l l o f the p a r t i c i p a n t s s t a t e d they f e l t c o n s t r a i n e d or "hemmed i n " before they l e f t . Each of the f i v e p a r t i c i -pants s t a t e d the elopement was a p o s i t i v e event and, given s i m i l a r circumstances, they would r e a c t i n the same way a g a i n . 51 One of the p a r t i c i p a n t s preplanned her l e a v i n g by o b t a i n -i n g a pass: "I wanted to l i e , l i e , p u r p o s e l y l i e , because I wanted to leave h o s p i t a l . " Though she r e a l i z e d her e l o p e -ment might a f f e c t her p r i v i l e g e s , she wanted to leave to have some time alone and decide i f h o s p i t a l i z a t i o n was " r i g h t " f o r her: R: How was your mood when you were out? How were you f e e l i n g ? P: Um, p r e t t y happy. J u s t f e l t , you know, i t f e l t l i k e , f e l t r e a l l y good to be r e s p o n s i b l e , when I d i d go shopping. I f e l t r e a l l y r e s p o n s i b l e . An i n t e r e s t i n g t w i s t o c c u r r e d with the p a t i e n t who was a f r a i d t o be d i s c h a r g e d home. She knew t h a t i f she eloped, she would l i k e l y be kept l o n g e r i n h o s p i t a l . She had eloped from other h o s p i t a l s i n the p a s t . She, too, d e s c r i b e d the simple p l e a s u r e s of being out o f h o s p i t a l : R: What stands out most i n your mind about the time you were out of here? P: The freedom. R: T e l l me more about t h a t . P: The freedom to do what I want to do. Freedom to feed the c h i c k e n s . Make bacon and t o a s t . Eat r e a l food. The e x p e r i e n c e s were c o n s i s t e n t l y d e s c r i b e d as p r o v i d i n g freedom f o r the p a r t i c i p a n t s : "I c o u l d breathe f r e s h a i r again;" "I was r e s p o n s i b l e f o r myself;" " I t f e l t g o o d — I got r i d o f a l l the cobwebs;" and "Do you know how g r e a t i t was not having someone t e l l you when you c o u l d have a c i g a -r e t t e ? " Two of the p a r t i c i p a n t s d e s c r i b e d ways i n which they 52 increased t h e i r power in more than the sense of freedom dur-ing t h e i r elopements. One patient telephoned the unit twice while she was out on her elopement. Each time she stated she was returning and each time she delayed. Another patient t o l d the researcher that while he was on his elopement he had disarmed some nuclear warheads, but no one had thanked him. As a r e s u l t of t h e i r elopements, two of the patients, one of whom was on committal papers, had t h e i r p r i v i l e g e s decreased. One of these patients was the person who wished to stay i n hospital longer and the other patient stated the b r i e f freedom more than compensated for the "punishment." Three patients stated t h e i r p r i v i l e g e s were not reduced, but two of them described a l t e r a t i o n s i n medications as a r e s u l t . One of these three f e l t he i n d i r e c t l y gained p r i v i l e g e s be-cause the s t a f f was more w i l l i n g to l i s t e n to him when he returned. In summary, then, feelings of powerlessness were exper-ienced by a l l the participants i n t h i s study. Incidents i n -volving these feelings were frequent. One way i n which the participants handled these emotions was to leave the physical setting to gain a sense of control over t h e i r l i v e s again. Meaninglessness and i s o l a t i o n . Seeman (1959/1972) de-scribed meaninglessness as "the individual's sense of under-standing the events in which he i s engaged" (p. 5 0). When th i s form of alienation i s strong, the person i s n ' t sure what he or she ought to believe. As w i l l be seen i n t h i s 53 section of the chapter, instances of meaninglessness usually involved the patient's understanding of his or her programme or treatment. These same circumstances often r e f l e c t e d Seeman's (1959/1972) d e f i n i t i o n of i s o l a t i o n i n which the person "assign[s] low reward value to goals or b e l i e f s that are t y p i c a l l y highly valued i n the given society" (p. 52), assuming the given society i s the hospital setting. Because in many instances there i s an overlapping or intertwining, these two categorizations of alienation w i l l be dealt with simultaneously. The discussion of meaninglessness/isolation w i l l centre on three f o c i : the patient's perception of whether or not he or she should be i n the hospital; the formal treatment of the patient; and the programme i n which the patient i s en-gaged . At some point, a l l of the participants queried whether or not h o s p i t a l i z a t i o n was correct for them. As stated e a r l i e r , four of the participants f e l t they should not have been admitted to h o s p i t a l . The patients obviously perceived what was occurring i n t h e i r l i v e s d i f f e r e n t l y than the people who had aided t h e i r admission. I t i s assumed the patients' perceptions also d i f f e r e d from those of the caretakers i n the hospital who had admitted and treated them: P: Just the thought of being here....I don't l i k e i t . R: Okay. You don't l i k e being i n the hospital because? P: Yeah. R: Because? Because why? 54 P: J u s t , I j u s t don't t h i n k I should be here. R: Mmhmm. Why d i d you come i n t o h o s p i t a l ? P: Doctor sent me. I don't know why. R: You're not sure of the reason then. P: No. R: So you don't f e e l you should be here, and you don't know why you're here. P: Yeah. R: What does i t mean f o r you to be i n h o s p i t a l ? P: I j u s t don't l i k e i t . Another p a r t i c i p a n t e x p l a i n e d her presence i n h o s p i t a l t h i s way: R: Do you f e e l you need to be i n h o s p i t a l ? P: No....Oh, yeah, 'cause I'm c r a z y . Does t h a t sound good? How should we put i t f o r the tape? I'm , c r i m i n a l l y insane. Thank you. Does t h a t sound good? R: (Laughing) I'm ask i n g you do you f e e l you need to be here? P: That's a joke. I can't f i n d a room out t h e r e . I can't f i n d meals, so I may as w e l l stay here u n t i l I can f i n d my meals. Because they viewed the need f o r h o s p i t a l i z a t i o n d i f f e r e n t l y , the p a r t i c i p a n t s were a u t o m a t i c a l l y i n disagreement with o t h e r s (the s t a f f ) i n t h e i r environment. I f each s t a r t s from the cornerstone t h a t they are c o r r e c t and they p e r c e i v e the same s i t u a t i o n q u i t e d i f f e r e n t l y , a chasm must be breached i f understanding i s t o be achieved. The p a r t i c i p a n t s f r e q u e n t l y q u e r i e d i f t h e i r treatment was the " r i g h t one" f o r them. Three of the p a r t i c i p a n t s 55 asked the r e s e a r c h e r her o p i n i o n iabout t h e i r treatment. Be-cause they had r e s e r v a t i o n s about t h e i r treatment, they t y p i c a l l y a ssigned i t a low value and made suggestions as to how i t c o u l d be improved: P: I'm so concerned maybe I need some, a b i t of h e l p , you know. L i k e , I need c o u n s e l l i n g , but I don't need me d i c a t i o n , and p s y c h i a t r i c wards t h a t ' l l worsen my head, I think....I'm w o r r i e d more about medication and how I'm going to f e e l once I get out of h o s p i t a l , i f i t ' s going to do me any good. Another p a t i e n t , who f e l t a l l h i s medications but one should be d i s c o n t i n u e d , was convinced he had been misdiagnosed: "That means a l l of t h i s i s a l o t of crap. Then—mind you, h o s p i t a l i s a l o t o f crap." Much o f the d i f f i c u l t y seems to a r i s e from the f a c t t h a t d e c i s i o n s were made about the p a t i e n t s , but the p a t i e n t s p e r c e i v e d t h i n g s d i f f e r e n t l y . T h i s i s w e l l i l l u s t r a t e d w i t h a woman whose treatment i n c l u d e d a low stimulus e n v i r o n -ment: P: But now l i k e , they got me mad. R: Um, who's they? P: The nurses. "Come out every hour f o r a c i g a -r e t t e . " I don't need t h a t . I don't need t h a t s h i t . Who do they t h i n k they are to t e l l me what to do? S t a f f was g e n e r a l l y p e r c e i v e d as not being very h e l p f u l . P: They're j u s t k i d s . I'm 20, but I've l i v e d on the s t r e e t s . They haven't l i v e d out t h e r e . They have n i c e homes, n i c e p a r e n t s , n i c e f a m i l y . I have r o t t e n home, r o t t e n f a m i l y , r o t t e n f r i e n d s . R: So you f e e l ? P: They don't understand. 56 The r o l e of the s t a f f was not very c l e a r t o the p a t i e n t s e i t h e r : P: Um, I don't r e a l l y understand the s t a f f here, how they work, i f they're nurses or s e c r e t a r i e s or what. They're h e l p f u l on a one to one b a s i s but i n groups they look i n on us and w r i t e down notes. We don't get feedback from them r e a l l y , and I f e e l they should give us a l i t t l e more i n -s i g h t . They've been to s c h o o l . . . . The d o c t o r s here are j u s t l i k e f r i e n d s , they j u s t ask a l o t o f q u e s t i o n s . I don't see them very long. They're a l o t b e t t e r than nurses. I t can be seen t h a t i f people do not have an understanding o f each o t h e r , i t i s d i f f i c u l t t o make t h e i r needs known. An important t h r u s t i s being i l l u s t r a t e d . What has meaning f o r the s t a f f does not n e c e s s a r i l y have meaning f o r the p a t -i e n t . As s t a t e d i n Kleinman's (1978) model, those i n the p r o f e s s i o n a l s e c t o r have t h e i r own b e l i e f s , r o l e s , and expec-t a t i o n s which d i f f e r from the b e l i e f s , r o l e s , and expecta-t i o n s o f those i n the p o p u l a r s e c t o r . Thus, while the s t a f f saw the p a t i e n t ' s low stimulus programme as needed to reduce her manic .behaviour, she p e r c e i v e d i t as an i n f a n t i l i z i n g punishment. While the p a t i e n t s saw the r u l e s as r e s t r i c t i n g t h e i r freedom, the s t a f f saw the r u l e s as a means of s a f e -guarding the p a t i e n t s or as a means of e n s u r i n g the p a t i e n t s acted i n a r e s p o n s i b l e way. The p a r t i c i p a n t s ' l a c k of understanding about the r o l e of the nurse can a l s o be l i n k e d to t h e i r p e r c e p t i o n of the nurse. As has been shown and w i l l continue to be shown, many o f the p a t i e n t s ' statements expressed anger or f r u s t r a -t i o n w i t h the nurses. Comments about the d o c t o r s tended.to 57 be neutral or p o s i t i v e . The following i s a t y p i c a l state-ment by one of the p a r t i c i p a n t s : "I do not l i k e the nurses. There are some, nurses that are r e a l l y uptight....The doctors, they know what's wrong with you." U n t i l the researcher examined the s o c i o c u l t u r a l setting i n which the subjective experiences of the patients were l o -cated, i t was d i f f i c u l t to understand t h i s perception of the nurses. When examining the t r a n s c r i p t s , one of the partic i p a n t ' s comments led to the analysis being u t i l i z e d : "Doctors got the authority and nurses don't." The researcher then began an investigation of the l i t e r a t u r e on power: The more legitimate one i s perceived to be, the greater  the l i k e l i h o o d of compliance with one's attempts to  influence, and the less resentment of going along. Power goes to those who are seen as having a r i g h t to i t . Conversely, the less legitimate forms of i n -fluence breed resistance and resentment....The more  a person has access to c o n t r o l l i n g rewards and punish-ments, the greater his/her power. Thus a person who can give the formal rewards or use the formal punish-ments of an organization... w i l l have the most power.... Whatever i t i s that people value.or fear, those who control i t w i l l have power to influence behavior.... The more power attributed to a person, the more he/she  I s the re c i p i e n t of... deference by others seeking power. (Cohen, Fink, Gadon, & W i l l i t t s , 1976, pp. 196-197) On the basis of the verbalizations of the participants i n t h i s study and on the basis of the l i t e r a t u r e on power, one can hypothesize that physicians are imbued with l e g i t i -mate authority by patients. Doctors c e r t a i n l y control "re-wards" and "punishments" for the patients: they determine a patient's admission; they determine a patient's medications; they decide i f a patient requires committal papers; and they decide on a patient's discharge. 58 Conversely, nurses are not p e r c e i v e d as having l e g i t i -mate power i f the r e a c t i o n s o f the p a r t i c i p a n t s i n t h i s study are a r e l i a b l e i n d i c a t o r . Most o f the p a t i e n t s s t a t e d they d i d n ' t r e a l l y know what the r o l e of the nurse was. T h i s may e x p l a i n the r e s i s t a n c e and resentment of the p a r t i c i -pants towards the nurses which Cohen e t a l . (1976) d e s c r i b e when those having a l e s s l e g i t i m a t e form of i n f l u e n c e t r y to e x e r t power. J u s t as the p a t i e n t s d i d not understand the r o l e of the s t a f f , they d i d not understand the purpose of t h e i r programme or the t h e r a p e u t i c m i l i e u . F r e q u e n t l y , p a t i e n t s expressed t h e i r own o p i n i o n o f what would be most h e l p f u l : R: So you were f e e l i n g okay and you c o u l d n ' t see any p o i n t i n being here anymore. P: I was s t i l l f e e l i n g a l i t t l e b i t , you know, strange, but i t wasn't nothing s e r i o u s . You know, I c o u l d l a y around home and r e s t a l o t e a s i e r and r e s t a l o t n i c e r t h e r e . That's a l l I need i s a r e s t , you know. Th i s same p a t i e n t l a t e r expressed how the programme " i n t e r -f e r e d " with h i s own g o a l : P: They [ s t a f f ] ask you t o go out to e x e r c i s e , and meetings and a l l t h a t k i n d of s t u f f . I'm not r e a l l y i n t e r e s t e d . My main concern i s to get b e t t e r . Another p a t i e n t was more openly c r i t i c a l o f the programme: P: You have to do c e r t a i n t h i n g s at c e r t a i n times. You've got to p a i n t l i k e a baby. You've got to c l e a n up a l l the time. Aw, i t ' s a joke. R: Why do you t h i n k they ask those t h i n g s ? P: F o r something to do. That's a l l . I t ' s not therapy. I can do t h a t anywhere. One o f the p a t i e n t s r e l a y e d her p e r c e p t i o n of the meaningless-59 ness of the rules regarding her physical movement. This re-s t r a i n t of movement was a major issue under the discussion of powerlessness. P: I wanted to get outside so I could f e e l free, and my mind could be at ease. They wouldn't l e t me go. No nurse would take me outside. They t o l d me to stick my hands outside the window. Isn't that stupid? I'm a person that l i k e s to go outside--I walk, and jog, and run. I t ' s hard to change. In general, i t was d i f f i c u l t for the patients to understand that the hospital i s a bureaucracy with a need for e f f i c i e n c y : "If I don't get to dinner between 5 and 5:30, that's i t . I don't eat." How does the theme of meaninglessness/isolation relate to the elopements? If indiv i d u a l s are having d i f f i c u l t y j u s t i f y i n g the events i n which they are engaged and i f they see these a c t i v i t i e s as having l i t t l e value, they w i l l l i k e l y seek a s i t u a t i o n which does have meaning and worth for them. During t h e i r elopements, the participants described the events i n which they were engaged: going for walks, going home, seeing friends, and shopping. When one of the patients was asked what stood out most i n her mind about being away from the h o s p i t a l , she r e p l i e d , "playing bingo." These con-crete, "normal" events had meaning and value for the people involved. Normlessness. In Seeman's (1959/1972) d e f i n i t i o n of normlessness "there i s a high expectancy that s o c i a l l y un-approved behaviors are required to achieve given goals" (p. 50). Elopements themselves are considered inappropriate 60 behaviours and i t can thus e a s i l y be seen that the p a r t i c i -pants i n t h i s study " f i t " t h i s d e f i n i t i o n . What w i l l be stressed i n t h i s section of the paper i s the pattern of normlessness which ex i s t s i n the l i v e s of the par t i c i p a n t s . While there are various ways of looking at the reasons coping behaviours are established (Eaton, Peterson, & Davis, 1976), i t i s generally agreed a coping behaviour i s used to help a person meet a need. The behaviour thus serves a purpose for the person who engages i n i t , though the purpose may not be evident to other people. A repertoire of coping behaviours i s developed to deal with l i f e . If a p a r t i c u l a r behaviour has been useful to the person i n the past, "this pattern i s l i k e l y to be one of the behaviors: c a l l e d forth from the person's memory bank and put into operation" (Grace, Layton, & C a m i l l e r i , 1977, p. 69). Though the behaviour i s not fixed and i t can be modified or eliminated, i f opportuni-t i e s are not provided for the behaviour to be changed i t usually p e r s i s t s (Millon & M i l l o n , 1974). The behaviour of elopement was the commonality which caused each pa r t i c i p a n t to be i n t h i s study. As some of the participants themselves stated, elopement i s a form of "running away" or "escaping." As the interviews progressed, i t became evident that "running away" was a pattern or style of behaviour for the par t i c i p a n t s : P':' You see, I've run away from a l o t of places when I was younger, and there's been a l o t of d i f f e r e n t people 1s places, and just that I've run away for, a l l my l i f e , so i t ' s pretty hard. 61 A l l the p a r t i c i p a n t s r e l a t e d past "escapes." Each of the p a r t i c i p a n t s i d e n t i f i e d a t l e a s t one p l a c e which they had l e f t and fo u r o f the p a r t i c i p a n t s i d e n t i f i e d at l e a s t three p l a c e s which they had l e f t . These i n c l u d e d : p s y c h i -a t r i c h o s p i t a l s ; s c h o o l s ; home; c o u r t ; f o s t e r homes; and j u v e n i l e d e t e n t i o n c e n t r e s . For the p a r t i c i p a n t s , "running away" was a means of d e a l i n g with the s i t u a t i o n a t hand: P: I was having problems, my parents were having problems, I was having problems a t s c h o o l . . . . That's what made me s t a r t running away f i r s t , my p a r e n t s , and j u s t l i f e i n g e n e r a l . Another p a r t i c i p a n t e x p l a i n e d i t t h i s way: P: Why d i d I leave? Same reason. J u s t don't f e e l r i g h t . J u s t t h a t you hate i t so much you can't even t h i n k . . . . I j u s t hated i t . J u s t the thought of being t h e r e . O v e r a l l , two reasons were given as to why people "ran away." The i n a b i l i t y to handle the s i t u a t i o n i n any other way was c i t e d as one reason: P: You've got the same t r o u b l e , problems, and you haven't r e a l l y been d e a l i n g with i t . I j u s t throw them o f f , run away, I d i d n ' t r e a l l y want to d e a l w i t h my problems. R: So i t seems t h a t when you have problems, t h a t --P: — t o o s t r e s s f u l f o r me, then I j u s t f e e l l i k e running away. Another p a r t i c i p a n t s t a t e d : P: I took o f f on the law one time, too. R: You took o f f . . . ? P: On the law. I was supposed t o appear i n c o u r t f o r undue care and a t t e n t i o n , and I took o f f f o r a yea r . . . . I was scared to stay. The second reason given as to why people "ran away" 62 was the need f o r freedom, the need to escape from c o n s t r a i n t s which the p a r t i c i p a n t s p e r c e i v e d : R: How come you used to do t h a t [run away from home]? P: I j u s t wanted freedom, t h a t ' s a l l . . . . T h e y [ p a r e n t s ] were work, work, work, a l l work, and t h a t ' s a l l there w a s — t h a t and s c h o o l . . . . I got n o t h i n g a g a i n s t work, but i t was a l i t t l e r i d i c u l o u s . . . . My f a t h e r had me on the t r a c t o r by the time I was about s i x . A second p a r t i c i p a n t a l s o l i s t e d the same need: R: Why d i d you leave at t h a t time [from a p r e v i o u s elopement]? P: J u s t bored, boredom. I wanted to get out, I, I l i k e t o walk a l o t , l i k e ten m i l e s sometimes, and I, I l i k e , r e a l l y l i k e to walk a l o t to keep me i n shape, and my mind me n t a l l y , i t helps i t , helps i t . R: O k a y — P: J u s t , freedom purpose, I t h i n k , more than anything. Each o f the p a r t i c i p a n t s i n t h i s study had used "running away" as a means o f coping w i t h d i f f i c u l t s i t u a t i o n s . I n -deed, each p a r t i c i p a n t l e a r n e d t h i s behaviour e a r l y i n l i f e , o f t e n d u r i n g adolescence. Not o n l y had the behaviour been i n t h e i r r e s p e c t i v e r e p e r t o i r e s , but i t had s u c c e s s f u l l y met a need a t l e a s t some of the time by e i t h e r a l l o w i n g them to leave the s i t u a t i o n f o r a time or a l l o w i n g the f r e e -dom they r e q u i r e d . The behaviour of "running away" had t h e r e f o r e served a u s e f u l purpose f o r these i n d i v i d u a l s i n the p a s t . A l c o h o l and/or drug misuse was a l s o a p a t t e r n f o r four of the p a r t i c i p a n t s . One o f the p a t i e n t s s t a t e d she became i n t o x i c a t e d while on her elopement. The reasons given f o r 63 t h e s u b s t a n c e m i s u s e v a r i e d : one i n d i v i d u a l s t a t e d i t was t h e t h i n g t o do a t t h e t i m e ; one s t a t e d i t was a means o f a v o i d i n g h e r p r o b l e m s ; and a n o t h e r s t a t e d he f e l t b e t t e r as a r e s u l t . W h a t e v e r t h e r e a s o n , t h e m i s u s e r e i n f o r c e s t h e p a t t e r n o f n o r m l e s s n e s s f o r t h e p a r t i c i p a n t s i n t h e s t u d y . S e l f - e s t r a n g e m e n t . As Seeman (1959/1972) s t a t e d , "To be s e l f - a l i e n a t e d i n t h e f i n a l a n a l y s i s , means t o be some-t h i n g l e s s t h a n one m i g h t i d e a l l y be i f t h e c i r c u m s t a n c e s i n s o c i e t y were o t h e r w i s e " (p. 53). S e l f - e s t r a n g e m e n t was t h e v a r i a t i o n o f a l i e n a t i o n w h i c h o c c u r r e d l e a s t o f t e n . T h i s theme was p a r t i c u l a r l y i m p o r t a n t f o r one p e r s o n t h o u g h , as i t was t h e main r e a s o n he e l o p e d . H i s t e r s e i n t e r a c t i o n w i t h t h e r e s e a r c h e r r e q u i r e s no f u r t h e r comment: R: No. So, i t was m a i n l y t h e way t h e s t a f f a c t e d t o w a r d y o u t h a t y o u eloped.' P: Yeah. R: Anyone i n p a r t i c u l a r ? P : No. R: No. Okay. D i d t h a t happen j u s t once i n a w h i l e , o r a l l t h e t i m e , o r j u s t o n c e ? P: A l l t h e t i m e . R: A l l t h e t i m e . P: Yeah. R: Do y o u f i n d t h a t ' s s t i l l h a p p e n i n g ? P: Y eah. R: You do....How doe s t h a t make yo u f e e l when t h e y , t h e y i g n o r e you? 64 P: Not too good. Quite bad. R: Yeah. Bad. P: I t just doesn't f e e l r i g h t . R: Yeah. P: Sort of a r e a l weird f e e l i n g . R: Mmhmm. Can you explain a b i t more about that weird feeling? P: Just doesn't seem l i k e you're here. Subjective Alienation Within an Objective Context The intertwining of subjective and objective alienation has been i l l u s t r a t e d i n the presentation and discussion of the p a r t i c i p a n t s ' accounts. Goffman (1961) eloquently sum-marized t h i s intertwining: On the outside, the i n d i v i d u a l can hold objects of s e l f - f e e l i n g — s u c h as his body, his immediate actions, his thoughts, and some of his possessions - - c l e a r of contact with a l i e n and contaminating things. But i n t o t a l i n s t i t u t i o n s , these t e r r i -t o r i e s of the s e l f are violated; the boundary be-tween his being and the environment i s invaded. (p. 23) Summary This chapter has been concerned with the concept of a l i e n a t i o n . The review of the l i t e r a t u r e on both subjective and objective a l i e n a t i o n analyzed a cross-section of read-ings which displayed how d i f f e r e n t l y and how widely the concept i s defined. The accounts of the participants were presented and discussed concurrently using Seeman's concep-t i o n of alienation as a framework. The major thrust of the 65 f e e l i n g s o f the p a r t i c i p a n t s was a sense o f l o s s o f c o n t r o l over what was happening t o and around them. They tended to see l i t t l e meaning or l i t t l e value i n t h e i r experiences i n the h o s p i t a l . A past p a t t e r n o f not conforming to s o c i a l norms was a l s o shown. A sense of separateness was a thread throughout t h i s chapter and t h i s sense was shown to be r e -l a t e d t o the o r g a n i z a t i o n o f the h e a l t h care system i n which the p a r t i c i p a n t s ' e x periences took p l a c e . The v e r t i c a l h i e r a r c h y i n a h o s p i t a l and the p a t i e n t ' s p o s i t i o n i n t h i s h i e r a r c h y were shown t o be c r u c i a l . The p a t i e n t ' s a c t u a l c o n t r o l was viewed as l i m i t e d and, while t h i s might be r e -q u i r e d i n c l i n i c a l matters, o t h e r areas of c o n t r o l might be amenable-to r e d i s t r i b u t i o n . Chapter F i v e Summary, C o n c l u s i o n s , and I m p l i c a t i o n s f o r Nursing Summary and Con c l u s i o n s T h i s study was designed to g a i n an understanding of how p s y c h i a t r i c p a t i e n t s view t h e i r own elopements from h o s p i t a l . The l i m i t e d amount of i n f o r m a t i o n a v a i l a b l e about elopement i s from the p e r s p e c t i v e o f the h e a l t h care worker. A b e t t e r understanding o f the behaviour i s impor-t a n t f o r nurses because much time and e f f o r t are u t i l i z e d when a p a t i e n t e l o p e s . Moreover, there i s concern f o r the s a f e t y o f the p a t i e n t . Because events do not occur i n i s o -l a t i o n , the experiences o f the p a t i e n t s were a l s o examined i n r e l a t i o n t o the s o c i o c u l t u r a l context i n which they o c c u r r e d . To gain an understanding o f those who l e f t the h o s p i t a l without the p e r m i s s i o n o f the s t a f f , an approach was used which emphasizes the importance of i d e n t i f y i n g what i s meaningful f o r the s u b j e c t s from t h e i r p o i n t o f view. T h i s approach complemented three o f the purposes of t h i s study: what l e d to the elopement; how the a c t u a l elopement was per-c e i v e d ; and what purpose the elopement served. The f o u r t h purpose of t h i s study, a n a l y z i n g the p e r c e p t i o n s o f the s u b j e c t s w i t h i n the s o c i o c u l t u r a l context, was congruent w i t h Kleinman 1s (1978) conceptual framework which was used 66 67 i n t h i s study. In Kleinman's framework, the p e r c e p t i o n s o f p a t i e n t s are addressed as w e l l as the f o r c e s which i n f l u e n c e those p e r c e p t i o n s . Interviews were conducted w i t h f i v e s u b j e c t s once they had r e t u r n e d to the h o s p i t a l . Through the i n t e r v i e w s , the p a t i e n t and the r e s e a r c h e r c o n s t r u c t e d an account of the e x p e r i e n c e . Through an i n t e r a c t i v e p r o c e s s , the r e -searcher came to an understanding of the s u b j e c t ' s perspec-t i v e . From the c o n s t r u c t i o n o f the accounts and the ensuing review of the l i t e r a t u r e , an i n t e r p r e t a t i o n o f the exper-i e n c e s of the p a r t i c i p a n t s was made. A l i e n a t i o n was the u n i f y i n g concept i d e n t i f i e d by the r e s e a r c h e r to e x p l a i n or make sense of the accounts of the p a t i e n t s . T h i s concept can be viewed as having both subjec-t i v e and o b j e c t i v e components. To p r e s e n t the broadest p o s s i b l e viewpoint and to be congruent w i t h Kleinman's con-c e p t u a l framework, both aspects of a l i e n a t i o n were u t i l i z e d . S u b j e c t i v e a l i e n a t i o n was i d e n t i f i a b l e i n the case of each s u b j e c t . The p a t i e n t s e x p e r i e n c e d a l o s s of c o n t r o l i n a v a r i e t y o f ways: over t h e i r e n t r y i n t o h o s p i t a l ; over t h e i r treatment and t h e i r programme; and over events d i r e c t l y l i n k e d t o t h e i r elopements. They f e l t t h a t events were o c c u r r i n g , but they had no i n p u t i n t o these. Four of the s u b j e c t s s t a t e d they had not sought h o s p i t a l i z a t i o n , but were admitted because of e x t e r n a l events or c o n t r o l s . The programme and the treatments were f r e q u e n t l y viewed as meaningless o r not making sense. The p a t i e n t s were asked 68 to engage i n a c t i v i t i e s which they p e r c e i v e d as being i n c o r -r e c t f o r them and t h e i r needs. Thus, the p a t i e n t s a s s i g n e d a low value to t h e i r treatment, t o t h e i r programme, and to t h e i r h o s p i t a l i z a t i o n . In each i n s t a n c e , the s u b j e c t i d e n t i -f i e d a " l a s t straw" which caused h i s or her unsanctioned l e a v i n g . In some cases, t h i s was a c r i s i s s i t u a t i o n such as when a s u b j e c t was p h y s i c a l l y a s s a u l t e d by another p a t i e n t . A c o n t i n u a l b u i l d i n g up of a p a r t i c u l a r concern a l s o l e d to elopement such as when a p a t i e n t f e l t t h e - s t a f f d i d not l i s t e n to h i s concerns. The elopement was viewed as p o s i t i v e by each s u b j e c t , though some p a t i e n t s d i d experience a r e d u c t i o n i n p r i v i l e g e s or an i n c r e a s e i n medications as a r e s u l t o f i t . A l l s t a t e d t h a t through t h e i r elopements they were able to r e g a i n some c o n t r o l and some freedom. T h i s p e r c e p t i o n o f elopement as a p o s i t i v e event c o n t r a d i c t s the p e r c e p t i o n s o f h e a l t h care workers as r e p o r t e d i n the l i t e r a t u r e . A p a t t e r n o f running away behaviour was t y p i c a l f o r the s u b j e c t s . T h i s coping p a t t e r n had helped them i n the past when they were e x p e r i e n c i n g a s t r e s s . Other nonconforming p a t t e r n s such as drug and a l c o h o l misuse were a l s o noted amongst them. When Kleinman 1s framework was u t i l i z e d to p l a c e the s u b j e c t i v e experiences o f the p a r t i c i p a n t s i n t h e i r s o c i o -c u l t u r a l context, the o r g a n i z a t i o n o f the h o s p i t a l as a bureaucracy was examined. I t was suggested t h a t , due to t h e i r placement i n the h i e r a r c h y , p a t i e n t s are o f t e n power-69 l e s s to a f f e c t what i s o c c u r r i n g . To a c e r t a i n e x t e n t , t h i s f e e l i n g i s i n e v i t a b l e ; h e a l t h care workers have an ex-p e r t knowledge which p a t i e n t s do not have. As such, s t a f f may o f t e n take c o n t r o l and do t h i n g s which don't "make sense" to the p a t i e n t s . As an example, one p a t i e n t who was "high" f e l t she was being punished by being kept i n a low stim u l u s environment. The s u b j e c t s f r e q u e n t l y f e l t they were not i n -formed about the r a t i o n a l e s f o r the d e c i s i o n s which were made about them. I t was suggested t h a t there were areas other than c l i n i c a l matters where p a t i e n t s might have more c o n t r o l . For example, one p a t i e n t commented she had to change her room on f i v e minutes n o t i c e and she had no choice i n her new roommate. One very s t r o n g c o n c l u s i o n which emerged from t h i s study was t h a t the s u b j e c t s tended t o p e r c e i v e nurses nega-t i v e l y w h i le they tended t o p e r c e i v e d o c t o r s n e u t r a l l y o r p o s i t i v e l y . I t was hypothesized the p a t i e n t s do not see the nurses as having l e g i t i m a t e power and thus r e s e n t e d the nurses' attempts t o i n f l u e n c e them. I m p l i c a t i o n s f o r Nursing P r a c t i c e The f i n d i n g s o f t h i s study suggest s e v e r a l d i r e c t i o n s f o r n u r s i n g p r a c t i c e . They are not new or unique but a r e i t e r a t i o n o f idea s which have been taught i n n u r s i n g pro-grammes and which have been addressed i n the l i t e r a t u r e f o r years. Nurses need t o l i s t e n t o the concerns of the p a t i e n t 70 from the p a t i e n t ' s p e r s p e c t i v e . Even when s i m i l a r words are used, the meanings attached to those words can vary g r e a t l y . To.reach a mutual understanding, nurses w i l l have to e x p l a i n t h e i r p e r c e p t i o n of the s i t u a t i o n . A process of n e g o t i a t i o n can then occur. Nurses need t o assess the understanding of the p a t i e n t b e f o r e they begin t e a c h i n g i f the t e a c h i n g i s to have mean-i n g f o r the p a t i e n t . Teaching about a treatment should be done i n advance of the event so the p a t i e n t knows, i f not understands, why the a c t i o n i s being taken. While the aims o f a programme may be e v i d e n t to the s t a f f , t h i s i s not n e c e s s a r i l y so f o r the p a t i e n t s . They w i l l r e q u i r e e x p l a n a t i o n s on admission and as d i f f e r e n t aspects o f the programme are expanded o r d e l e t e d . The reasons f o r the r u l e s i n a programme a l s o r e q u i r e d i s c u s s i o n . Nurses should i n v e s t i g a t e p r e v i o u s p a t t e r n s o f coping which p a t i e n t s have u t i l i z e d when they have f e l t c o n s t r a i n e d or powerless. A r e l e v a n t n u r s i n g assessment may h e l p the nurse to a n t i c i p a t e c e r t a i n behaviours. The nurse should r e s t o r e as much c o n t r o l as p o s s i b l e to the p a t i e n t . A l l o w i n g the e x p r e s s i o n o f f e e l i n g s and encouraging v e r b a l p a r t i c i p a t i o n can help i n t h i s area even when the a c t u a l d e c i s i o n s the p a t i e n t can make are minimal. While i t may be d i f f i c u l t f o r the s t a f f , acknowledging the need f o r r e b e l l i o u s behaviour can help the s e l f - c o n c e p t of the p a t i e n t . A l l o w i n g a sense of c o n t r o l over the e n v i r o n -ment may be one concrete way o f i n c r e a s i n g the p a t i e n t ' s per-71 c e p t i o n o f c o n t r o l . I t i s imperative t h a t the nurse e x p l a i n why c e r t a i n events cannot be m o d i f i e d t o s u i t the p a t i e n t . Again, i t i s important t o do t h i s i n advance so the p a t i e n t does not r e c e i v e a f a l s e p e r c e p t i o n o f a s i t u a t i o n . T h i s r e l a t e s to c o n s i s t e n c y . I f one t h i n g i s s a i d and another done, p a t i e n t s may p e r c e i v e t h e i r concerns are not being t r e a t e d s e r i o u s l y . There i s a d i r e c t i m p l i c a t i o n f o r n u r s i n g a d m i n i s t r a -t i o n i n t h i s study. In the p r o f e s s i o n , the uniqueness of the i n d i v i d u a l i s v e r b a l l y acknowledged. However, there i s no one answer s u i t a b l e f o r a l l p a t i e n t s and y e t we permit l i t t l e f l e x i b i l i t y i n p o l i c i e s and approaches. As a p r o f e s s i o n , n u r s i n g needs to examine i t s p r i o r i -t i e s . I f we t r u l y b e l i e v e i n a r o l e as a p a t i e n t advocate and i f we t r u l y b e l i e v e i n i n t e r a c t i n g w i t h the p a t i e n t as a b i o - p s y c h o - s o c i a l being, we need to be congruent i n our a c t i o n s . Nurses should be i n v o l v e d i n i n c r e a s i n g the competence of h e a l t h consumers so they can make informed d e c i s i o n s . I f consumers band t o g e t h e r , c o l l e c t i v e a c t i o n can be p r o-moted to i n f l u e n c e the o r g a n i z a t i o n o f h e a l t h care. As a p r o f e s s i o n , n u r s i n g should be i n v o l v e d i n d e c i s i o n s r e g a r d i n g o r g a n i z a t i o n of the h e a l t h care system and other s t r u c t u r e s which a f f e c t p a t i e n t s . To have the g r e a t e s t i n -f l u e n c e , nurses must have i n p u t a t the decision-making l e v e l . 72 I m p l i c a t i o n s f o r Nursing E d u c a t i o n Nursing c u r r i c u l a need to prepare students to examine d i f f e r e n t views o f c l i n i c a l r e a l i t y . Students, as a p a r t o f being s o c i a l i z e d i n t o a new r o l e , must r e a l i z e t h a t the p e r s p e c t i v e o f the p a t i e n t may be d i f f e r e n t from t h a t o f the h e a l t h care p r o f e s s i o n a l . To e l i c i t the p e r s p e c t i v e o f the p a t i e n t and to promote e f f e c t i v e communication, s k i l l i s r e q u i r e d i n the use o f s o p h i s t i c a t e d i n t e r p e r s o n a l techniques. P l a c i n g students i n the r o l e o f the p a t i e n t might h e l p them t o be more s e n s i t i v e towards the needs of "the o t h e r s i d e . " I n s t i l l i n g an awareness of how behaviour can a f f e c t o t h e r s i s c r u c i a l . H e a l t h p r o f e s s i o n a l s are f r e q u e n t l y un-aware o f the impact on p a t i e n t s o f c a s u a l r e p l i e s or un-e x p l a i n e d a c t i o n s . Students should have the knowledge and the s k i l l s to p r e s e n t t h e i r r o l e to p a t i e n t s and to f e l l o w h e a l t h care workers. T h i s o b v i o u s l y r e q u i r e s a sense of p r o f e s s i o n a l i d e n t i t y . I f nurses do accept the r e s p o n s i b i l i t y of being the p a t i e n t ' s advocate, students need to l e a r n ways to o p e r a t i o n a l i z e t h i s r o l e . C u r r i c u l a must f o s t e r an understanding o f the h e a l t h care system and the f a c t o r s which i n f l u e n c e the system i f students are to understand how they can make an impact at the decision-making l e v e l . The p o l i t i c a l s k i l l s to a f f e c t the system a l s o heed to be p r o v i d e d . I t i s p a r t i c u l a r l y important to note t h a t , w hile we as 73 nurses b e l i e v e we address these i s s u e s i n both e d u c a t i o n and p r a c t i c e , implementation may not be as e f f e c t i v e or c o n s i s -t e n t as we might wish. I m p l i c a t i o n s f o r Nursing Research Subsequent s t u d i e s on the elopement of p s y c h i a t r i c p a t i e n t s would produce a broader knowledge o f t h i s s u b j e c t . I f a s i m i l a r methodology were used, other concepts or themes might be i d e n t i f i e d . A d d i t i o n a l i n t e r a c t i o n s with the sub-j e c t s c o u l d heighten the r i c h n e s s o f the data. In r e t r o -s p e c t , i t would have been u s e f u l to i n t e r v i e w the p a t i e n t s once they had l e f t the h o s p i t a l t o assess t h e i r p e r c e p t i o n s when they were " f r e e . " An obvious e x t e n s i o n of t h i s study would be t o examine the p e r c e p t i o n s o f p a t i e n t s who elope from n o n - p s y c h i a t r i c u n i t s of a h o s p i t a l . As a d i r e c t r e s u l t of t h i s study, some q u e s t i o n s have been r a i s e d which would b e n e f i t from f u r t h e r i n v e s t i g a t i o n . Would p a t i e n t s who were o l d e r p e r c e i v e t h e i r s i t u a t i o n d i f -f e r e n t l y ? Is there a c o n s i s t e n t r e l a t i o n s h i p between e l o p e -ment and a p r e v i o u s coping p a t t e r n of running away? How do the s t a f f p e r c e i v e the behaviour o f a p a t i e n t who e l o p e s ? Would p a t i e n t s who had i n i t i a l l y wanted to be i n h o s p i t a l and subsequently eloped p e r c e i v e t h e i r s i t u a t i o n d i f f e r e n t l y ? I f elopement i s p e r c e i v e d as one b e h a v i o u r a l m a n i f e s t a t i o n of a l i e n a t i o n , are there o t h e r m a n i f e s t a t i o n s t h a t can be i d e n t i f i e d ? How can p a t i e n t s be allowed more c o n t r o l a t the same time t h a t safe and e f f e c t i v e care i s provided? 74 An unexpected f i n d i n g o f t h i s study was the f a c t t h a t the r o l e o f the s t a f f was u n c l e a r t o the s u b j e c t s . I t would be u s e f u l to know how p a t i e n t s p e r c e i v e s t a f f j u s t as i t would be u s e f u l t o know what e x p e c t a t i o n s p a t i e n t s have of h e a l t h care p r o f e s s i o n a l s . T h i s i n f o r m a t i o n would be u s e f u l t o e s t a b l i s h a b a s i s f o r n e g o t i a t i o n with p a t i e n t s . Research on how the h i e r a r c h y o f the h o s p i t a l c o u l d be more respon s i v e t o p a t i e n t s ' needs as w e l l as an examination of the e f f e c t s o f the f l a t t e n i n g o f t h i s . h i e r a r c h y i s i n d i -c a t e d . T h i s i n f o r m a t i o n c o u l d be used as a b a s i s f o r chang-i n g the p a r t s o f the system which c o u l d be improved or st r e n g t h e n i n g those f e a t u r e s which are b e n e f i c i a l f o r p a t i e n t c a r e . In c o n c l u s i o n , then, t h i s t h e s i s w i l l have made obvious the f a c t t h a t continued r e s e a r c h i n t o t h i s f i e l d i s neces-sa r y . The reasons f o r the p a t i e n t s ' elopements have been viewed from t h e i r p e r s p e c t i v e and i t i s c l e a r t h a t the p a t i e n t s p e r c e i v e j u s t i f i a b l e r a t i o n a l e s f o r t h i s behaviour. Through f u r t h e r examination o f these reasons, h e a l t h care workers w i l l expand t h e i r understanding o f the elopements of p s y c h i a t r i c p a t i e n t s . T h i s continued r e s e a r c h w i l l help p r a c t i t i o n e r s cope w i t h an area o f s e r i o u s ..concern both f o r them and f o r the p a t i e n t s who have eloped. 75 References A l t s c h u l , A.T. Use of the nursing process i n psychiatric care. Nursing Times, 1977, 73, 1412-1413. Aspy, V i r g i n i a H. Are patients people? Nursing Times, 1972, 6_8, 690. Bailey, Janet T. The problem behavior report sheet and coding t o o l . In M.J. Ward & CA. Lindeman (Eds.) , Instruments for measuring nursing practice and other  health care variables (Vol. 2). H y a t t s v i l l e , Maryland: U.S. Department of Health, Education, and Welfare, 1979. Bastable, E., Gordon, W., M i l l e r , W., & Tregunna, M. Standards of care for p s y c h i a t r i c nursing: The behavioral  concepts of depression and anxiety. Vancouver: R.N.A.B.C., 1977. Blauner, Robert. Alienation and modern industry. In Ada W. F i n i f t e r (Ed.), Alienation and the s o c i a l system. New York: John Wiley and Sons, Inc., 1972. (Originally published, 1964). Bloch, Dorothy W. Alienation. In Carolyn E. Carlson & Betty Blackwell (Eds.), Behavioral concepts and nursing  intervention (2nd ed.). Philadelphia: J.B. Lippincott Co., 1978. Burdock, Eugene I., & Hardesty, Anne S. Ward behavior inven-tory. In M.J. Ward & CA. Lindeman (Eds.) , Instruments  for measuring nursing practice and other health care  variables (Vol. 1). H y a t t s v i l l e , Maryland: U.S. Depart-ment of Health, Education, and Welfare, 1979. Carser, Diane L., & Doona, Mary E l l e n . A l ienation: A nurs-ing concept. Journal of Psychiatric Nursing and Mental  Health Services, 1978, 16(9), 33-40. Cherns, Albert B. Accounting for a l i e n a t i o n . 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C. Brown Pub. Co., 1977. Hays, David G. On "alienation": An essay i n the psycho-l i n g u i s t i c s of science. In R. F e l i x Geyer & David R. Schweitzer (Eds.), Theories of al i e n a t i o n : C r i t i c a l  perspectives i n philosophy and the s o c i a l sciences. Leiden, the Netherlands: Martinus Nijhoff Social Sciences Divi s i o n , 1976. Howard, Jan. Humanization and dehumanization of health care: A conceptual view. In Jan Howard & Anselm Strauss (Eds.), Humanizing health care. New York: John Wiley and Sons, Inc., 1975. Johnson, Dorothy. Powerlessness: A s i g n i f i c a n t determinant i n patient behavior? The Journal of Nursing Education, 1967, 6 ( 2 ) , 39-44. Johnson, Frank. Alienation: Concept, term, and word. In Frank Johnson (Ed.), Alienation: Concept, term, and  meanings. New York: Seminar Press, Inc., 1973. (a) Johnson, Frank. Ali e n a t i o n : Overview and introduction. In Frank Johnson (Ed.), Alienation: Concept, term, and  meanings. New York: Seminar Press, Inc., 1973. (b) Johnson, Frank. Alienation: Some concluding observations. In Frank Johnson (Ed.), Alienation: Concept, term, and  meanings. New York: Seminar Press, Inc., 1973. (c) Johnson,. Frank. Some problems of r e i f i c a t i o n i n e x i s t e n t i a l psychiatry: Conceptual and p r a c t i c a l considerations. In R. F e l i x Geyer & David R. Schweitzer (Eds.), Theories  of a l i e n a t i o n : C r i t i c a l perspectives i n philosophy  and the s o c i a l sciences. Leiden, the Netherlands: Martinus Nijhoff S o c i a l Sciences Divi s i o n , 1976. Kaluzny, Arnold D., Warner, D. Michael, Warren, David G., & Zelman, William N. Management of health services. Englewood C l i f f s , New Jersey: Prentice-Hall, Inc., 1982 . Keniston, Kenneth.. The v a r i e t i e s of ali e n a t i o n : An attempt at d e f i n i t i o n . In Ada W. F i n i f t e r (Ed.), Alienation  and the s o c i a l system. New York: John Wiley and Sons, Inc., 1972. 78 Kleinman, Arthur. Concepts and a model for the comparison of medical systems as c u l t u r a l systems. Social Science 1  and Medicine, 1978, 12, 85-93. Kleinman, Arthur, Eisenberg, Leon, & Good, Byron. Culture, i l l n e s s , and care: C l i n i c a l lessons from anthropologic and c r o s s - c u l t u r a l research. Annals of Internal Medi-cine, 1978, 88, 251-258. K r a l l , Mary Louise. Guidelines for writing mental health treatment plans. American Journal of Nursing, 1976, 76, 236-237. Kyes, Joan, & Hofling, Charles K. Basic p s y c h i a t r i c concepts  i n nursing (4th ed.). Philadelphia: J.B. Lippincott Co., 1980. Ludz, Peter C h r i s t i a n . Alienation as a concept i n the s o c i a l sciences. In R. F e l i x Geyer & David R. Schweitzer (Eds.), Theories of al i e n a t i o n : C r i t i c a l perspectives  i n philosophy and the s o c i a l sciences. Leiden, the Netherlands: Martinus N i j h o f f Social Sciences Divi s i o n , 1976. Ludz, Peter Ch r i s t i a n . A forgotten i n t e l l e c t u a l t r a d i t i o n of the alienation concept. In R. F e l i x Geyer & David Schweitzer (Eds.), Alienation:. Problems of meaning, theory and method. London: Routledge and Kegan Paul, 1981. Manderscheid, Ronald W. Stress and coping:. A biopsycho-s o c i a l perspective on a l i e n a t i o n . In R. F e l i x Geyer & David Schweitzer (Eds.), Alienation:: Problems of mean-ing, theory and method. London: Routledge and Kegan Paul, 1981. Matheney, Ruth V., & Topalis, Mary. Psych i a t r i c nursing (6th ed.). St. Louis: The C.V. Mosby Co., 1974. Mellor, Peter D. Moral dilemmas i n ps y c h i a t r i c nursing. Nursing Mirror, 1977, 145 (3) , 20-22. Mil l o n , Theodore, & Mi l l o n , Renee. Abnormal behavior and  personality: A b i o s o c i a l learning approach. Philadelphia: W.B. Saunders Co., 1974. Moran, Janet Carter. An alternative to constant observation: The behavioral c h e c k l i s t . Perspectives i n Psych i a t r i c  Care, 1979, 17, 114-117. Nowakowska, Maria. Alienation: A formal theory. In R. F e l i x Geyer & David Schweitzer (Eds.), Alienation : Problems of meaning, theory and method. London: Routledge and Kegan Paul, 1981. 79 Numerof, Rita E. The practice of management for health care  professionals. New York: AMACOM, 1982. Oi l e r , Carolyn. The phenomenological approach i n nursing research. Nursing Research, 1982 , 3_1, 178-181. Olsen, Marvin E. P o l i t i c a l powerlessness as r e a l i t y . In R. F e l i x Geyer & David R. Schweitzer (Eds.), Theories  of a l i e n a t i o n : : C r i t i c a l perspectives i n philosophy  and the s o c i a l sciences. Leiden, the Netherlands: Martinus Nijhoff Social Sciences Divi s i o n , 1976. Peplau, Hildegard. Psychiatric nursing: Role of nurses and psy c h i a t r i c nurses. International Nursing Review, 1978, 25, 41-47. Peplau, Hildegard E. The ps y c h i a t r i c nurse - accountable? to whom? for what? Perspectives i n Psychi a t r i c Care, 1980, 18, 128-134. Ragucci, Antoinette T. The ethnographic approach and nursing research. Nursing Research, 1972 , 2_1, 485-490. Rist , Ray C. On the means of knowing: Qualitative research i n education. New York University Education Quarterly, 1979, Summer, 17-21. Roberts, Sharon L. Behavioral concepts and nursing through-out the li f e s p a n . Englewood C l i f f s , New Jersey: Prentice-Hall Inc., 1978. Robinson, L i s a . P s y c h i a t r i c nursing as a human experience. Philadelphia: W.B. Saunders Co., 1972. Schacht, Richard. Alienation, the "is-ought" gap and two sorts of discord. In R. F e l i x Geyer & David R. Schweitzer (Eds.), Theories of al i e n a t i o n : C r i t i c a l  perspectives i n philosophy and the s o c i a l sciences. Leiden, the Netherlands: Martinus Nijhoff Social Sciences Divi s i o n , 1976. Schacht, Richard. On power and powerlessness. In J. Milton Yinger & Stephen J. Cutler (Eds.), Major s o c i a l issues: A m u l t i d i s c i p l i n a r y view. New York: The Free Press, 1978. Schaff, Adam. Alienation as a s o c i a l phenomenon. Oxford: Pergamon Press Ltd., 1980. Schrock, Ruth A. Planning nursing care for the mentally i l l . Nursing Times, 1980, 7_6, 704-706. 80 Schutz, A l f r e d . On phenomenology and s o c i a l r e l a t i o n s . Chicago: The University of Chicago Press, 1970. Schweitzer, David. Contemporary alienation theory and re-search. In Tom Bottomore, Stefan Nowak, & Magdalena Sokolowska (Eds.), Sociology: The state of the a r t . London: SAGE Publications Ltd., 1982. Seeman, Melvin. On the meaning of al i e n a t i o n . In Ada W. F i n i f t e r (Ed.), Alienation and the s o c i a l system. New York: John Wiley and Sons, Inc., 1972. (Originally published, 1959.) Shoham, S. Giora. The tantalus r a t i o : A scaffolding for an ontological personality theory. In R. 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In Tom Bottomore, Stefan Nowak, & Magdalena Sokolowska (Eds.), Sociology: The state of the a r t . London: SAGE Publications Ltd., 1982. Vousden, Martin. The one that nearly got away. Nursing  Times, 1979, 75, 1642-1643. Wilson, Holly S., & Kneisl, Carol Ren. Psychiatric nursing. Menlo Park, C a l i f . : Addison-Wesley Pub. Co., 1979. 81 Appendix A Information and Consent Form 82 Information and Consent Form My name i s Kathy Mclndoe. I am a r e g i s t e r e d nurse who i s c u r r e n t l y working on a Master's Degree i n n u r s i n g a t the U n i v e r s i t y o f B r i t i s h Columbia. I am i n t e r e s t e d i n l e a r n i n g about people who have l e f t the h o s p i t a l without the p e r m i s s i o n o f the s t a f f . My i n t e r e s t i n t h i s developed when I was working and I c o u l d f i n d out l i t t l e i n f o r m a t i o n about t h i s matter. I would l i k e t o meet with you twice to d i s c u s s your r e c e n t l e a v i n g o f the h o s p i t a l . While you may not b e n e f i t from my study, other than having the o p p o r t u n i t y to d i s c u s s the matter, i t i s hoped t h a t other people i n the f u t u r e w i l l b e n e f i t . I f you give your consent, I would l i k e to tape r e c o r d the c o n v e r s a t i o n s . The tapes w i l l be erased a f t e r my t h e s i s has been f i n i s h e d . Your name w i l l not appear on the tapes or i n the t h e s i s . Your p r i v a c y w i l l be ensured. You: may r e f u s e to answer any q u e s t i o n s . Your p a r t i c i p a -t i o n or n o n - p a r t i c i p a t i o n w i l l not a f f e c t your care or t r e a t -ment i n any way. I f you do e n t e r the study, you may w i t h -draw a t any time. I f you have any q u e s t i o n s , p l e a s e f e e l f r e e to ask them. I understand the nature of the study and give my consent to p a r t i c i p a t e . Date : P a t i e n t ' s s i g n a t u r e : Researcher's s i g n a t u r e : Appendix B I n t e r v i e w Guide 84 Sample of Interview Questions 1. What things made you decide to leave the hospital without the permission of the s t a f f ? 2. What was i t l i k e for you while you weren't here? (How did i t feel?) 3. Do you f e e l i t was a pos i t i v e or a negative event for you, or both? In what ways was i t ? 4. What stands out most i n your mind about the experience? 5- What purposes did the elopement serve for you? Has i t affected your h o s p i t a l i z a t i o n i n any way? 

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