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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 U n i v e r s i t y o f 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 o f Nursing)  We accept t h i s  t h e s i s as conforming  to the r e q u i r e d  standard  THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1983 © Katherine I s o b e l Mclndoe, 1983  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of  requirements f o r an advanced degree at the  the  University  of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make it  f r e e l y a v a i l a b l e f o r reference  and  study.  I further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may  be granted by  department or by h i s or her  the head o f  representatives.  my  It i s  understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain  s h a l l not be  allowed without my  permission.  Department of  hlUTtbl'^  The U n i v e r s i t y of B r i t i s h 1956 Main Mall Vancouver, Canada V6T 1Y3  DE-6  Columbia  written  Abstract  This patients  s t u d y was d e s i g n e d explain  their  t o i n v e s t i g a t e how p s y c h i a t r i c  elopements from h o s p i t a l .  A limited  amount i s known a b o u t e l o p e m e n t and t h e a v a i l a b l e is written The  from t h e p e r s p e c t i v e  literature  of the caretaker.  s t u d y was q u a l i t a t i v e i n d e s i g n .  Indepth  interviews  were c o n d u c t e d w i t h f i v e  p a t i e n t s when t h e y r e t u r n e d  hospital  elopements.  following their  interviews  were a n a l y z e d  using  this  a n a l y s i s , conceptual  cept  o f a l i e n a t i o n was u t i l i z e d  the  linked  by t h e r e s e a r c h e r The p a t i e n t s  t r e a t m e n t a n d programme,  to their  elopements.  were f r e q u e n t l y  these  c o n t e n t a n a l y s i s and f r o m  experienced a l o s s o f c o n t r o l over over t h e i r  The d a t a f r o m  themes were c o n s t r u c t e d .  accounts of the p a t i e n t s .  t o the  The c o n to explain  i n the study  their entry  into hospital,  and o v e r e v e n t s  The programmes  directly  and t r e a t m e n t s  viewed as m e a n i n g l e s s o r n o t making  sense.  E l o p e m e n t was v i e w e d a s a p o s i t i v e e v e n t by e a c h o f t h e patients  because  and  freedom.  some The  i t provided  an o p p o r t u n i t y  i n t e r d e p e n d e n c e between t h e p a t i e n t s '  e x p e r i e n c e s and t h e o b j e c t i v e o r g a n i z a t i o n was e x a m i n e d . in  in for  I t was e x p l a i n e d  the hierarchy  less  study  o f the h o s p i t a l , p a t i e n t s  felt  the decisions  subjective  o f the h o s p i t a l  t h a t due t o t h e i r  t o a f f e c t what i s o c c u r r i n g .  this  f o r some c o n t r o l  often  placement feel  power-  Moreover, t h e p a t i e n t s  t h e y were n o t i n f o r m e d  about the r a t i o n a l e s  t h a t were made a b o u t them.  I t was  argued  that while nurses  believe  of  d i d not occur  patients,  this  Implications concluded  this  they  are a d d r e s s i n g the f o r the people  for nursing practice,  study.  concerns  in this  e d u c a t i o n and  study. research  iv  Table o f Contents Page Abstract  i i  Table of Contents  iv  Acknowledgements Chapter One:  vii  Introduction  t o t h e Problem and  Purposes  1  Conceptual Framework  5  Statement o f the Problem  8  Purposes o f the Study  9  T h e o r e t i c a l and M e t h o d o l o g i c a l  Perspective  o f the Study  9  Assumptions o f the Study  11  Limitations  11  o f t h e Study  Summary Chapter Two:  12 Methodology  Selection of Participants  13 13  Criteria for selection  13  S e l e c t i o n procedure  14  Description  14  o f the p a r t i c i p a n t s  Data C o l l e c t i o n Construction  15 o f the accounts  16  Data A n a l y s i s  17  E t h i c a l Considerations  18  Summary  19  Chapter Three: the Data  The Process o f the A n a l y s i s o f  Introduction  20 t o the Theme  20  R e l a t i o n s h i p o f A l i e n a t i o n t o Kleinman's Conceptual Framework Implications  22  f o r T h i s Study  24  Summary Chapter Four:  25 Alienation  26  L i t e r a t u r e Concerning S u b j e c t i v e  Alienation . . .  26  Seeman's c o n c e p t u a l i z a t i o n o f s u b j e c t i v e alienation  27  Writings  27  r e f l e c t i n g Seeman's work  Conceptual frameworks f o r s u b j e c t i v e alienation  29  A p p l i c a t i o n o f the concept t o the therapeutic milieu  31  L i t e r a t u r e Concerning O b j e c t i v e  Alienation. . . .  W r i t i n g s r e l a t i n g o b j e c t i v e a l i e n a t i o n and the h e a l t h care system Summary o f the l i t e r a t u r e on o b j e c t i v e alienation Presentation  32 34 38  and D i s c u s s i o n o f the Accounts  o f the P a r t i c i p a n t s  39  Powerlessness  41  Meaninglessness and i s o l a t i o n  52  Normlessness  59  Self-estrangement  63  Subjective Context Summary  A l i e n a t i o n Within  an O b j e c t i v e 64 64  Chapter F i v e : Summary, Conclusions, t i o n s f o r Nursing  and I m p l i c a -  66  Summary and Conclusions  66  Implications  69  f o r Nursing P r a c t i c e  vi  I m p l i c a t i o n s f o r Nursing Education  72  I m p l i c a t i o n s f o r Nursing Research  73  References  75  Appendix A  81  Appendix B  83  vii  Acknowledgements  The w r i t i n g o f t h i s efforts  o f many p e o p l e .  acknowledge Dr.  required  In p a r t i c u l a r ,  the following  for their  t h e combined I would  invaluable  J o a n A n d e r s o n , c h a i r p e r s o n o f my  sistently Dr.  thesis  provided  support, e x p e r t i s e ,  M a r i l y n Willman's o b j e c t i v i t y  instrumental  r e s p o n s e and t h e i r  t o thank the p a t i e n t s time.  assistance.  committee, con-  and c r i t i c a l  the  The s t a f f  for their  candid  i n t h e a g e n c i e s must access  patients.  The s u p p o r t o f my out  insight.  thesis.  a l s o be a c k n o w l e d g e d f o r a l l o w i n g and f a c i l i t a t i n g to  to  and i n c i s i v e comments were  i n the completion o f t h i s  I would l i k e  like  this process.  f o r making  family  Finally,  and f r i e n d s was  I must t h a n k my  lead balloons f l y .  crucial  husband  through-  Brendan  Chapter Introduction  t o the Problem  P e o p l e make i n f e r e n c e s serving tal  their  health  behaviour  p r a c t i c e , one  (Kyes  about  and  Purposes  t h e minds o f o t h e r s by  ( C u r t i n , 197 9).  b e h a v i o u r has m e a n i n g . " literature  One  often This  & Hofling,  In p s y c h i a t r i c / m e n -  hears the statement, " A l l same d e c l a r a t i o n  1980;  Robinson,  i s seen  1972).  t h e u n d e r s t a n d i n g o f human b e h a v i o u r r e m a i n s  primitive  state  ally  1976).  One  o c c u r s on a p s y c h i a t r i c u n i t  patient. staff  Elopement  sanction,  i n which  the p a t i e n t  returning  the p a t i e n t  f o r the p a t i e n t , ing  supervisor,  relatives at  who  the nurse  i n charge  who  The  When  nurse  this  caring  of the u n i t , the nurs-  eloped are t y p i c a l l y  Time and e n e r g y incident  chart.  D e s p i t e t h e number o f p e o p l e  documentation,  one  perception  report  are also  o f an  patient's  hospital  are t y p i c a l l y ^ i n v e s t e d  has e l o p e d .  writing  the  without  t h e p r i m a r y t h e r a p i s t , t h e p o l i c e , and  of the p a t i e n t  some l e v e l .  of a  boundaries of the  energy  in a  occasion-  i s the elopement  i s currently hospitalized.  b e h a v i o u r o c c u r s , much t i m e and in  behaviour which  i s the departure of a p a t i e n t ,  from the p h y s i c a l  i n the  Unfor-  tunately,  (Clare,  element  and  invested  involved  and  the  involved i n the  i n t h e w r i t i n g on  the  despite  seems t o be m i s s i n g :  o f the events r e l a t e d to the  1  ob-  the  elopement.  2  The  behaviour of elopement p e r t a i n s  nurses. volved  Nurses are i n the  psychiatric attempted  nurse  daily  the  i s to  behaviour  of  of  the  often  the  health  patient  involved  p a t i e n t who  care  to provide  i n the  the  stance  ( R o b i n s o n , 1972).  by  s t a t i n g nurses  behavior, client's  and...aid the  v i e w e d as  healthy  a mandate t o be nurses should a  sense of  A  frequently  learn  the  ones which are  "promote h e a l t h and  Other  or personal  g o i n g t o happen?"  the  (1980) r e i n f o r c e s  a negative  asked q u e s t i o n  psychiatric  of  nurse  patient.  Litigation  this  conducive  development of  behaviour,  the  the  nurse  r e a s o n s a l s o e x i s t as  behaviour. failure  i s , "Why  Nurses o f t e n  when a p a t i e n t didn't  i f s o m e t h i n g does happen t o  against  health professionals  has to  why  feel  elopes.  I know t h i s  Another concern r e l a t e s t o the  liability  mal-  Thus, whether elopement i s  know a b o u t t h i s  guilt  other  s e t t i n g i n w h i c h t h e y can  should  involved.  or  with  the  and  their  release  a p o s i t i v e or  As  in-  1980)  return  of  aspects of  Peplau  p o t e n t i a l " (p. 131).  i n the  r o l e of  more e f f e c t i v e b e h a v i o u r s t o r e p l a c e adaptive  (Schrock,  elopes.  team, t h e  support p a t i e n t s  and  practice  p r o f e s s i o n a l s most f r e q u e n t l y  life  n u r s e s are  return  members o f  the  t o the  was  legal the i s becom-  i n g more common. Whether e l o p e m e n t i s a p o s i t i v e o r is  open t o d e b a t e .  briefly tions  Two  o u t l i n e d to  f o r the Patients  i n d i c a t e how  profession who  opposing points  of  have e l o p e d  the  a negative  behaviour  of view w i l l  b e h a v i o u r has  be  implica-  nursing. may  o r may  not  be  committed.  3  If they  are  committed,  without  giving  they  can  be  detained  their permission.  The  i n the  hospital  p a t i e n t s are  considered  a danger e i t h e r  to themselves or to others.  committed,  have c h o s e n t o l e a v e a s e t t i n g w h i c h  they  technically  have t h e  w i s h t o l e a v e may tion  of l i b e r t y  to p s y c h i a t r i c rently  right  be  and  t o do.  s e e n as an  units"  ( M e l l o r , 1977,  o n e s e l f as one  sees  the  21).  right  i n f l u e n c e one  1979).  intervene  terfering and  As  as  the  the  t h e methods u s e d t o r e a c h  well,  nurses  grounds to j u s t i f y  in this  are  behaviour  extensive The  use  " f o r the  of resources"  an  another?  i s cur-  individual, and  purpose of i n -  aims o f t h e i r goals  b e s t use  1980,  t h a t are  more common and  ment v i e w s t h e b e h a v i o u r Certain psychiatric  logical  actions  as  ( M e l l o r , 1977)  of t h e i r  (Peplau,  in  (Curtin,  They must have  their  the  "protec-  p.  and  132). the  currently mobilized?  more t r a d i t i o n a l as a p o t e n t i a l  problems are  approach to  t h r e a t to the p a t i e n t .  c h a r a c t e r i z e d by  defective perception  elope-  impaired  (Kyes & H o f l i n g , 1980).  N u r s e s a r e 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 variety t o be  of p a t i e n t s  (Darcy,  highly suicidal,  staff  .  care,  time,  of elopement a u t o m a t i c a l l y warrant  resources  j u d g e m e n t and  they  o f the growing expense o f h e a l t h  accountable  economical  Does t h e  age  not  admitted  much t h e n ,  f o r the  (Matheney & T o p a l i s , 1974).  rational  well  just  the  There  t o be  How  what manner, s h o u l d p e o p l e Nurses cannot  on  of p a t i e n t s  p.  fit.  are  c o n t r a v e n t i o n of  infringement  of personal r i g h t s  a g r e a t v a l u e p l a c e d on  to express  The  I f they  1978). are  I f a p a t i e n t i s known  concerned  about the p a t i e n t  4  who  has disappeared.  As Darcy s t a t e s :  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 f o r , the nurse must be prepared to r e f u t e the a c c u s a t i o n t h a t she i s c u s t o d i a l or over-prot e c t i v e simply because she i s p r o t e c t i n g p a t i e n t s or s t a f f from harm. (p. 31) There i s l i t t l e w r i t t e n i n f o r m a t i o n on the p a t i e n t elopes.  who  In a R e g i s t e r e d Nurses' A s s o c i a t i o n o f 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 der the b e h a v i o u r a l concept  of d e p r e s s i o n .  un-  The nurse i s  i n s t r u c t e d to assess the p a t i e n t ' s p o t e n t i a l f o r ''selfm u t i l a t i n g and  suicidal acts" —  s i o n i s given as an example Tregunna, 1977,  p. 29).  with the p a t i e n t who  the behaviour  (Bastable, Gordon, M i l l e r , &  Another book a s s o c i a t e s elopement  uses p r o j e c t i o n or the p a t i e n t  abuses a l c o h o l and becomes " r e b e l l i o u s " 1974,  pp.  253,  under d i s c u s -  who  (Matheney & T o p a l i s ,  358).  Though r e b e l l i o n can be viewed as e i t h e r 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 c a t e g o r i z e d as a negative event. behavior  The author  of a "problem  i  r e p o r t sheet" l i s t s elopement as a "high d e f i a n c e "  problem behaviour  which " d e v i a t e s from the s t a f f d e s i r e d ,  standing p a t t e r n s of behavior" Another behaviour  ( B a i l e y , 1979,  pp.  488-494).  i n v e n t o r y which s t a t e s i t measures  "the  s e v e r i t y o f p s y c h o p a t h o l o g i c a l d i s t u r b a n c e i n the ward  be-  h a v i o r s of a d u l t p s y c h i a t r i c p a t i e n t s " a l s o l i s t s elopement (Burdock & Hardesty,  1979,  p. 221).  One  b e h a v i o u r a l check-  5  list ing of  c l a s s i f i e s elopement i n the same category as sexual a c t out, a s s a u l t i v e or t h r e a t e n i n g behaviour, and  p r o p e r t y (Moran,  destruction  1979).  Of the l i t e r a t u r e reviewed, o n l y three authors mention  elopement c o n s i d e r examining  haviour. for  ^Krall  who  the reason f o r the be-  (1976) simply s t a t e s t h e r e must be a cause  the behaviour and t h i s must be c o n s i d e r e d when p l a n n i n g  the p a t i e n t ' s treatment. t h a t p a t i e n t s who  Matheney and T o p a l i s  (1974) w r i t e  are s u s p i c i o u s b e l i e v e they are c o r r e c t i n  t h e i r concerns and t h a t h o s p i t a l i z a t i o n i s t h e r e f o r e unnecessary.  As a r e s u l t , they leave the h o s p i t a l without permis-  sion.  In an a n e c d o t a l account o f a p a t i e n t who  Vousden  eloped,  (1979) w r i t e s t h a t i f the p a t i e n t had been warned a  group o f people would be v i s i t i n g , the p a t i e n t might not have l e f t the u n i t . In  summary, d e s p i t e the concern nurses have when a  p a t i e n t e l o p e s from a p s y c h i a t r i c u n i t , t h e r e i s o n l y a l i m i t e d amount known about the behaviour.  When elopement i s  c o n s i d e r e d i n the l i t e r a t u r e , i t tends to be viewed t i v e event though t h e r e i s l i t t l e How  justification  as a nega-  for this.  the p a t i e n t p e r c e i v e s the behaviour i s not known.  Conceptual Framework Whether elopement i s a p o s i t i v e or a negative behaviour, nurses should have an understanding of the experiences of the p a t i e n t .  Since nurses are accountable to p a t i e n t s ,  they  should work w i t h them to r e s o l v e i s s u e s i n ways t h a t are most  6  beneficial  f o r them  ( P e p l a u , 1980).  n e e d s o f t h e p a t i e n t m i g h t be than  through  i n s t a n c e , the  some means o t h e r  elopement. Nursing  patient Curtin  has  as an (197 9)  acknowledged the need t o u n d e r s t a n d  i n d i v i d u a l who  106).  To  i s different  s t r e s s e s that each person  "filters...experiences (p.  met  In t h i s  through  from o t h e r  i s unique  h i s o r h e r own  best help the i n d i v i d u a l ,  the  and  people. thus  perceptions"  nurses  must have  some knowledge o f t h e p a t i e n t ' s p e r s p e c t i v e .  A variety  authors  Kyes & H o f l i n g ,  1980;  reiterate  Matheney  Kneisl  this point  & Topalis,  (1979) a d d r e s s  the  (Altschul,  1974;  Schrock,  issue i n this  1977;  1980).  Wilson  of  and  manner:  The n o t i o n t h a t p e o p l e a c t i n a s i t u a t i o n b a s e d on t h e u n i q u e meaning t h a t s i t u a t i o n has f o r them i s a l l b u t i g n o r e d i n many a p p r o a c h e s t o p s y c h i a t r i c nursing. I n s t e a d , human c o n d u c t i s t r e a t e d as t h e p r o d u c t o f 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 b e i n g s . . . . t h e meaning o f e x p e r i e n c e s for, t h e p a r t i c u l a r p e r s o n i s e i t h e r b y p a s s e d o r s w a l l o w e d by t h e o t h e r f a c t o r s t h a t a r e used t o 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 t h e r o l e o f meaning i n t h e f o r m a t i o n o f human b e h a v i o r . . . . t h e p s y c h i a t r i c n u r s e must be wary o f i n t e r v e n t i o n s t h a t c o n v e y an i n v a l i d a t i o n o f the. m e a n i n g o f an e x p e r i e n c e t o t h e 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 uation. A c o r o l l a r y i s t h e need f o r n u r s e s t o d e v e l o p 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 r e s p o n d i n g t o t h e m e a n i n g s w i t h i n t h e c l i e n t ' s frame o f r e f e r e n c e i n t h e hope o f a r r i v i n g a t a common g r o u n d o f n e g o t i a t e d meanings. (p. 6) Smith portance She  (1975), a C a n a d i a n  of examining  the everyday  a l s o emphasizes the  ual's experience  sociologist,  importance  w i t h i n the broader  world  d i s c u s s e s the  of the  of locating  im-  individual. the  sociocultural  individcontext:  [The s t u d y o f t h e i n d i v i d u a l ] i s n o t l e f t d a n g l i n g therefore. I t becomes an e s s e n t i a l p a r t o f t h e work  7  of understanding a t o t a l process. The m i c r o - s o c i o l o g i c a l l e v e l o f study o f the everyday world and the m a c r o - s o c i o l o g i c a l i n q u i r y . . . are p u l l e d i n t o a r e l a t i o n o f necessary interdependence .... The experienced world, the worlds i n which people are a c t u a l l y l o c a t e d and which o r g a n i z e t h e i r e x p e r i e n c e , are viewed as generated i n t h e i r v a r i e t i e s by an o r g a n i z a t i o n of s o c i a l and m a t e r i a l r e l a t i o n s because t h a t i s indeed how they are r e l a t e d . (p. 375) Kleinman  (1978) has c o n s t r u c t e d a conceptual framework  of the h e a l t h care system which acknowledges the  importance  of the p a t i e n t ' s p e r c e p t i o n and which a l s o l o c a t e s the p a t i e n t ' 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 h e a l t h care system as a c u l t u r a l system i n v o l v e s the  arti-  c u l a t i o n o f the h e a l t h , i l l n e s s , and h e a l t h care aspects o f societies. for this  Kleinman's framework has p r o v i d e d the d i r e c t i o n  study.  A s t a t e o f nonhealth has three dimensions: i l l n e s s , and s i c k n e s s .  S i c k n e s s i s a complex phenomenon  which has b i o l o g i c a l , p s y c h o l o g i c a l , and aspects  disease,  sociocultural  (Kleinman, E i s e n b e r g , & Good, 1978).  Kleinman s t a t e s  s i c k n e s s can be experienced i n three d i f f e r e n t  structural  domains o f the h e a l t h care system: the p r o f e s s i o n a l s e c t o r which i n c l u d e s s c i e n t i f i c medicine;  the f o l k s e c t o r which  i n c l u d e s n o n - p r o f e s s i o n a l h e a l e r s ; and the popular s e c t o r which i n c l u d e s the i n d i v i d u a l , the f a m i l y , and the network.  Each s t r u c t u r a l domain has i t s own  social  clinical  i t y which i n c l u d e s b e l i e f s , e x p e c t a t i o n s , r o l e s , and ships  (Kleinman,  1978).  realrelation-  For the same s i c k n e s s episode,  the  d i f f e r e n t domains would have d i f f e r e n t e x p l a n a t o r y models t o d e s c r i b e "what i s wrong w i t h the p a t i e n t and what should  8  be  done"  ( K l e i n m a n e t a l . , 1978,  different can  lead  sectors  i n t e r a c t , the  to c o n f l i c t i n g  is  commonly a s s o c i a t e d  is  v i e w e d as  processes. w i t h the or  interpersonal  concrete  from s i c k n e s s "  group, those  i n the  as  well  professional sector  as  social Neither  and  This  The  result  patient's  this  true  i s equally  (Kleinman e t  ethnic for  a l . , 1978).  located within historical  re-  social,  settings As  which  Kleinman  t o examine b o t h i n d i v i d u a l care  beliefs  and  a satisfactory analysis  of  89).  Problem  study i s designed view t h e i r  subjective the  alone gives (p.  non-technical,  ( K l e i n m a n , 1978). able  personal  as  dimensions of h e a l t h  healing"  Statement of the  and  experience  the  such i n f l u e n c e s  experiences are  " [ M o d e l s ] . . . m u s t be  sickness  --  associated  problems t h a t  88).  t e c h n i c a l , e c o n o m i c , and  actions.  patients  family  Disease  " I l l n e s s . . . i s most  life  p.  models  psychological  i s commonly  I l l n e s s i s v i e w e d as  i s a f f e c t e d by  c l a s s , or  from  disease  sector.  b i o l o g i c a l or  illness  ( K l e i n m a n , 1978,  influence personal states:  concept of  professional  concerned w i t h the  subjective  cultural,  The  response to d i s e a s e :  sickness  social  People's  w i t h the  sector.  When p e o p l e  a r t i c u l a t e d i n a highly personal,  idiom  sponse t o  expectations.  concept of  popular  254).  incorigruent explanatory  a d i s r u p t i o n i n the The  frequently  p.  own  to gain  elopements.  an  understanding of  This understanding  r e c o l l e c t i o n encompasses r e a s o n s  experiences during  the  elopement.  f o r the These  how or  behaviour  subjective  9  r e c o l l e c t i o n s are then analyzed w i t h i n the broader c o n t e x t o f the s o c i o c u l t u r a l s t r u c t u r e s which i n f l u e n c e the e x p e r i ences o f the p a t i e n t s .  Purposes o f the Study The purposes o f the study a r e : 1.  t o d e s c r i b e p a t i e n t s ' p e r c e p t i o n s o f what l e d t o t h e i r elopements;  2.  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 x p e r i e n c e s of the elopements;  3.  t o 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  4.  t o analyze the s u b j e c t i v e e x p e r i e n c e s o f 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 .  T h e o r e t i c a l and M e t h o d o l o g i c a l P e r s p e c t i v e o f the Study Phenomenology, which i s a p h i l o s o p h y , an approach, and a method, d e s c r i b e s human experience 1982).  as i t i s l i v e d  (Oiler,  T h i s approach was chosen as a p p r o p r i a t e f o r meeting  the purposes o f t h i s study because i t emphasizes  the under-  standing o f behaviour from the p a t i e n t ' s own p e r s p e c t i v e ( R i s t , 1979).  As Davis (1978) s t a t e s :  "human a c t i o n s are  h i g h l y s i t u a t i o n a l and human a c t o r s a c t i n .accord w i t h t h e i r c o n s t r u c t i o n s o f meaning f o r the concrete s i t u a t i o n s they f a c e "  (p. 194). The phenomenological approach thus  a l l o w s f o r a g r e a t e r depth o f understanding than i s u s u a l i n the more t r a d i t i o n a l methods o f i n v e s t i g a t i o n  (Rist,  1979).  10  Using t h i s approach a l s o melds with the p h i l o s o p h y of nursing profession: e x p e r i e n c e s " and own  "emphasizing a reverence f o r c l i e n t s '  advocating "the  world; d e f i n e r of h i s own Data c o l l e c t i o n and  i n d i v i d u a l as author of  reality"  ( O i l e r , 1982,  data a n a l y s i s d i f f e r  proaches used i n the more common q u a n t i t a t i v e  cause they " f i t " what i s being s t u d i e d .  One  compared and  noticed.  T h i s a l l o w s i d e n t i f i c a t i o n of the  the phenomenon and other"  contrasted  the way  ( O i l e r , 1982,  p.  the  180).  I t i s the  "As  are of  r e s p o n s i b i l i t y of  i n t e r p r e t a t i o n was  made by r e f e r r i n g to the reader can  the  r e l a t e to each  the  the  be-  descrip-  ingredients  r e s e a r c h e r to c l e a r l y i n t e r p r e t the data and  In t h i s way,  ap-  begins w i t h  the  collected.  178).  chosen  r e c u r r i n g elements  ingredients  his  investigations.  p e r c e p t i o n s of these p a r t i c i p a n t s .  t i o n s are  p.  from the  In the phenomenological approach, p a r t i c i p a n t s are  subjective  the  to show  how  information  determine i f the  r e s e a r c h e r ' s i n t e r p r e t a t i o n i s v a l i d ( C i c o u r e l , 1968). The  r e l a t i o n s h i p between p a r t i c i p a n t and  researcher i s  viewed i n a v e r y d i f f e r e n t manner than i n more orthodox forms of r e s e a r c h .  Schutz  (1970) d e s c r i b e s the concept of i n t e r -  s u b j e c t i v i t y which e x i s t s between two  people who  are  inter-  acting: T h i s world i s not only mine but a l s o my f e l l o w men's environment; moreover these f e l l o w men are elements of my s i t u a t i o n , as I am of t h e i r s . A c t i n g upon the others and acted upon by them I know of t h i s mutual r e 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 w i t h a unique background or knowledge, but  through a v e r b a l  i n t e r a c t i o n of q u e s t i o n i n g  11  and c l a r i f i c a t i o n one (Schutz, 1970).  can gain an understanding  of the other  T h e r e f o r e , the r o l e of the r e s e a r c h e r i s an  i n t e g r a l p a r t of phenomenological r e s e a r c h -- the major i n strument f o r the c o l l e c t i o n o f data i s the (Ragucci, 1972).  investigator  B i a s of the r e s e a r c h e r cannot be e l i m i n a t e d ,  but i t can be r e c o g n i z e d and i n c o r p o r a t e d i n t o the  study  (Davis, 197 8). Kleinman's  (1978) conceptual framework i s complemented  by the phenomenological approach to r e s e a r c h . cerned with the understanding vidual.  Each i s con-  of the p e r s p e c t i v e of the  indi-  The phenomenological approach p r o v i d e s the v e h i c l e  f o r e x p l o r i n g the c l i n i c a l r e a l i t y of those s e c t o r of the h e a l t h care system.  i n the  popular  Using Kleinman's concep-  t u a l framework, the r e s e a r c h e r i s then able to r e l a t e data to the surrounding  sociocultural  these  context.  Assumptions of the Study T h i s study i s based on three assumptions: has meaning f o r the person who  engages i n i t ;  elopement t h i s meaning  can be r e l a y e d to o t h e r s so they can b e t t e r e v a l u a t e care; and the p a t i e n t who  elopes w i l l  speak t r u t h f u l l y about the  experience.  L i m i t a t i o n s o f the Study There are two main l i m i t a t i o n s i h t h i s study. primary  The  l i m i t a t i o n i s the l i k e l i h o o d t h a t s u b j e c t s may  not  have always been f u l l y open i n the i n t e r v i e w s as some f e l t  12  uncomfortable pants  In a d d i t i o n ,  t h e d a t a may  been  requested data.  At times,  partici-  r e f u s e d t o answer o r c o n t i n u a l l y e v a d e d c e r t a i n  tions. of  in divulging  due  t o time  n o t have been as  constraints, fully  ques-  the r i c h n e s s  e x p l o r e d as m i g h t  have  possible.  Summary T h i s c h a p t e r has has  presented  p a t i e n t who  a survey  elopes  are  of the  from  amount i s known a b o u t w h i c h do e x i s t  d e s c r i b e d the problem literature  hospital.  I t has  t h i s behaviour  formulated  from  The  e x p l o r e the p a t i e n t ' s understanding  need t o p l a c e t h i s u n d e r s t a n d i n g tural  c o n t e x t were shown.  the  shown t h a t that  into  need  a  limited  the w r i t i n g s  f o r the  the nurse  o f e l o p e m e n t and the  and  psychiatric  the p e r s p e c t i v e o f  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 . to  and  on  under study  larger  the  sociocul-  Chapter Two Methodology  T h i s chapter d e s c r i b e s the methodological f o r t h i s study.  perspective  Four major areas w i l l be d i s c u s s e d :  s e l e c t i o n o f the p a r t i c i p a n t s f o r the study, data  the  collection,  data a n a l y s i s , and the e t h i c a l c o n s i d e r a t i o n s i n v o l v i n g the participants.  Selection of Participants Criteria for selection.  F i v e c r i t e r i a were u t i l i z e d  in selecting participants for this 1.  study:  The p a t i e n t s r e t u r n e d to the u n i t from which they  had e l o p e d .  T h i s r e t u r n c o u l d be o f the p a t i e n t s ' choice  or i t c o u l d be i n s p i t e o f t h e i r c h o i c e .  This  criterion  was employed so the r e s e a r c h e r would be able t o make c o n t a c t with the p a r t i c i p a n t s through an agency. 2.  The p a t i e n t s gave consent f o r the f i r s t  interview  with the r e s e a r c h e r w i t h i n 7 2 hours o f r e t u r n i n g from t h e i r elopements. pants'  T h i s time p e r i o d was e s t a b l i s h e d so the p a r t i c i -  experiences  would s t i l l  be v i v i d and c l e a r i n t h e i r  memories. 3.  The p a t i e n t s were f l u e n t i n E n g l i s h .  was important  This  criterion  because the i n t e r v i e w s needed f o r t h i s type o f  study r e q u i r e d indepth d i s c u s s i o n s .  14  4. to  T h i s was due.  the r e s e a r c h e r ' s i n t e r e s t i n the e x p e r i e n c e s o f a d u l t s . 5.  for  The p a t i e n t s were 18 years o r o l d e r .  The p a t i e n t s were competent t o give informed  consent  the i n t e r v i e w s . S e l e c t i o n procedure.  T h i s study was conducted on the  p s y c h i a t r i c u n i t s o f three g e n e r a l h o s p i t a l s i n the Vancouver area.  Depending on the p r e f e r e n c e o f the i n s t i t u t i o n i n v o l v e d ,  two methods were used t o a l e r t the r e s e a r c h e r when a p a t i e n t had r e t u r n e d from an elopement:  the s t a f f on a u n i t contacted  the r e s e a r c h e r or t h e r e s e a r c h e r r o u t i n e l y c o n t a c t e d the h o s p i t a l every second day. A f t e r c o n s u l t i n g with a s t a f f member t o v e r i f y t h a t the p a t i e n t was capable o f g i v i n g informed consent, the r e s e a r c h e r made the i n i t i a l The  c o n t a c t with the p a t i e n t who had e l o p e d .  study was e x p l a i n e d t o the p a t i e n t , and, i f the p a t i e n t  expressed an i n t e r e s t i n p a r t i c i p a t i n g , he o r she was shown the consent form  (see Appendix A ) .  signed by the p a t i e n t , t h e f i r s t  I f the consent form was  i n t e r v i e w then began.  D e s c r i p t i o n o f the p a r t i c i p a n t s .  There were three  female and two male p a r t i c i p a n t s i n t h i s study.  The o l d e s t  was 33 years o l d and the o t h e r s were under the age o f 25. All  the p a r t i c i p a n t s were Caucasian.  One o f the p a t i e n t s  was married, two were s i n g l e , and two were i n v o l v e d i n h e t e r o sexual r e l a t i o n s h i p s .  P r i o r t o h o s p i t a l i z a t i o n , three o f the  p a r t i c i p a n t s had l i v e d with t h e i r f a m i l i e s o f o r i g i n , one had l i v e d with h i s spouse and c h i l d r e n , and one had l i v e d  15  with a friend. employed  diagnoses as e i t h e r  l e n g t h o f time  ments r a n g e d  affective  the p a t i e n t s  Three  o r thought  had been i n h o s p i t a l  to three  Two  felt  they  sidered  t o be p o t e n t i a l l y  someone  else.  Approximately  individual  Such p a t i e n t s  harmful e i t h e r  i n the study.  to discuss their  t h e s t a f f might  committal  s h o u l d be i n h o s p i t a l  situation.  reassurance o f c o n f i d e n t i a l i t y ,  How  a r e con-  t o themselves  t o be a  cri-  D e s p i t e the r e s e a r c h e r ' s  they expressed  age d e m a r c a t i o n  regarding participation  or to  M o s t o f them were  have a c c e s s t o t h e d a t a .  this  who  though  concern  some  Most o f the  r e f u s e d t o t a l k w i t h t h e r e s e a r c h e r were  t h e age o f 35.  Data  elope-  t e n p e o p l e who met t h e r e s e a r c h e r ' s  were n o t i n c l u d e d  decision  from  forms f o r h o s p i -  o f t h e p a r t i c i p a n t s were on  t h e y d i d n o t want t o be t h e r e .  p e o p l e who  ranged  days.  T h i s meant two d o c t o r s and a n o t h e r  hesitant  The  The l e n g t h o f t h e a c t u a l  a few h o u r s  knew t h e p a t i e n t s  appear  disorders.  i n t h a t t h e y had s i g n e d c o n s e n t  talization.  of  to hospitalization.  o f t h e 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  papers.  from  had been un-  o f t h e p a r t i c i p a n t s were b r o a d l y c a t e -  t h r e e d a y s t o two months.  teria  participants  f o r t h e s i x months p r i o r  The gorized  Four o f the f i v e  "fits"  over  w i t h the  i s n o t known, b u t i t d i d  factor.  Collection Data  were c o l l e c t e d  i n audiotaped  i n t e r v i e w s w h i c h were  16  conducted i n the h o s p i t a l . four o f the p a r t i c i p a n t s . terview  s t a t i n g he was  Two  i n t e r v i e w s were h e l d with  One  "too  p a t i e n t r e f u s e d a second i n -  sick."  The  l e n g t h o f the  inter-  views ranged from 30 t o 90 minutes. The  first  i n t e r v i e w was  hours a f t e r p a t i e n t s had elopements.  to occur w i t h i n a maximum o f  returned  to the h o s p i t a l from t h e i r  Four of the i n i t i a l i n t e r v i e w s were, i n f a c t ,  completed w i t h i n 4 8 hours of the p a r t i c i p a n t ' s r e t u r n . concerns of the p a r t i c i p a n t s were the questions  72  were used e x t e n s i v e l y .  The  f o c i and open ended  However, the  were s t r u c t u r e d i n the sense t h a t the r e s e a r c h e r  interviews covered  c e r t a i n broad areas which were suggested by the purposes of the  study  (see Appendix B ) .  The  second i n t e r v i e w was  a f t e r the f i r s t .  conducted s i x to e i g h t days  In the time i n t e r v e n i n g , the f i r s t  was  t r a n s c r i b e d and analyzed.  two  main purposes:  The  to c l a r i f y any  a f t e r l i s t e n i n g to the p r e v i o u s the p a r t i c i p a n t ' s p e r c e p t i o n in  second i n t e r v i e w questions  tape; and  tape served  which arose  to a s c e r t a i n i f  of the experience had  altered  the i n t e r v e n i n g week. Construction  explained  of the accounts.  t h a t the r e s e a r c h e r  c i p a n t s viewed t h e i r own  The  formation  would d e s c r i b e how  elopements.  between each p a r t i c i p a n t and data.  In Chapter One,  s t r u c t i o n was  the r e s e a r c h e r  to gather  parti-  the  gathered the i n -  the c o n s t r u c t i o n o f the accounts. a f f e c t e d by both the  the  Interviews were h e l d  process by which the r e s e a r c h e r was  i t was  T h i s con-  individuals involved  as  17  e a c h came t o t h e i n t e r a c t i o n w i t h t h e i r own e x p e c t a t i o n s . taught  i n the c l i n i c a l  identify  certain  a r e a o f p s y c h i a t r y -- she t r i e d t o  The p a r t i c i p a n t s  her  t h e r e was a n y t h i n g t o say —  results. an  acknowledged they,  gruent  "special"  felt  nurses  the r e s e a r c h e r would  asked like  she wanted t h e r e s e a r c h e r t o o b t a i n t h e " r i g h t "  A l l o f t h e 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  ensure the p a r t i c i p a n t i n their  searcher  -- b o t h  One o f t h e p a r t i c i p a n t s  o p p o r t u n i t y t o make a s t a t e m e n t To  t o o , had  Two o f t h e p a r t i c i p a n t s  t o the r e s e a r c h e r as " d o c t o r "  d i d n o t engage i n r e s e a r c h . if  assumptions about p a t i e n t s  i d e a s about the i n t e r a c t i o n .  referred  own e x p e r i e n c e s and  The r e s e a r c h e r had worked and had  h e r own p r e c o n c e i v e d  who e l o p e d .  their  understanding  about t h e i r  difficulties.  and t h e r e s e a r c h e r were o f events  f r e q u e n t l y sought c l a r i f i c a t i o n  from t h e p a r t i c i p a n t .  Even w i t h  this  that misunderstandings  c o u l d have  con-  o r words, t h e r e o r f u r t h e r data  approach, i t i s l i k e l y  occurred.  Data A n a l y s i s A f t e r each i n t e r v i e w , t h e r e s e a r c h e r t r a n s c r i b e d t h e audiotape.  The r e s e a r c h e r t h e n  examined e a c h  n o t i n g e m e r g i n g t r e n d s o r themes. in  relation  to the l i t e r a t u r e .  transcript,  These were t h e n  B a s e d on c o n s t a n t  a n a l y s i s o f t h e d a t a and t h e i n v e s t i g a t i o n  examined comparative  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  future interviews with  The  m a j o r theme w h i c h was c o n s t r u c t e d f r o m t h e a n a l y s i s o f  the  d a t a was t h e c o n c e p t  which the researcher  participants.  felt  was t h e  18  most c o n s i s t e n t  a n d t h e most u n i f y i n g  f o r each  participant.  Ethical Considerations Ethical ways.  Before  c o n s i d e r a t i o n s were a d d r e s s e d contacting the patient,  i n a variety of  the researcher  dis-  c u s s e d w i t h a s t a f f member t h e competency o f t h e p a t i e n t t o give  an i n f o r m e d  consent  and t h e n p e r s o n a l l y a s s e s s e d  this  competency. After  t h e r e s e a r c h e r had c l a r i f i e d  was e x p l a i n e d t o t h e p a t i e n t . reiterated patient and  i n the consent  had t h e r i g h t  that  her r o l e ,  T h i s same-information  form.  I t was s t a t e d  to refuse to participate  such a r e f u s a l  the study  would n o t a f f e c t  was  that the i n the study  the care r e c e i v e d .  P a t i e n t s were a s s u r e d t h a t t h e i n t e r v i e w m a t e r i a l s would be kept  confidential  mation.  except  They were t o l d  i n cases o f l i f e their  tapes o r i n the t h e s i s .  if  names w o u l d n o t a p p e a r on t h e  I t was a l s o e x p l a i n e d t h a t t h e  t a p e s w o u l d be e r a s e d a f t e r The  t h e t h e s i s was  p a t i e n t s were i n f o r m e d  they p a r t i c i p a t e d  i n the study.  the o p p o r t u n i t y t o t a l k  s t u d y m i g h t be b f b e n e f i t were a l s o study  informed  I t was e x p l a i n e d f o r them o t h e r  about  a t any p o i n t i n t i m e .  risk that,  than  the experience, the  t o o t h e r s i n the f u t u r e .  t h e y had t h e r i g h t  a summary o f t h e r e s u l t s  written.  t h e r e was no e x p e c t e d  w h i l e t h e r e may be no known b e n e f i t having  threatening infor-  They  t o withdraw from t h e  F o r t h o s e who were  o f t h e s t u d y was  interested,  offered.  19  Summary This chapter plore  has  d e s c r i b e d the methodology used t o  t h e p e r c e p t i o n s o f p a t i e n t s who  psychiatric f o r the  unit.  selection  The  researcher's c r i t e r i a  o f the p a r t i c i p a n t s  the  selection  procedure  The  concurrent processes  were d i s c u s s e d . the  study  have e l o p e d  and  collection  A discussion of ethical  completed  the  chapter.  a  rationale  were d e s c r i b e d as  the p a r t i c i p a n t s  of data  and  from  ex-  were  themselves. and  data a n a l y s i s  considerations for  Chapter The  This  c h a p t e r has  the r e a d e r the  of A n a l y s i s of the  two  purposes:  1  will  to r e l a t e  (1978) c o n c e p t u a l  enable  the  Introduction  i n the  few  preconceived  interviews with  the  first  noted  individuals  the  t h a t both over  their  hospital.  related  The  literature  occurred  and  as t h e  c e p t i o n s o f the strengthened. alienation,  strate  how  lives  the i n t e r p r e t a t i o n  of  following chapter.  participants,  identified  and  at this  entered  i d e a s as p o s s i b l e .  a sense  point.  As  a sense  The  further  concept,  in  of  these  the  per-  and  that of  framework w h i c h  following chapter w i l l data.  of  interviews  the trends p e r s i s t e d  theme m e l d s w i t h t h e  20  "fit"  investigation  p r o v i d e d an e x p l a n a t o r y  of the data.  After  of a loss  r e s e a r c h e r began t o f o c u s on  r e s e a r c h e r , one  the  however, i t was  they d i d not  r e s e a r c h e r began an  F o r the  the  two  participants,  clearly  "made s e n s e "  from  This information  r e s e a r c h , she  w i t h as  control  constructed  t o t h e Theme  When t h e w r i t e r began t h e process  introduce  t h i s theme t o  framework.  reader to understand  data which i s p r e s e n t e d  Data  to b r i e f l y  t o t h e m a j o r theme w h i c h was  a n a l y s i s o f t h e d a t a and  Kleinman s  the  Process  Three  demon-  21  The term a l i e n a t i o n was used by the a n c i e n t Greeks and Romans t o denote the t r a n s f e r o f p r o p e r t y o r the s a l e o f goods.  The Romans a l s o used the word i n d e s c r i b i n g  mental c a p a c i t y  (Ludz, 1981).  one's  I t can thus be seen a l 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 o f our modern age. The term has r e c e n t l y been used i n a v a r i e t y o f d i s c i p l i n e s : theology, p h i l o s o p h y , h i s t o r y , p s y c h i a t r y , psychology, s o c i ology, anthropology, ethnography, economics, and e d u c a t i o n (F.  Johnson, 1973b).  Despite i t s h i s t o r y and frequent use,  a l i e n a t i o n i s not a c l e a r l y d e f i n e d concept. and s t i l l  I t has been,  i s , i n t e r p r e t e d i n a myriad o f ways:  The p r o l i f e r a t i o n o f a l i e n a t i o n concepts, terms, and synonyms which has o c c u r r e d i n r e c e n t years has produced a c o r r e s p o n d i n g i n t e r e s t i n f i n d ing a core theme, common denominator, o r u n i f y i n g m u l t i d i m e n s i o n a l concept under which a l l v a r i e t i e s of a l i e n a t i o n can be subsumed. The suggestion i s t h a t a l i e n a t i o n i s a "syndrome" o f d i v e r s e forms which d i s p l a y a c e r t a i n u n i t y , and t h e r e i s a common meaning which extends beyond some general notion of separation. Whether t h i s s u g g e s t i o n i s p l a u s i b l e , o r whether i t i s even worthwhile to pursue, i s a matter f o r debate. (Geyer & Schweitzer, 1976, p. x x i i i ) Hays (1976), who uses a p s y c h o l i n g u i s t i c approach t o analyze e x i s t i n g t h e o r i e s o f a l i e n a t i o n , expresses r e l i e f a t o n l y having t o t r a n s c r i b e t h e o r i e s r a t h e r than decide which i s the  " r i g h t " one. O v e r a l l , however, a l i e n a t i o n i s viewed as a l a c k o f a  bond between an i n d i v i d u a l and something o r someone e l s e . Although u s u a l l y viewed as a n e g a t i v e occurrence (F. Johnson, 1973a), a l i e n a t i o n i s a l s o sometimes viewed as being e i t h e r  22 of p o s i t i v e or of n e u t r a l v a l u e . that perception and  Two  major c a t e g o r i e s  by most w r i t e r s  objective  states individual  (1981) s t a t e s t h a t a l i e n a t i o n can  creative individual.  and  (1982)  o f a l i e n a t i o n can b e n e f i t both the  s o c i e t y ; Ludz  are d e l i n e a t e d  Schweitzer  alienation.  i n the  the  of a l i e n a t i o n  field:  In s u b j e c t i v e  aid  subjective  alienation:  A t t e n t i o n i s focussed upon p s y c h o l o g i c a l s t a t e s — upon people's p e r c e p t i o n s o f , f e e l i n g s about and a t t i t u d e s toward the s i t u a t i o n s and r e l a t i o n s h i p s i n which they f i n d themselves. The forms of d i s cord encountered here might thus be termed " e x p e r i ential." (Schachi;, 1976, p. 136) In o b j e c t i v e  alienation:  A t t e n t i o n i s focussed upon s o c i a l r e l a t i o n s — u p o n the [ l a c k o f ] i n t e g r a t i o n or "mutual f i t " of the behavior and a c t i v i t i e s of i n d i v i d u a l s w i t h the conventions and e x p e c t a t i o n s 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 o r d e r i n which they l i v e . The forms of d i s c o r d here might thus be termed " s o c i a l s t r u c tural." (Schacht, 1976, p. 136) Thus, one  category r e l a t e s t o the p s y c h o l o g i c a l  situation  w h i l e the o t h e r r e l a t e s to the s o c i o l o g i c a l s i t u a t i o n . examining the two  categories  t a i n amount of o v e r l a p p i n g of one  In  of a l i e n a t i o n , there i s a c e r -  of i d e a s .  or the other i s apparent and  Usually the  a dominance  researcher  has  separated the readings on t h i s b a s i s .  Relationship As patient system.  of A l i e n a t i o n to Kleinman's Conceptual Framework  stated  i n Chapter One,  i n Kleinman's model the  i s a member of the p o p u l a r domain of the h e a l t h As  t i o n s , and  such, the  i n d i v i d u a l has  e x p l a n a t o r y models.  The  care  c e r t a i n b e l i e f s , expectaperceptions,  feelings,  23  and a t t i t u d e s which e x i s t i n s u b j e c t i v e a l i e n a t i o n can be l o c a t e d w i t h i n t h i s sphere o f K l e i n m a n s model. 1  Interacting  w i t h the p o p u l a r domain are the p r o f e s s i o n a l and f o l k s e c t o r s of the h e a l t h care system and the e x t e r n a l f a c t o r s which a f f e c t the h e a l t h care system as a whole. the s i t u a t i o n which surrounds  The r e a l i t y o f  the p a t i e n t can be seen as a  p o t e n t i a l source o f o b j e c t i v e a l i e n a t i o n . In r e c e n t years, emphasis has been p l a c e d on the concept of s u b j e c t i v e a l i e n a t i o n .  As a r e s u l t , problems i n the  s o c i a l s t r u c t u r e have been i g n o r e d .  Geyer and Schweitzer  (1976) s t a t e t h a t even when a l i e n a t i o n i s seen as a subject i v e e x p e r i e n c e , the o b j e c t i v e circumstances the experience should be examined.  surrounding  T h i s would a l l o w the r e -  searcher t o make a judgement about the s o c i o c u l t u r a l surrounding the i n d i v i d u a l ' s  context  feelings:  What i s a t stake here i s a choice n o t so much between o b j e c t i v e and s u b j e c t i v e d e f i n i t i o n s o f a l i e n a t i o n , but between competing e p i s t e m o l o g i e s and departure p o i n t s e x p l i c i t l y a s s o c i a t e d with these d i s t i n c t conceptualizations of alienation. The choice between o b j e c t i v e and s u b j e c t i v e concepts, w i t h t h e i r concomitant p o i n t s o f departure, determines not o n l y the way q u e s t i o n s and answers are formulated, but a l s o the methodologies, s t r a t e g i e s , and remedies f o r change, a c t i o n , and d e - a l i e n a t i o n . (Schweitzer, 1982, p. 69) Twaddle  (1982) r e i n f o r c e s the need f o r an examination  of the i n d i v i d u a l ' s f e e l i n g s and the surrounding c o n t e x t . He d e s c r i b e s a movement from medical s o c i o l o g y t o a s o c i o l o g y of health.  In the p a s t , emphasis has been p l a c e d on the  b i o l o g i c a l , p s y c h o l o g i c a l , and s o c i a l dimensions v i d u a l i n poor h e a l t h .  of an i n d i -  Now, emphasis i s being p l a c e d "on  24  a l l k i n d s o f events, s t r u c t u r e s , e t c . t h a t l i m i t choice and/or  reduce p e r s o n a l e f f e c t i v e n e s s "  freedom of  (p. 349).  some c r i t i c s have s t a t e d t h a t a movement toward  While  examining  l a r g e r s o c i a l u n i t s w i l l l e a d t o dehumanization,  o t h e r s be-  l i e v e t h a t c e r t a i n events can o n l y be a c c u r a t e l y  understood  by examination a t a h i g h e r l e v e l than the i n d i v i d u a l 1982).  Twaddle  (Twaddle,  (1982) makes an eloquent p l e a f o r both  levels  of examination: I am v e r y d i s t u r b e d by the stance o f some o f my c o l l e a g u e s t h a t understanding macrosystemic p r o cesses and s t r u c t u r e s i s both necessary and s u f ficient. E q u a l l y necessary, and e q u a l l y i n s u f f i c i e n t , are the microsystemic s t r u c t u r e s and p r o c e s s e s : 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 t o be aware o f both the a t o m i s t i c and the e c o l o 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 f o r m a i n t a i n i n g a d i a l e c t a l cons c i o u s n e s s o f the f a c t t h a t s o c i e t i e s are s i m u l t a n e o u s l y made o f s t r u c t u r e s and people. (p. 356)  I m p l i c a t i o n s f o r T h i s Study I n f l u e n c e d by the w r i t i n g s o f Twaddle and Schweitzer  (1982), and Geyer  (1976), t h i s study addresses both s u b j e c t i v e  and o b j e c t i v e a l i e n a t i o n .  The phenomenological  approach  promotes the understanding o f the s u b j e c t i v e experiences of the p a r t i c i p a n t s .  Kleinman's  c o n c e p t u a l framework p r o -  motes the a n a l y s i s o f these e x p e r i e n c e s w i t h i n the broader s o c i o c u l t u r a l context. The r e s e a r c h e r has presented the f i n d i n g s o f t h i s i n the f o l l o w i n g format.  study  Chapter Four addresses the l i t e r a -  t u r e on both s u b j e c t i v e and o b j e c t i v e a l i e n a t i o n .  The 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 p a r t i c i p a n t s ' accounts are  25  then interwoven  w i t h an e x a m i n a t i o n  o f the h e a l t h  care  system.  Summary In t h i s c h a p t e r , the c o n s t r u c t i o n o f t h e c o n c e p t alienation 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  Kleinman's approach  f r o m t h e a n a l y s i s o f t h e d a t a has  c o n c e p t u a l framework and  to research.  of  been d e s c r i b e d .  have been r e l a t e d  to the  to  phenomenological  Chapter  Four  Alienation  In t h i s chapter, some o f the l i t e r a t u r e on both  subjec-  t i v e a n d . o b j e c t i v e a l i e n a t i o n i s presented and examined. Because o f the s p e c i f i c theme which emerged from the a n a l y s i s of the data and because most of the i n f o r m a t i o n on  this  t o p i c i s i n the f i e l d o f s o c i o l o g y , the l i t e r a t u r e  review  i s l a r g e l y based on w r i t i n g s i n s o c i o l o g y . l a y s the foundation f o r understanding  This  review  the f e e l i n g s and  c e p 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.  per-  These e x p e r i -  ences w i l l be shown to be a r e f l e c t i o n o f the l a r g e r s o c i o c u l t u r a l context i n which they took p l a c e . The 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 o f the p a r t i c i p a n t s are o r g a n i z e d a c c o r d i n g to Seeman s (1959/1972) 1  conception and the concept o f o b j e c t i v e 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 h i g h l i g h t e d .  L i t e r a t u r e Concerning  Subjective Alienation  Before embarking on the a c t u a l review of the  literature,  the r e s e a r c h e r f e e l s o b l i g a t e d to e n t e r a caveat to the reader: T h i s 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 a l i e n a t i o n ] has c e r t a i n l y not r e s u l t e d 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 n e a r l y everyone c o n c e p t u a l i z e s a l i e n a t i o n i n a 26  27  s l i g h t l y d i f f e r e n t way, without b o t h e r i n g to s p e c i f y the d i f f e r e n c e s and the s i m i l a r i t i e s w i t h the a l i e n a t i o n concepts used by o t h e r s . Research r e s u l t s are consequently d i f f i c u l t t o compare, l e t alone to accumulate. These d i f f i c u l t i e s , i n t u r n , impede e f f e c t i v e theory b u i l d i n g . (Geyer, 1976, p. 189) Seeman's c o n c e p t u a l i z a t i o n o f s u b j e c t i v e  alienation.  Seeman's 195 9 p i e c e , "On the Meaning o f A l i e n a t i o n , " i s cons i d e r e d a c l a s s i c work on s u b j e c t i v e a l i e n a t i o n .  His a r t i c l e ,  which appears to be the c a t a l y s t f o r much o f the renewed interest in this field,  is still  (Geyer, 1976; Ludz, 1976;  a basis for discussion  Schweitzer, 1982).  While he  later  expanded the number o f c a t e g o r i e s to s i x , 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 a l i e n a t i o n was expressed.  The o r i g i n a l f i v e c a t e g o r i e s o f power-  l e s s n e s s , meaninglessness, normlessness, i s o l a t i o n ,  and  self-estrangement d e a l t p r i m a r i l y w i t h "the i d e a s of expectat i o n and v a l u e " (p. 46).  He acknowledged  the need f o r r e -  s e a r c h t o determine what s o c i a l c o n d i t i o n s caused the v a r i o u s types o f a l i e n a t i o n j u s t as he acknowledged h a v i o u r a l consequences  o f a l i e n a t i o n must be  t h a t the beinvestigated.  Seeman thus saw h i s work as an attempt t o o r g a n i z e a common language f o r those i n the f i e l d -- he d i d not see i t as an answer to a l l q u e s t i o n s about the concept. W r i t i n g s r e f l e c t i n g Seeman's work. 1972)  work d i s c u s s i n g modern i n d u s t r y was  o f s u b j e c t i v e and o b j e c t i v e  Blauner's  (1964/  actually a hybrid  alienation:  A l i e n a t i o n i s viewed as a q u a l i t y o f p e r s o n a l experience which r e s u l t s from s p e c i f i c k i n d s o f s o c i a l a r r a n g e m e n t s . . . A l i e n a t i o n i s a g e n e r a l syndrome made  28  up of d i f f e r e n t o b j e c t i v e c o n d i t i o n s and s u b j e c t i v e f e e l i n g - s t a t e s which emerge from c e r t a i n r e l a t i o n s h i p s between workers and the sociotechn i c a l s e t t i n g s 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 h i s conceptualization  of a l i e n a t i o n :  subjective-objective  h i s four  a l i e n a t i o n can  subcategories  be d i r e c t l y l i n k e d  Seeman's s u b c a t e g o r i e s of s u b j e c t i v e  of  to  alienation.  Geyer (1976) u t i l i z e d a g e n e r a l systems theory approach in analyzing alienation.  Individuals  were viewed as  i n i n t e r a c t i o n with t h e i r environments.  systems  Because o n l y human  beings have p o t e n t i a l awareness o f t h e i r s t a t e , o n l y they as i n d i v i d u a l s can  Seeman's f i v e  types  of a l i e n a t i o n were seen as v a r i o u s problems which c o u l d  arise  i n the  be  seen as a l i e n a t e d .  i n f o r m a t i o n p r o c e s s i n g by  ness, or the expectancy h e l d by determine the  system.  system's output.  i n two  important ways:  Thus, powerless-  i n d i v i d u a l s t h a t they cannot  outcome they seek, was  i n the  l e v e l and  the  r e l a t e d to a d i f f i c u l t y  Geyer's work d i f f e r s from Seeman's 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  i t a l s o r e l a t e s the  causes of a l i e n a t i o n to  the  system. Bloch  (1978), who  of a l i e n a t i o n , t r a c e d logical factors.  u t i l i z e d Seeman's f i v e i t s causes to e i t h e r  While she  d i d not  s o c i a l or psycho-  develop her own  of a l i e n a t i o n , she  c i t e d a s e r i e s of s t u d i e s  the  health  concept to the  l a r l y relevant  because she  i n a l i e n a t i o n and  she  care f i e l d . stated  categories  how  Her  theory  which r e l a t e d  work i s p a r t i c u -  nurses can  intervene  u t i l i z e d c l i n i c a l examples as  illus-  29  trations. D. Johnson  (1967) , who d i s c u s s e d powerlessness as a  v a r i a t i o n o f Seeman's conception o f a l i e n a t i o n , it  described  as a more o r l e s s permanent p e r s o n a l i t y t r a i t .  i n c o n t r a d i c t i o n t o Seeman s 1  This i s  (1959/1972) own viewpoint.  L i n k i n g the subtheme w i t h R o t t e r ' s s o c i a l l e a r n i n g t h e o r y , she s t a t e d t h a t i f powerlessness was high, l e a r n i n g was adversely affected.  T h i s would o b v i o u s l y i n f l u e n c e the  t e a c h i n g nurses d i d with p a t i e n t s .  I f a nurse r e c o g n i z e d  the powerlessness of a p a t i e n t who was extremely  dependent,  the nurse might be b e t t e r able t o cope w i t h the s i t u a t i o n . Johnson thus a p p l i e d the concept d i r e c t l y t o n u r s i n g p r a c t i c e though, l i k e B l o c h (1978), she d i d not formulate her own d e f i n i t i o n o f the concept. Roberts  (1978) , l i k e D. Johnson  (1967) , addressed  powerlessness as a v a r i a t i o n o f Seeman's conception o f a l i e n a t i o n and d e s c r i b e d two causes:  a l a c k o f knowledge  o r a l o s s o f p s y c h o l o g i c a l , p h y s i c a l , o r environmental control.  Due t o the f e e l i n g s o f powerlessness e x p e r i e n c e d by  a p a t i e n t , h i s o r her behaviour may be a l t e r e d .  One o f the  b e h a v i o u r a l p o s s i b i l i t i e s d e s c r i b e d was " a c t i n g out" and elopement  was i d e n t i f i e d as a c t i n g out by some o f the authors  quoted i n Chapter One.  Roberts' work i s u s e f u l due t o her  suggestions on how the nurse can help the p a t i e n t  reduce  the experience o f a l i e n a t i o n . Conceptual frameworks f o r s u b j e c t i v e Keniston  alienation.  (1972) has attempted t o d e f i n e s u b j e c t i v e  alienation  30  on the b a s i s o f f o u r f a c e t s : agent.  f o c u s , replacement, mode, and  Focus asks from what i s the person a l i e n a t e d ; r e -  placement  asks what r e p l a c e s the o l d r e l a t i o n s h i p ; mode  asks how i s the a l i e n a t i o n shown; and agent asks who o r what decided on t h i s f e e l i n g .  Keniston used a l i e n a t i o n t o r e f e r  o n l y t o those s i t u a t i o n s which the i n d i v i d u a l has chosen to reject.  H i s use o f the term thus excluded such s i t u a t i o n s  as a person being r e j e c t e d by an i n s t i t u t i o n o r another i n dividual.  T h i s i s a s i g n i f i c a n t departure from some of the  definitions. Manderscheid  (1981) formulated a b i o p s y c h o s o c i a l model  which viewed a l i e n a t i o n as a method o f coping w i t h s t r e s s . T h i s model i s being d i s c u s s e d under the heading o f s u b j e c t i v e 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 psychol o g i c a l and p h y s i o b i o c h e m i c a l r e a c t i o n s t o s t r e s s : A l i e n a t i o n was c o n c e p t u a l i z e d as an i n t e r v e n i n g v a r i a b l e c o n t i n g e n t on t h e dynamics o f s o c i a l s t r u c t u r e and antecedent t o p e r c e p t u a l s t y l e . . . and a l i e n a t i o n was viewed as a s u c c e s s f u l form of coping w i t h s t r e s s . (p. 178) T h i s model i s noteworthy  f o r f o u r reasons:  i t acknowledges  both s u b j e c t i v e and o b j e c t i v e a l i e n a t i o n ; i t addresses both o v e r t and c o v e r t responses t o s t r e s s ; i t s t a t e s t h a t  indi-  v i d u a l s need n o t be aware o f t h e i r s t r e s s ; and i t views a l i e n a t i o n as p o s i t i v e . Shoham (1976) viewed o n t o l o g i c a l framework.  s u b j e c t i v e a l i e n a t i o n w i t h i n an  In h i s p e r s o n a l i t y theory, people  were i n e v i t a b l y a l i e n a t e d due t o the three developmental stages o f b i r t h , the formation o f an ego boundary,  and the  31  s o c i a l i z a t i o n process: A f t e r 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 l o n e l y and t r y i n g d e s p e r a t e l y t o r e g a i n the togetherness of h i s l o s t fold. 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 e i t h e r l e g i t i m a t e o r i l l e g i t i m a t e paths, e i t h e r s t r i c t l y acceptable or d e v i a n t avenues, (p. 106) In  t h i s c o n c e p t u a l i z a t i o n , then, people are a l i e n a t e d  they cannot a l t e r t h i s  and  fact.  A p p l i c a t i o n of the concept t o the t h e r a p e u t i c m i l i e u . F. Johnson his  (1976) employed a phenomenological  psychotherapy  with s c h i z o i d a l p a t i e n t s .  withdrawn i n d i v i d u a l s were viewed  approach i n These s e v e r e l y  as e x p e r i e n c i n g a  self-  a l i e n a t i o n w i t h o n t o l o g i c a l concerns a t the crux of t h e i r experiences.  As w e l l 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 i n t h e i r actions.  By emphasizing  the d i r e c t i o n given by phenomenology,  Johnson focussed on i n t e r a c t i v e techniques such as  examining  the meaning o f the experience f o r the p a t i e n t and u s i n g empathy and c l o s e n e s s i n h i s treatment.  Johnson thus r e -  l a t e d a l i e n a t i o n to p a t i e n t s with a p a r t i c u l a r p s y c h i a t r i c d i a g n o s i s and he used h i m s e l f as the major t h e r a p e u t i c t o o l . C a r s e r and Doona (1978) addressed a l i e n a t i o n as a p r i m a r i l y s u b j e c t i v e experience which can be e i t h e r p o s i t i v e or  n e g a t i v e f o r the i n d i v i d u a l .  The concept was  used  by  the authors t o help t h e i r n u r s i n g students to become more aware of a l i e n a t i o n as i t a f f e c t e d themselves patients.  and  their  32  In a very b r i e f v i g n e t t e , Aspy (1972) d e s c r i b e d experience  of an i n d i v i d u a l who  c a t a r a c t surgery.  was  admitted  the  to h o s p i t a l f o r  A sense o f bewilderment and a l o s s o f con-  t r o l were c l e a r l y o u t l i n e d as a r e l a t i v e l y h e a l t h y person was  processed  i n t o the r o l e of a p a t i e n t .  L i t e r a t u r e Concerning O b j e c t i v e A l i e n a t i o n Schaff  (1980) wrote t h a t to d e f i n e both s u b j e c t i v e  and  o b j e c t i v e a l i e n a t i o n by u s i n g the same noun c r e a t e s a d i f f i c u l t y because the two  concepts are q u i t e d i f f e r e n t .  He  suggested t h a t a d i f f e r e n t term f o r each would help to the s i t u a t i o n .  He viewed a connection  though, as s u b j e c t i v e a l i e n a t i o n was objective alienation.  between the  two,  seen as a d e r i v a t i v e of  To S c h a f f , d e a l i n g o n l y with  t i v e a l i e n a t i o n d i d not convey a t r u e understanding situation: process ous  clarify  subjecof a  " O b j e c t i v e a l i e n a t i o n i s always primary, the  of change s t a r t s w i t h i t , which l a t e r leads to v a r i -  forms of s u b j e c t i v e a l i e n a t i o n " (p. 66). The  w r i t i n g s of Marx ( F i n i f t e r , 1972)  are  the c l a s s i c works on o b j e c t i v e a l i e n a t i o n .  considered  Because h i s w r i t -  ings focussed on the work f o r c e , many of the c u r r e n t continue  to r e f l e c t t h i s i n f l u e n c e .  researcher  Due  articles  to the f a c t t h a t the  i s i n t e r e s t e d i n o b j e c t i v e a l i e n a t i o n as i t r e -  l a t e s to p a t i e n t s , t h i s aspect of the concept w i l l not emphasized.  There are, however, two  crucial points:  there i s i n e q u a l i t y i n the d i s t r i b u t i o n of v a l u a b l e  be 1)  resources  (Nowakowska, 1981); 2) because of the v e r t i c a l h i e r a r c h y i n  33  most b u r e a u c r a c i e s ,  w i t h c o n t r o l h e l d by only a few i n d i -  v i d u a l s , people who are a t the bottom o f an o r g a n i z a t i o n are o f t e n powerless t o a f f e c t what occurs  (Cherns, 1981;  Olsen, 1976). " A l i e n a t i o n . m e a n s a s o c i a l s i t u a t i o n which i s beyond the c o n t r o l o f the a c t o r , and hence, unresponsive to h i s b a s i c human needs" ( E t z i o n i , 1968, p. 879). E t z i o n i s t a t e d t h a t a c e r t a i n degree o f a l i e n a t i o n was i n e v i t a b l e : i n g one need, another need might be thwarted.  i n meet-  He a l s o saw,  however, t h a t most forms o f a l i e n a t i o n were r e d u c i b l e . A l i e n a t i o n c o u l d u s u a l l y be decreased through the r e d i s t r i b u t i o n o f power o r through t h e development o f s o c i o c u l t u r a l patterns  which would be more responsive  t o human needs.  E t z i o n i ' s viewpoint again demonstrates the i d e a t h a t some e x t e r n a l f o r c e i s n e g a t i v e l y a f f e c t i n g the degree o f c o n t r o l h e l d by an i n d i v i d u a l . Etzioni  (1968) a l s o addressed the way i n which the  structures of organizations  a f f e c t people.  An a u t h e n t i c  s o c i a l c o n d i t i o n was one which appeared t o be, and s t r u c t u r a l l y was, responsive were seen as being ance o f being  inauthentic:  responsive  d i d not permit t h i s . t h i s work.  t o human needs.  Some s t r u c t u r e s  while they gave the appear-  t o needs, the u n d e r l y i n g  structure  An important p o i n t i s being made i n  While groups may say one t h i n g , t h e i r  actions  may not be congruent w i t h t h e i r s t a t e d p h i l o s o p h i e s .  A  h i g h l y 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) d e v i s e d  a t a b l e f o r r e l a t i n g the  34  l e v e l of s o c i a l r e l a t i o n s h i p s i e n c e s of a l i e n a t i o n . table the  The  or a s s o c i a t i o n s  between an  to which he or she  i n d i v i d u a l and  belonged.  An  To  an  and  described  organization  i n d i v i d u a l was  f l u e n c e d by p a r t s of an o r g a n i z a t i o n dealt with d i r e c t l y .  exper-  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  dealt with i n s t i t u t i o n a l r e l a t i o n s h i p s  association  to the  seen as i n -  which the person never  a c e r t a i n extent, a l i e n a t i o n  seen as i n e v i t a b l e i n a s o c i a l o r g a n i z a t i o n ,  was  but:  T h i s b a s i c and i n e v i t a b l e estrangement i s e i t h e r amplif 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 s y m b o l i c a l l e v e l ) w i t h the o v e r a l l purposes, e t h i c s , and norms of the larger organization. I f one's s t a t u s and i d e n t i f i c a t i o n w i t h i n the i n s t i t u t i o n are agreeable, then the experience of both s o c i a l and p s y c h o l o g i c a l alienation would be minimized. Conversely, i f one's s t a t u s i s f e l t t o 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 o f the i n s t i t u t i o n (or f i n d s such goals meaningless), the sense of a l i e n a t i o n would be high. (p. 375) As  i n E t z i o n i ' s viewpoint, a l i e n a t i o n  degree o f a l i e n a t i o n can individual's  vary w i t h the o r g a n i z a t i o n  " f i t " with t h a t  In summary, o b j e c t i v e "lack of f i t " between an which he or she  belongs.  i s i n e v i t a b l e , but  the  and  the  organiqation.  a l i e n a t i o n can  i n d i v i d u a l and  be viewed as  some s t r u c t u r e  This lack usually  involves  a  a to valu-  able resource such as c o n t r o l , of which there i s o n l y a l i m i t e d amount. Writings r e l a t i n g objective care system. was  Geiger  hospitalized  a l i e n a t i o n and  the  health  (1975) d e s c r i b e d h i s experience when he  on the  u n i t on which he was  an  intern:  At one moment I was a p h y s i c i a n : e l i t e , technically s k i l l e d , vested w i t h a u t h o r i t y , w i e l d i n g 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, s a n c t i o n e d i n an i l l ness o n l y i f I was c o o p e r a t i v e . A p r o t e c t e d dependency and the promise o f e f f e c t i v e t e c h n i c a l h e l p were m i n e - - i f I accepted a c o n s i d e r a b l e degree o f p s y c h o l o g i c a l and s o c i a l s e r v i t u d e . . . . I f I had t o choose between having my i l l n e s s a c c u r a t e l y d i a g nosed and competently t r e a t e d or having my emotional needs as a p a t i e n t f i l l e d , I would choose the former every time. (pp. 13-15) Geiger's w r i t i n g i s important f o r a number of reasons.  In  d e s c r i b i n g h i s s u b j e c t i v e f e e l i n g s t a t e when h i s r o l e changed, he openly acknowledged h i s former power which  was  s t r i p p e d when he became a p a t i e n t .  indi-  cated t h a t the primary purpose was  He a l s o i n d i r e c t l y  o f the h e a l t h care  to d e a l with the immediate problem.  system  The p s y c h o l o g i c a l  i n t e g r i t y o f the p a t i e n t , while a p l e a s a n t n i c e t y , was secondary  requirement.  Geiger humanizing  (1975) viewed elements  f o u r sources of humanizing  i n health care:  sources i n the  order or g e n e r a l s o c i e t y ; sources i n our r a t i o n a l , approach  a  or desocial scientific  t o the world; sources i n the s u b c u l t u r e of the  h e a l t h p r o f e s s i o n s ; and sources i n p o l i t i c a l movements t r y i n g to a f f e c t h e a l t h c a r e .  He,  too, l i n k s the experience  of the p a t i e n t to the l a r g e r s o c i a l order j u s t as the authors d e s c r i b i n g o b j e c t i v e a l i e n a t i o n l i n k e d a person's  experience  to the l a r g e r s o c i a l o r d e r . Howard's (1975) approach was t h a t of Geiger.  She  g e n e r a l l y c o n s i s t e n t with  saw the dehumanization  i n h e a l t h care  not as an i n d i v i d u a l ' s problem, but as a r e f l e c t i o n of the o r g a n i z a t i o n of medical work and the process of s i c k n e s s .  36  Torrance  (1981) d e s c r i b e d the growth o f h o s p i t a l s i n  Canada "from s m a l l , simple o r g a n i z a t i o n s t o l a r g e , bureauc r a t i z e d , t e c h n o l o g i c a l l y complex i n d u s t r i e s " Coburn, D'Arcy, New,  and Torrance  (1981) saw  (p. 254). the Canadian  h e a l t h care system as o r i e n t e d t o cure, r a t h e r than p h y s i c a l , mental,  and s o c i a l w e l l being of the  the  individual:  There i s l i t t l e attempt to view h e a l t h as r e l a t e d to the l i f e experiences of d i f f e r e n t s o c i a l c l a s s e s , as deeply i n d i c a t e d i n i s s u e s of h e a l t h i n the workp l a c e , with income i n e q u a l i t y , or as r e l a t e d to broad s o c i e t a l goals and s o c i a l p o l i c y g e n e r a l l y . . . . T h e h e a l t h s e c t o r has been changing from a "cottage" i n d u s t r y t o a complex, t e c h n o l o g i c a l l y s o p h i s t i c a t e d , 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 l a b o u r . The system i s s t i l l i n the midst of these processes of r e o r g a n i z a t i o n , r a t i o n a l i z a t i o n , and b u r e a u c r a t i z a t i o n . The h o s p i t a l , the c e n t r a l h e a l t h - c a r e i n s t i t u t i o n , more and more resembles o t h e r i n d u s t r i a l , s e r v i c e , and w e l f a r e b u r e a u c r a c i e s , as the t e c h n o c r a t s seek t o apply the c u l t of e f f i c i e n c y to the care and cure of the s i c k . (p. 439) Two  important elements are noted i n t h i s a r t i c l e :  care system was  the h e a l t h  viewed as a bureaucracy w i t h an emphasis on  e f f i c i e n c y and the primary g o a l o f the h e a l t h care system was  again seen as the cure o f the immediate problem. Though Kaluzny, Warner, Warren, and Zelman  (1982) are  d e s c r i b i n g the American system, they r e i t e r a t e the viewpoint of  Coburn e t a l . (1981).  managerial  As h e a l t h s e r v i c e s have to prove  accountability, particularly in financial  s t a f f and p a t i e n t s may  be a d v e r s e l y a f f e c t e d .  t h a t h e a l t h care workers may "burnout"  They f e a r  face an i n c r e a s e d chance of  and t h a t p a t i e n t s w i l l i n c r e a s i n g l y face a r b i t r a r y  and f i x e d r u l e s . ful  matters,  These authors address the p o t e n t i a l l y harm-  e f f e c t s o f bureaucracy  on both p a t i e n t s and  staff.  37  While the g e n e r a l consensus i s t h a t the h e a l t h  care  system holds the g r e a t e s t amount of power, Numerof (1982) wrote t h a t some o f t h i s c o n t r o l may p a t i e n t , a t l e a s t i n the U n i t e d  now  States.  be s h i f t i n g to  the  People are expect-  i n g more o f h e a l t h care, s o c i a l i n s t i t u t i o n s i n g e n e r a l being c r i t i c i z e d , and  consumers are i n c r e a s i n g l y e x p r e s s i n g  t h e i r d i s p l e a s u r e through such a c t i o n s as l a w s u i t s . sumers are thus making a more concerted needs  are  Con-  e f f o r t to have t h e i r  met. Twaddle's (1982) work has  tween a l i e n a t i o n and  shown a s t r o n g connection  the h e a l t h care  be-  system:  A l i e n a t i o n and autonomy are l i n k e d by the c e n t r a l i s s u e o f resource c o n t r o l . The more any group gains c o n t r o l over an important set of resources (e.g. the means of p r o d u c t i o n ) , the more any other group i s barred from meaningful d e c i s i o n making (e.g. the more t h a t group i s a l i e n a t e d ) . T h i s r e f e r s , of course, to o b j e c t i v e a l i e n a t i o n . (p. 336) Twaddle saw had  t h a t i n four d i s t i n c t areas where p h y s i c i a n s  a high degree o f p r o f e s s i o n a l autonomy, p a t i e n t s had  correspondingly  h i g h degree o f a l i e n a t i o n .  Two  o f the  areas are p a r t i c u a r l y r e l e v a n t to t h i s d i s c u s s i o n and t y p i c a l o f the h e a l t h c a r e system i n g e n e r a l .  The  a  four are  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 o r g a n i z a t i o n a l c o n t r o l / alienation. The  element of c l i n i c a l c o n t r o l cannot be  or underestimated.  eliminated  P r o f e s s i o n a l s i n the h e a l t h care  field  have a s p e c i a l i z e d knowledge which p a t i e n t s do not have. t h i s sense, the p r o f e s s i o n a l s have a monopoly. sense of a l i e n a t i o n due  While  to c l i n i c a l c o n t r o l can be  In  the  reduced,  38  it  i s inevitable: 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 v a l u e s , e s s e n t i a l l y i n v o l v e an i n e q u i t a b l e d i s t r i b u t i o n o f powers, r e s e r v i n g forms o f i n f l u e n c e and c o n t r o l to some while denying them to o t h e r s . And by s e i z i n g upon the e x i s t e n c e o f avoidable forms o f powerlessness i n such cases, w h i l e n e g l e c t i n g to c o n s i d e r the contexts i n which they occur, the s i g n i f i c a n c e of the i n s t i t u t i o n s of which they are f e a t u r e s 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.  i n the h e a l t h care they may  Because the  professionals  f i e l d do have a s p e c i a l i z e d knowledge,  make d e c i s i o n s about p a t i e n t s which do not make  sense o r have meaning f o r them.  The  s a f e t y and  the care  the p a t i e n t must be maintained, thus c l i n i c a l c o n t r o l be  shared, but o n l y to a c e r t a i n degree.  d e c i s i o n s can  and  should  be e x p l a i n e d  be  Organizational  and  discussed  As  with  the  the p o t e n t i a l  decreased.  c o n t r o l r e f e r s to the s e t t i n g s i n which  h e a l t h care i s provided. formal  can  However, c l i n i c a l  p a t i e n t s so care does have more meaning and f o r a l i e n a t i o n may  of  Most care i s now  provided  i n the  h e a l t h care s e t t i n g r a t h e r than the p a t i e n t ' s home.  such, the p a t i e n t i s i n someone e l s e ' s t e r r i t o r y  automatically  has  decreased c o n t r o l as a r e s u l t :  dures are s e t f o r the convenience o f the maximize inconvenience to the p a t i e n t s " p. 168).  and  "Proce-  s t a f f , which o f t e n (Twaddle,  1979,  I t i s i n t h i s realm where more adjustments might  be made to accommodate p a t i e n t s . Summary o f the l i t e r a t u r e on o b j e c t i v e 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 c o n d i t i o n s i n the s o c i o c u l -  39  tural  setting.  vertical  I t appears  i n many o r g a n i z a t i o n s  h i e r a r c h y which allows  a small  The o f the tive cal  control.  cracy with needs of s u c h as  e m p h a s i s on  t h e p a t i e n t has  little  Presentation This  and  f o c u s was  assumed a low  study  their  personal  provide  lives  ments; t o d e s c r i b e  the  r e c o g n i t i o n of priority.  In  the  elopements.  These d a t a  areas the  partici-  While  the purposes of t h i s  how  and  to  have been woven accounts  study:  because  to  de-  o f what l e d t o t h e i r  p a t i e n t s view t h e i r experiences what p u r p o s e p a t i e n t s f e e l  f o r them; and  to analyze  purposes are  broader  the  investigated,  the d i s c u s s i o n o f the  of p a t i e n t s w i t h i n the  The  the  shared  how  behaviour being  emerged.  to describe  elopements served experiences  clini-  become a l a r g e b u r e a u -  describes own  patients' perceptions  elopements;  effec-  team r e t a i n  related to t h e i r h o s p i t a l i z a t i o n  to c l a r i f y  the  context.  on  a c c o u n t s and  help  chapter  viewed t h e i r  initially  information  i n t o the  management  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  other  the  efficiency,  the  input.  s e c t i o n of the  pants i n the  scribe  health care  To  o r g a n i z a t i o n a l c o n t r o l w h i c h c o u l d be  p a t i e n t has  they  the  patient.  B e c a u s e t h e h o s p i t a l has  an  to  however.  immediate problem o f the t h e members o f  the  A c e r t a i n amount  primary goal of the .hospital i s s t i l l  care,  to  number o f p e o p l e  have a d i s p r o p o r t i o n a t e amount o f c o n t r o l . of a l i e n a t i o n i s i n e v i t a b l e ,  due  the  elopeof the  subjective  sociocultural  r e l a t e d t o Seeman's f i v e  cate-  40  gorizations of subjective a l i e n a t i o n .  These c a t e g o r i e s  have  been u t i l i z e d t o "make sense" of the experience of elopement. The  researcher  chose Seeman's work as a framework f o r the  d i s c u s s i o n o f the p a r t i c i p a n t s ' accounts f o r three reasons:  i t i s considered  a c l a s s i c work and  specific  i s thus f a m i l i a r  to a great number of people; i t made no pretences to absolute and  answer on the t o p i c ; and  i t can be r e a d i l y u t i l i z e d  understood. As one  i l l u s t r a t i o n o f how  of the p a r t i c i p a n t s can be ing  the  the s u b j e c t i v e e x p e r i e n c e s  l i n k e d to the o b j e c t i v e  c o n d i t i o n s , Goffman's w r i t i n g w i l l be In h i s c l a s s i c work, Asylums, Goffman  t o t a l i n s t i t u t i o n as "a p l a c e of residence  surround-  used. (1961) d e f i n e d  and work where a  l a r g e 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 wider s o c i e t y f o r an a p p r e c i a b l e l e a d an e n c l o s e d , (p. x i i i ) .  He  saw  by the b u r e a u c r a t i c is  the key  p e r i o d o f time,  f o r m a l l y administered t h a t "The  handling  a  round of  the  together life"  of many human needs  o r g a n i z a t i o n of whole b l o c k s o f people...  f a c t of t o t a l i n s t i t u t i o n s "  (p. 6).  Many of  the  f e a t u r e s o f a t o t a l i n s t i t u t i o n , as d e f i n e d by Goffman, were described  by the p a r t i c i p a n t s i n t h i s  study:  Features o f a t o t a l i n s t i t u t i o n  Comments of the p a r t i c i p a n t s  S t a f f and p a t i e n t s see each other i n s t e r e o t y p e s , w i t h s t a f f t y p i c a l l y seen as s u p e r i o r , and w i t h p a t i e n t s t y p i c a l l y seen as i n f e r i o r .  "Who i s h e l p f u l here? The c l e a n e r s at l e a s t t a l k to you. That's b e t t e r than most people here."  D e c i s i o n s are u s u a l l y made about the p a t i e n t s without t h e i r input.  "They changed my room. I was happy where I was, but I had to go."  41  Features of  a total  institution  Comments o f  the  participants  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 o f h a v i n g t o ask f o r everyday things.  "Um, no, to leave  P a t i e n t s see t h e m s e l v e s as a b l e t o e x e r t autonomy.  "I j u s t l i s t e n t o what t o l d and t h a t ' s i t . "  un-  I asked permission t o go s h o p p i n g . "  I'm  A p r i v i l e g e system o f r u l e s encourages conformity.  " [ S i n c e my e l o p e m e n t ] , t h e y won't change my p h a s e , t h e y won't e v e n c o n s i d e r i t . "  To be r e l e a s e d s t i t u t i o n , one  " I t pays not  from the i n must be "good."  to  complain."  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 w i t h the i n s t i t u tion .  "I've a s k e d my p h a s e . "  " M e s s i n g up," o r d o i n g somet h i n g which i s forbidden, can be a means o f p u r p o s e f u l l y p r o l o n g i n g a s t a y i n the institution.  "I t o o k o f f f r o m h e r e b e c a u s e 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 t h e y were g o i n g to r e l e a s e me."  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 t o become b e t t e r , t h e y must a d o p t a new way o f b e h a v i n g .  " I t seems t o me t h e y wanted me t o change my whole l i f e . They gave me a whole page o f problems."  Obviously, total  institution  iences  i n the  subjective care non  many o f  are  f a c e t s o f Goffman's d e s c r i p t i o n of r e l a t e d to the  hospital.  Other w r i t e r s be  Seeman  n e s s as  probably being  Defined  as  the  structure of  discussions  of  which  the  the  this  (1959/1972) d e s c r i b e d  health phenome-  follow. powerless-  most common f o r m o f a l i e n a t i o n .  expectancy or  p r o b a b i l i t y held  by  cannot determine  the  vidual  t h a t h i s own  behaviour  of  outcomes, o r  reinforcements,  the  linkage  have a l s o d e s c r i b e d  i n d i c a t e d i n the  Powerlessness.  "the  objective  a  p a r t i c i p a n t s ' exper-  There i s a strong  f e e l i n g s to the  system. as w i l l  the  f o r a change i n  he  seeks"  (p.  an  indi-  occurrence 46),  42  powerlessness the person. lationship  does n o t Seeman saw  to the  been i n t e r p r e t e d  ing  the  Powerlessness  was  of a l i e n a t i o n  in this  be  with each  t o any  study.  o f t h e p a r t i c i p a n t s and  events  surround-  situations  and management o f t h e of the p a r t i c i p a n t s  at least  and  saw  Only  she  person  and  two  years  t o get the h e l p I need."  who  were r e l u c t a n t , they  admission.  One  also  the  Of  hospital.  o t h e r s were a l l  to the  had  to  them-  hospitalization  freely  the  chosen  to enter  " I t took  me  four participants  t h r e e a c k n o w l e d g e d t h e y were h a v i n g felt  and  he o b v i o u s l y t h o u g h t  The  four patients f e l t  financial  admission  the o p p o s i t e problem:  these problems d i d not  participant  into hospitalization  directly  surrounding  significant  hospital,  blems, but  had  one  situations  someone o t h e r t h a n  t w i c e as c o n t r i b u t i n g  the p a t i e n t s .  surrounding  patient.  s e l v e s as b e i n g i n s t r u m e n t a l i n t h e i r Doctors, welfare workers,  readily  these i n s t a n c e s  situations  to the h o s p i t a l ;  t o t h e e l o p e m e n t ; and  Four  of  study, i t  I n s t a n c e s were  described i n three c l u s t e r s :  treatment  cited  In- t h i s  t h e 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 -  the p a t i e n t ' s admission linked  i n t e r m s o f man's r e -  s o c i a l order.  in relationship  for  person.  apparent will  the value o f the c o n t r o l  powerlessness  larger  has  tion  reflect  he  d e n i e d he was  t h e y had  by e i t h e r  i n some way the  warrant  h a v i n g any  s h o u l d n o t have been been  pro-  problem,  hospitalized. coerced  t h r e a t o f withdrawn  support o r the t h r e a t o f withdrawn l i v i n g q u a r t e r s :  P(articipant): here u n t i l  W e l l , I knew, I knew I ' d have t o come I , t h e g o v e r n m e n t s o r t o f f o r c e s me t o  43  come h e r e b e c a u s e I c a n ' t go anywhere e l s e . I c a n ' t g e t w e l f a r e , wh-, when w e l f a r e wants me t o be i n t h e h o s p i t a l , r i g h t ? So how am I g o i n g t o do f i n a n c i a l l y , I'm n - , I'm n o t w e l l enough t o go t o work r i g h t now. I have no p l a c e t o s a y , s t u f f like that. R(esearcher): sure then, P:  —about  Sounds l i k e y o u were f e e l i n g y o u saw i t a s b e i n g --  the only place  Thus, f o u r o f the p a r t i c i p a n t s c o n t r o l over and  their  admission  I c o u l d go. felt  they  d i d n o t e v e n have  to hospital.  D e c i s i o n s by o t h e r s  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  they  staff  t h e h o s p i t a l were l i n k e d  f e e l i n g s o f powerlessness the p a r t i c i p a n t s , preted  as r e l a t i n g  sparked  with  and e v e n t s  a specific  s i t u a t i o n s which  One p a t i e n t l e f t c h a r g e h a d been d e n i e d  I n two o t h e r  cases,  inter-  powerlessness  feelings of being  received  leaving of the hospital.  the hospital  after  by t h e d o c t o r .  h i s request  Since  p a p e r s had been s i g n e d by h i s w i f e , he f e l t able  caused  W i t h two o f  of  t o the care or treatment  t o the unsanctioned  occurred  i n c i d e n t w h i c h c o u l d be  t o the p a t i e n t ' s f e e l i n g s  related  which  i n the p a r t i c i p a n t s .  t h e i r elopements.  powerlessness led  i n which  d i d n o t want t o b e . Both i n t e r a c t i o n s with  in  some p r e s -  t o d i s c o n t i n u e them a n d t h u s  the  for dis-  committal  she s h o u l d be  f r e e him:  P:  She [ h i s w i f e ] d i d n ' t want... she to help out...  d i d n ' t want...  R:  And when she d i d n ' t want t o h e l p o u t , how d i d t h a t make y o u 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, s o y o u g o t a n g r y f o r you —  P:  She knows t h a t I'm c o m m i t t e d , r i g h t ? She knows t h a t I c a n ' t j u s t walk o u t . She c o u l d j u s t t e a r up t h e p a p e r s l i k e I wanted h e r t o . She s i g n e d me i n , and I s a i d she c o u l d j u s t s i g n me o u t !  In t h i s tary  instance,  that  she w o u l d n ' t  t h e p a t i e n t was v e r y aware o f h i s i n v o l u n -  s t a t u s a s he was a d m i t t e d  "on p a p e r s . "  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 the a i d o f h i s wife. off life  the u n i t .  s t a n d up  With her r e f u s a l  He was p o w e r l e s s  Having  hope" was t o e n l i s t t o h e l p h i m , he r a n  t o take charge  a n d he h a d been p o w e r l e s s  i n h i s attempts  Another  surrounds  dramatic i n c i d e n t  woman who e l o p e d a f t e r  another p a t i e n t  been r e -  o f h i s own t o sway h e r .  t h e case o f a young  tried  to physically  harm h e r : R:  What happened t h a t made y o u d e c i d e t o l e a v e hospital?  P:  When I g o t i n t o h e r room she g r a b b e d me by t h e t h r o a t w i t h one hand a n d s q u e e z e d h a r d . I got r e a l l y s c a r e d a n d h i t h e r and r a n back t o my room ....The n u r s e s came a n d a s k e d what was wrong. I t o l d them a n d t h e y d i d n ' t b e l i e v e me. They s a i d t h a t ' s n o t t r u e , she's n o t v i o l e n t . I got r e a l l y u p s e t a n d t h o u g h t why am I h e r e i f nobody b e l i e v e s me.  T h u s , t h e p a t i e n t was s u d d e n l y c o n f r o n t e d w i t h a over which  she h a d no c o n t r o l .  of the s t a f f ,  When she s o u g h t  the support  t h e y compounded h e r f e e l i n g s o f p o w e r l e s s n e s s  by n o t t a k i n g h e r c o n c e r n s  seriously.  As a r e s u l t , the  patient's perception o f the nursing s t a f f affected:  situation  was n e g a t i v e l y  45  P:  I was r e a l l y a n g r y when I t o o k o f f . I had a headache t h a t j u s t t h r o b b e d . I f they'd t r i e d t o s t o p me, I ' d have t a k e n o f f a g a i n as soon a s I had t h e c h a n c e .  R:  Who were y o u a n g r y  P:  The n u r s e s and [ p a t i e n t who t r i e d t o harm h e r ] , b u t m a i n l y t h e n u r s e s . She h a s a p r o b l e m , t h a t ' s why s h e ' s h e r e , b u t s u p p o s e d l y the s t a f f has i t t o g e t h e r .  a t when y o u l e f t ?  Two o t h e r p a t i e n t s , w h i l e n o t h a v i n g events which sparked t h e i r powerlessness to  over t h e i r  t h e i r elopement.  departure, described feelings of  addiction, effect  to hospital  forpsychiatric  the side-effects,  o f t h e m e d i c a t i o n s on h e r l i f e  She  strongly  and  t h a t what she r e a l l y  wasn't  drug  she was  care,  receiving.  the p o s s i b i l i t y o f  how l o n g she w o u l d be t a k i n g  felt  contributed  One p a t i e n t , who had a p a r e n t who was  was v e r y p r e o c c u p i e d w i t h t h e m e d i c a t i o n s wondered a b o u t  dramatic  treatment which d i r e c t l y  c o n t i n u a l l y being admitted  She  such  the drugs,  and t h e  when she was d i s c h a r g e d .  t r e a t m e n t was i n a p p r o p r i a t e f o r h e r , r e q u i r e d was c o u n s e l l i n g  " s i c k enough" t o w a r r a n t  a s she  hospitalization:  R:  Okay. Had y o u t o l d t h i s t o p e o p l e h e r e , had y o u t o l d t h i s t o the d o c t o r t h a t you're working w i t h , or the nurses t h a t you're working with?  P:  Umm, y e a h , b u t t h e y d o n ' t , t h e y j u s t t h i n k I'm a h a p y c h o n d r i a c (sic).  E v e n when t h e p a t i e n t the s t a f f ,  she f e l t  attempted  they  t o negotiate treatment  she h a d no i m p a c t .  a c t i o n w i t h t h e sense  don't,  She l e f t  she d i d n o t have c o n t r o l  with  the i n t e r -  over  what  was b e i n g done t o t r e a t h e r . Another  patient  left  hospital  because  of her perceived  46  inability She  The  to influence  her length of stay i n the i n s t i t u t i o n .  knew i f she was d i s c h a r g e d , she w o u l d r e t u r n  home:  P:  I t o o k o f f f r o m h e r e b e c a u s e 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 t h e y were g o i n g t o r e l e a s e me t o t h e o u t s i d e w o r l d and I wasn't r e a d y f o r i t .  R:  So t h e y were gonna l e t y o u go and y o u d i d n ' t want t o go.  P:  Yeah. I t was t o o e a r l y . No p l a c e t o go b u t home, and l o o k a t i t . I t ' s f u l l o f h e a d a c h e s , p a i n , and sorrow. But i f you're i n a home-like b o a r d i n g home, i t ' 1 1 be n i c e .  R:  What h e a d a c h e s and  P:  My d a d i s m e a n — h e b e a t me up l a s t week. Bad news bears, right? He s t a r t e d s l u g g i n g me w h i c h i s why I was b l a c k a n d b l u e when y o u saw me. My d a d ' 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 .  patient,  sorrow?  who was p o w e r l e s s  home and p o w e r l e s s  t o extend  t o deal with the s i t u a t i o n a t  her stay i n the h o s p i t a l , ran  away. In the f o u r  instances cited,  over the events i n the h o s p i t a l patient.  In each case, though  a sense o f p o w e r l e s s n e s s  l e d t o the elopement  of the  o t h e r c o n c e r n s were a l s o  pre-  s e n t , none were a s paramount a s t h e e v e n t s a l r e a d y d i s c u s s e d . An  inability  situation,  though  precipitating she  tried  t o 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 this  factor.  to explain  inability In each  i n each  was n o t n e c e s s a r i l y t h e  instance,  the p a t i e n t  stated  t h e c o n c e r n t o a t l e a s t one s t a f f  R:  Had y o u a s k e d them b e f o r e y o u t o o k o f f a b o u t s t a y i n g here?  P:  Yuh.  R:  What d i d t h e y  P:  No way, J o s e .  say?  member.  47 A s e r i e s o f i n c i d e n t s w h i c h c o u l d be v o l v i n g powerlessness  were r e l a t e d  management o f t h e p a r t i c i p a n t s of  to the treatment  t h a n o t h e r s and  tended  those  t o be  while i n the h o s p i t a l .  have a n o i s y e n v i r o n m e n t ;  of  activities;  lost  and  i n another  sought  i t was  hospital,  l e s s n e s s when one  actual  described t h e y had  felt  annoying  t o have o n e ' s  lack clothes  t h e wards were r u n i n s u c h a way  this no  t h e y had  c o n t r o l was  input into  very limited.  one  " I f they're honest,  she was  she was  informed  increased.  everyday  lives  nothing. s t i c k me  —  The  o u t on u s .  I can  live  patient  told with  then  h e r m e d i c a t i o n s w o u l d n ' t be -- and  that.  dealtered  then  her dosage o f  haloperidol  Comments r e f l e c t i n g  powerlessness  in their  " I f I get  a shot;"  "I'm  of the  little  they don't  listen;"  "What c a n you do?  Sweet  room;"  tired  too  g i v e me  They've got you;" i n my  participants  than being  on t h e ward were f r e q u e n t :  upset, they j u s t baby s t a f f  told  The  that,  decision-making, Two  as b e i n g more f r u s t r a t i n g  power:  s c r i b e d how  don't.  I t was  b u t i t c r e a t e d f e e l i n g s o f power-  when t h e y p r e t e n d , you know."  unless  occurrences  b o r i n g t o have a  frustrating  Some  being  c o u l d not o b t a i n the r e i n f o r c e m e n t  w h i l e t h e y were t o l d  It's  i t was  the  from o t h e r s .  Patients  their  these c r i t i c a l  i n v o l v i n g other people.  to  as i n -  and  t h e i n c i d e n t s were p e r c e i v e d by t h e p a t i e n t s as  more c r u c i a l  was  interpreted  "They want a b r e a k ,  "Doctors got the a u t h o r i t y  nurses get p i s s e d  o f f and  We're t h e b o t t o m l i n e ; "  frustrated  and  "The  so  they  and  nurses  and  take i t  student  nurses  48  are.-here now.  They're always w r i t i n g  f r o n t o f me. This in  Where d o e s t h a t  sense o f r o u t i n e  s t u f f go?"  A patient described  a change i n h e r p r i v i l e g e the protocol  She  followed  not  b r o u g h t up a t t h e a p p r o p r i a t e  was q u e s t i o n e d ,  an e x p l a n a t i o n  their The as  patients  issues  meeting.  was g i v e n ,  frequently  disagreed  When t h e s t a f f "but they  ignored  where t h e p a t i e n t s  was  my  should  request."  with the nature o f involved.  had u n s u c c e s s f u l l y  listed  t r i e d to  control.  their  as t h e p a t i e n t s  perceived  a lack  treatment, they a l s o perceived  information disagreed  w h i c h r e l a t e d t o them.  with h i s diagnosis,  a report  could  influence  t h a t he h i m s e l f  h i s length  sequences.  that  "things"  o f stay  f o r three  stated  p u t on  i n hospital,  having to deal  errors  with the con-  sleeping  or four nights.  p u r s u e d t h e i s s u e , and i n d e e d t h e r e l a y i n the fact  over  into the report.  I n one i n c i d e n t , a p a t i e n t ' s  t i o n was d i s c o n t i n u e d  frustration  One p a t i e n t  s i t u a t i o n s , s t a f f members made  which r e s u l t e d i n the p a t i e n t s  over  b u t he knew he c o u l d n o t  d i d n o t have i n p u t  I n two d i f f e r e n t  of control  a lack of control  change i t ; a n o t h e r p a r t i c i p a n t s t a t e d  but  a f t e r she e l o p e d .  t r e a t m e n t s , e s p e c i a l l y when m e d i c a t i o n s were  Just  he  how she r e -  amount a n d t y p e s o f m e d i c a t i o n s were f r e q u e n t l y  gain  the  level  illustrated  as o u t l i n e d , b u t h e r r e q u e s t  have t o l d me b e f o r e h a n d , n o t j u s t The  down, r i g h t i n  lack of control i s well  t h e f o l l o w i n g example.  quested  stuff  medicaShe d o g g e d l y  h a d been an e r r o r .  she had t o c o n t a c t  three  Her  staff  49  members b e f o r e someone r e c t i f i e d had  t o do was In  cally  another  abused P:  In  c h e c k my  f a t h e r had  instances, staff  r o l e which the p a t i e n t s Two on  o f the  committal  five  felt  positive  been  physi-  visitors:  about  r e t u r n e d because  Of had  the safeguarding  t h e t h r e e o t h e r s , o n l y one v o l u n t a r i l y e n t e r e d the  her d e c i s i o n  t h e y had  R:  Ok, have y o u p a s t week?  P:  Yeah.  R:  Uh  The  nowhere e l s e  about  d i d you  o t h e r two t o go.  hospital,  participants  This  inter-  o f these  l e a v i n g here  actually  per-  " I wanted t o  i n t e r v i e w w i t h one  thought  And  to return:  back."  concluded the second  - huh.  fulfill  expected.  h e l p i f t h e y ' d have me  P:  r e q u e s t e d no  d i d not  papers.  t h e i n d i v i d u a l who  action  had  p a r t i c i p a n t s were r e t u r n e d t o t h e h o s p i -  son,  get  t h e p a t i e n t who  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 t o see my f a m i l y . He [Dad] came up w i t h . I was r e a l l y u p s e t a b o u t t h a t b e c a u s e I t o l d t h e n u r s e s I d i d n o t want any c o n 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 sponsibility. 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 d o n ' t t h i n k i t was fair at a l l . I t h o u g h t , " S h i t , i s he g o i n g t o h i t me, o r what?"  both  tal  " A l l they  chart properly."  situation,  by h e r  the s i t u a t i o n :  two:  i n the  leave?  No.  R:  What s t o p p e d  you  from  going?  P:  Nothing.  R:  Nothing? way. Why  P:  Uh, b e c a u s e I had no p l a c e t o go and I s t i l l no p l a c e t o go u n t i l t h e end o f t h e month.  You must have s t o p p e d y o u r s e l f d i d y o u d e c i d e n o t t o go?  i n some have  5 0>  One  has  he was  the sense powerless  powerless So of  the p a r t i c i p a n t  o v e r h i s coming i n t o  a  hospital  and  f a r i n t h i s d i s c u s s i o n of powerlessness,  this variation  of alienation has  pital  does t h i s  experience.  elopements  The  How  to a f f e c t  what was  the s o c i o c u l t u r a l  The  hospital  have d i f f e r e n t  be  happening  because  i t was  i s a h i e r a r c h y and  the system.  The  The  participants situation.  T h u s , as T w a d d l e  t h o s e who  p a n t s were t h e v e h i c l e s  or  The  A l l o f the p a r t i c i p a n t s  hosactual the  environment.  patient  i s a t the  t h u s has in this  limited i n -  study,  c i r c u m s t a n c e s , t h e y would r e a c t  then,  "We're [ t h e p a t i e n t s ] argued, i f  resource  elopements  Each  ex-  i n a h i e r a r c h y people  (1979) has  stated  as  true to a c e r t a i n  they  of the  such  struggle partici-  in their  f e l t constrained  of the  s t a t e d t h e e l o p e m e n t was a p o s i t i v e  similar  The  i s examined,  t o r e g a i n some c o n t r o l  "hemmed i n " b e f o r e t h e y l e f t .  pants  the  have l e s s o f t h e r e s o u r c e may  obtain a greater portion.  lives.  incident  focus of  in their  some p e o p l e have g r e a t e r a c c e s s t o a d e s i r e d as c o n t r o l ,  one  study p e r c e i v e d themselves  levels of control.  the bottom l i n e . "  the  s e t t i n g o f the p a t i e n t s  were s i m p l y aware o f t h e i r  to  was  theme b l e n d w i t h t h e  b o t t o m o f t h e h o s p i t a l ' s h i e r a r c h y , and into  he  followed another.  This w i l l  in this  this perception existed  put  circle:  discussion.  participants  powerless  has  been shown t h r o u g h o u t  o f the p a t i e n t s ?  c o n c l u s i o n o f the  tent.  completed  over h i s l e a v i n g .  theme o f p o w e r l e s s n e s s  If  has  event  five and,  particigiven  i n t h e same way  again.  51  One ing  of the p a r t i c i p a n t s preplanned  a pass:  "I wanted t o l i e , hospital."  ment m i g h t a f f e c t  her p r i v i l e g e s ,  "right"  decide  she  realized  because her  elope-  wanted t o l e a v e  i f hospitalization  to  was  R:  How you  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 t o be r e s p o n s i b l e , when I d i d go s h o p p i n g . I felt really responsible.  afraid  was y o u r mood when you feeling?  interesting t o be  simple  were o u t ?  twist occurred with  discharged  would l i k e l y  from o t h e r  The  and  Though she  lie,  obtain-  f o r her:  An  she  alone  l e a v i n g by  l i e ,purposely  I wanted t o l e a v e  have some t i m e  her  be k e p t  home.  She  pleasures of being out of  were  t h e p a t i e n t who  knew t h a t i f she  longer i n h o s p i t a l .  h o s p i t a l s i n the p a s t .  How  She,  She  was  eloped,  had  eloped  too, described  the  hospital:  R:  What s t a n d s o u t most i n y o u r mind a b o u t y o u were o u t o f h e r e ?  the  time  P:  The  R:  Tell  P:  The f r e e d o m t o do what I want t o do. Freedom t o feed the chickens. Make b a c o n and t o a s t . Eat r e a l food.  freedom. me  experiences  freedom  f o r the  again;"  " I was  more a b o u t t h a t .  were c o n s i s t e n t l y participants:  "I c o u l d breathe  r e s p o n s i b l e f o r myself;"  got  r i d o f a l l t h e cobwebs;" and  was  not  having  d e s c r i b e d as p r o v i d i n g  someone t e l l  you  "Do  you  when you  fresh a i r  "It felt know how  good—I great i t  c o u l d have a  ciga-  rette?" Two  o f the  participants  d e s c r i b e d ways i n w h i c h  they  52  i n c r e a s e d t h e i r power i n more than the sense of freedom i n g t h e i r elopements.  dur-  One p a t i e n t telephoned the u n i t twice  w h i l e she was out on her elopement.  Each time she s t a t e d  she was r e t u r n i n g and each time she d e l a y e d .  Another  t o l d the r e s e a r c h e r t h a t w h i l e he was on h i s elopement  patient he  had disarmed some n u c l e a r warheads, but no one had thanked him. As a r e s u l t o f t h e i r elopements,  two of the p a t i e n t s ,  one o f whom was on committal papers, had t h e i r decreased.  privileges  One o f these p a t i e n t s was the person who  wished  to s t a y i n h o s p i t a l l o n g e r and the o t h e r p a t i e n t s t a t e d the b r i e f freedom more than compensated f o r the  "punishment."  Three p a t i e n t s s t a t e d t h e i r p r i v i l e g e s were not reduced, but two o f them d e s c r i b e d a l t e r a t i o n s i n medications as a r e s u l t . One o f these t h r e e 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 because the s t a f f was more w i l l i n g t o l i s t e n to him when he returned. In summary, then, f e e l i n g s o f powerlessness were experienced by a l l the p a r t i c i p a n t s i n t h i s study. v o l v i n g these f e e l i n g s were f r e q u e n t .  Incidents i n -  One way i n which the  p a r t i c i p a n t s handled these emotions was t o leave the p h y s i c a l s e t t i n g t o g a i n a sense o f c o n t r o l over t h e i r l i v e s a g a i n . Meaninglessness and i s o l a t i o n .  Seeman  (1959/1972) de-  s c r i b e d meaninglessness as "the i n d i v i d u a l ' s sense of unders t a n d i n g the events i n which he i s engaged" (p. 5 0).  When  t h i s form o f a l i e n a t i o n i s s t r o n g , the person i s n ' t sure what he or she ought to b e l i e v e .  As w i l l be seen i n t h i s  53  s e c t i o n o f the chapter,  i n s t a n c e s o f meaninglessness u s u a l l y  i n v o l v e d the p a t i e n t ' s understanding of h i s or her programme or treatment.  These same circumstances o f t e n 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 " a s s i g n [ s ] low  reward value  are t y p i c a l l y h i g h l y valued assuming the given i n many i n s t a n c e s these two  to goals or b e l i e f s  i n the given  society"  (p.  s o c i e t y i s the h o s p i t a l s e t t i n g . there i s an o v e r l a p p i n g  that 52),  Because  or i n t e r t w i n i n g ,  c a t e g o r i z a t i o n s of a l i e n a t i o n w i l l be d e a l t with  simultaneously. The  d i s c u s s i o n of meaninglessness/isolation  on three  foci:  he or she  should  the p a t i e n t ; and  the p a t i e n t ' s p e r c e p t i o n be i n the h o s p i t a l ; the  will  centre  o f whether or formal  not  treatment of  the programme i n which the p a t i e n t i s en-  gaged . At some p o i n t , a l l o f the p a r t i c i p a n t s q u e r i e d or not h o s p i t a l i z a t i o n was earlier,  who  had  As  stated  four o f the p a r t i c i p a n t s f e l t they should not have  been admitted to h o s p i t a l . what was  c o r r e c t f o r them.  whether  The  patients obviously  perceived  o c c u r r i n g 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 aided t h e i r admission.  perceptions  I t i s assumed the  patients'  a l s o d i f f e r e d from those o f the c a r e t a k e r s  the h o s p i t a l who  had  admitted and  P:  J u s t the thought o f being  R:  Okay. You because?  P:  Yeah.  R:  Because?  t r e a t e d them: here....I don't l i k e i t .  don't l i k e being  Because why?  in  i n the h o s p i t a l  54  P:  Just,  I j u s t don't t h i n k  I s h o u l d be h e r e .  R:  Mmhmm.  P:  D o c t o r s e n t me.  R:  You're  P:  No.  R:  So y o u d o n ' t f e e l y o u s h o u l d be h e r e , and y o u d o n ' t know why y o u ' r e h e r e .  P:  Yeah.  R:  What does i t mean f o r y o u t o be i n h o s p i t a l ?  P:  I j u s t don't  Why d i d y o u come i n t o  hospital?  I d o n ' t know why.  not sure o f the reason then.  like 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  this  way: R:  Do y o u f e e l  P:  No....Oh, y e a h , 'cause I'm c r a z y . Does t h a t sound good? How s h o u l d we p u t i t f o r t h e t a p e ? 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 a s k i n g y o u do y o u f e e l t o be h e r e ?  P:  That's a joke. I c a n ' t f i n d a room o u t t h e r e . I c a n ' t f i n d m e a l s , so I may a s w e l l s t a y h e r e u n t i l I c a n f i n d my m e a l s .  Because t h e y viewed  y o u need  t h e need  t o be i n h o s p i t a l ?  forhospitalization  t h e 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 others  (the s t a f f )  i n their  from t h e c o r n e r s t o n e t h a t t h e same s i t u a t i o n if  quite  y o u need  differently,  i n disagreement  environment.  I f each  they are c o r r e c t differently,  with  starts  and t h e y  perceive  a chasm must be b r e a c h e d  u n d e r s t a n d i n g i s t o be a c h i e v e d . The  participants  was t h e " r i g h t  frequently queried  o n e " f o r them.  i ftheir  treatment  Three o f the p a r t i c i p a n t s  55  asked  t h e r e s e a r c h e r h e r o p i n i o n iabout t h e i r  cause  they  typically t o how  r e s e r v a t i o n s about  Another  their  treatment,  Be-  they  a s s i g n e d i t a low v a l u e and made s u g g e s t i o n s  i t c o u l d be  P:  be  had  treatment.  as  improved:  I'm so c o n c e r n e d maybe I n e e d some, a b i t o f 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 d o n ' t n e e d m e 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 t h i n k . . . . I ' m w o r r i e d more a b o u t m e d i c a t i o n and how I'm g o i n g t o f e e l once I g e t o u t o f h o s p i t a l , i f i t ' s g o i n g t o do me any good. p a t i e n t , who  d i s c o n t i n u e d , was  felt  c o n v i n c e d he had  " T h a t means a l l o f t h i s hospital  a l l h i s medications been  i s a l o t of crap.  b u t one  should  misdiagnosed: Then—mind  you,  i s a l o t of crap."  Much o f t h e d i f f i c u l t y  seems t o a r i s e  from the  t h a t d e c i s i o n s were made a b o u t  the p a t i e n t s ,  perceived  This i s well  things d i f f e r e n t l y .  w i t h a woman whose t r e a t m e n t  i n c l u d e d a low  fact  but the p a t i e n t s illustrated stimulus environ-  ment: P:  But  now  R:  Um,  who's  P:  The n u r s e s . "Come o u t e v e r y h o u r f o r a c i g a rette." I d o n ' t need t h a t . I d o n ' t need t h a t shit. Who do t h e y t h i n k t h e y a r e t o t e l l me what t o do?  S t a f f was  like,  t h e y g o t me  mad.  they?  g e n e r a l l y p e r c e i v e d as n o t b e i n g v e r y  helpful.  P:  They're j u s t k i d s . I'm 2 0 , b u t I've l i v e d on the s t r e e t s . They h a v e n ' t l i v e d o u t 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  P:  They d o n ' t  feel? understand.  56  The  role  of the  s t a f f was  not very c l e a r  to the p a t i e n t s  either: P:  It  Um, I d o n ' t r e a l l y u n d e r s t a n d t h e s t a f f h e r e , how t h e y work, i f t h e y ' r e n u r s e s o r s e c r e t a r i e s o r what. T h e y ' r e h e l p f u l on a one t o one b a s i s b u t i n g r o u p s t h e y l o o k i n on us and w r i t e down notes. We d o n ' t g e t f e e d b a c k from them r e a l l y , and I f e e l t h e y s h o u l d g i v e us a l i t t l e more i n sight. T h e y ' v e been t o s c h o o l . . . . The d o c t o r s h e r e a r e j u s t l i k e f r i e n d s , t h e y j u s t ask a l o t of questions. I d o n ' t see them v e r y l o n g . They're a l o t b e t t e r than nurses.  c a n be  seen  that i f people  do  of each other, i t i s d i f f i c u l t An  important  f o r the ient.  thrust  staff As  i s being i l l u s t r a t e d .  i n Kleinman's  s e c t o r have t h e i r  t a t i o n s which d i f f e r t i o n s o f those saw  from  t h e p a t i e n t ' s low  h e r manic . b e h a v i o u r , punishment. their  While  freedom, the  guarding acted  f o r the  she  (1978) m o d e l , t h o s e  i n the  own  and  beliefs,  roles,  roles,  sector.  and  saw  the  the r u l e s  expec-  expecta-  Thus, w h i l e the  p e r c e i v e d i t as an  t h e p a t i e n t s saw staff  pat-  staff reduce  infantilizing  rules  as  restricting  as a means o f  safe-  t h e p a t i e n t s o r as a means o f e n s u r i n g t h e p a t i e n t s  participants'  of the nurse nurse.  meaning  s t i m u l u s programme as n e e d e d t o  i n a responsible The  What has  have meaning  the b e l i e f s ,  i n the popular  understanding  t o make t h e i r n e e d s known.  does n o t n e c e s s a r i l y  stated  professional  n o t have an  As  can  has  way. lack of understanding  a l s o be  linked  been shown and  many o f t h e p a t i e n t s ' t i o n w i t h the nurses.  the  to t h e i r perception of  will  statements  about  c o n t i n u e t o be  expressed  Comments a b o u t  anger  the d o c t o r s  role the  shown, or  frustra-  tended.to  57  be n e u t r a l or p o s i t i v e .  The  following i s a typical  ment by one o f the p a r t i c i p a n t s :  state-  "I do not l i k e the nurses.  There are some, nurses t h a t are r e a l l y uptight....The d o c t o r s , they know what's wrong with  you."  U n t i l the r e s e a r c h e r examined the s o c i o c u l t u r a l  setting  i n which the s u b j e c t i v e e x p e r i e n c e s of the p a t i e n t s were l o cated, i t was the nurses.  d i f f i c u l t to understand When examining  t h i s p e r c e p t i o n of  the t r a n s c r i p t s , one of the  p a r t i c i p a n t ' s comments l e d t o the a n a l y s i s being "Doctors got the a u t h o r i t y and nurses don't."  utilized:  The  researcher  then began an 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 on power: The more l e g i t i m a t e one i s p e r c e i v e d to be, the g r e a t e r the l i k e l i h o o d of compliance w i t h one's attempts to i n f l u e n c e , and the l e s s resentment o f going a l o n g . Power goes t o those who are seen as having a r i g h t to it. Conversely, the l e s s l e g i t i m a t e forms of i n f l u e n c e breed r e s i s t a n c e and resentment....The more a person has access to c o n t r o l l i n g rewards and p u n i s h ments, the g r e a t e r h i s / h e r power. Thus a person who can give the formal rewards or use the formal p u n i s h ments o f an o r g a n i z a t i o n . . . w i l l have the most power.... Whatever i t i s t h a t people v a l u e . o r f e a r , those who c o n t r o l i t w i l l have power to i n f l u e n c e b e h a v i o r . . . . The more power a t t r i b u t e d t o a person, the more he/she I s the r e c i p i e n t o f . . . deference by o t h e r s seeking power. (Cohen, F i n k , Gadon, & W i l l i t t s , 1976, pp. 196-197) On the b a s i s o f the v e r b a l i z a t i o n s of the p a r t i c i p a n t s i n t h i s study and on the b a s i s o f the l i t e r a t u r e on power, one  can hypothesize t h a t p h y s i c i a n s are imbued with  mate a u t h o r i t y by p a t i e n t s . wards" and  Doctors c e r t a i n l y c o n t r o l " r e -  "punishments" f o r the p a t i e n t s :  p a t i e n t ' s admission;  legiti-  they determine  they determine  a p a t i e n t ' s medications;  they decide i f a p a t i e n t r e q u i r e s committal papers; decide on a p a t i e n t ' s d i s c h a r g e .  a  and  they  58  C o n v e r s e l y , nurses are mate power i f t h e study are  a reliable  they didn't This  may  reactions  really  explain  of  perceived the  indicator.  know what t h e  the  pants towards the  not  resistance  as  the  patients  they d i d not  or  therapeutic  t h e i r own  the  patients  r o l e of  the  nurse  and  opinion  d i d not  u n d e r s t a n d the milieu.  the  a l . (1976)  form o f  stated  was.  resentment of  partici-  describe  influence  understand  the  purpose of  Frequently,  o f what w o u l d be  try  r o l e of  their  patients  expressed  most h e l p f u l :  So you were f e e l i n g o k a y and you c o u l d n ' t any p o i n t i n b e i n g h e r e 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, s t r a n g e , but i t wasn't n o t h i n g s e r i o u s . You know, I c o u l d l a y a r o u n d 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 n e e d i s a r e s t , you know.  same p a t i e n t  P:  l a t e r e x p r e s s e d how  the  see  programme  "inter-  goal:  T h e y [ s t a f f ] ask you t o go o u t t o e x e r c i s e , and m e e t i n g s and a l l t h a t k i n d o f s t u f f . I'm not really interested. My main c o n c e r n i s t o g e t better.  A n o t h e r p a t i e n t was  more o p e n l y c r i t i c a l  of  the  programme:  P:  You have t o do c e r t a i n t h i n g s a t c e r t a i n t i m e s . You've g o t t o p a i n t l i k e a baby. You've g o t t o c l e a n up a l l t h e t i m e . Aw, i t ' s a j o k e .  R:  Why  P:  F o r s o m e t h i n g t o do. That's a l l . therapy. I c a n do t h a t anywhere.  of  the  programme  R:  f e r e d " w i t h h i s own  One  this  Most o f  n u r s e s w h i c h Cohen e t  staff,  This  legiti-  power.  Just  the  having  participants in  when t h o s e h a v i n g a l e s s l e g i t i m a t e to e x e r t  as  the  do  you  patients  think  t h e y ask  relayed  her  those  perception  things? It's  of  the  not  meaningless-  59  ness o f the r u l e s r e g a r d i n g her p h y s i c a l movement. s t r a i n t of movement was  This r e -  a major i s s u e under the d i s c u s s i o n  of powerlessness. P:  I wanted to get o u t s i d e so I c o u l d f e e l f r e e , and my mind c o u l d be a t ease. They wouldn't l e t me go. No nurse would take me o u t s i d e . They t o l d me to s t i c k my hands o u t s i d e the window. I s n ' t t h a t s t u p i d ? I'm a person t h a t l i k e s to go o u t s i d e - - I walk, and j o g , and run. I t ' s hard to change.  In g e n e r a l , i t was  difficult  f o r the p a t i e n t s to understand  t h a t the h o s p i t a l i s a bureaucracy w i t h a need f o r e f f i c i e n c y : " I f I don't get t o d i n n e r between 5 and 5:30,  that's i t .  I  don't e a t . " How  does the theme of m e a n i n g l e s s n e s s / i s o l a t i o n  to the elopements?  relate  I f i n d i v 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  v a l u e , they w i l l  likely  seek a s i t u a t i o n which does have meaning and worth f o r them. During t h e i r elopements,  the p a r t i c i p a n t s d e s c r i b e d the  events i n which they were engaged: home, s e e i n g f r i e n d s , and shopping. was  going f o r walks,  going  When one of the p a t i e n t s  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 ,  " p l a y i n g bingo."  These con-  c r e t e , "normal" events had meaning and value f o r the people involved. Normlessness. normlessness approved (p. 50).  In Seeman's (1959/1972) d e f i n i t i o n of  "there i s a h i g h expectancy t h a t s o c i a l l y  un-  behaviors are r e q u i r e d to achieve g i v e n g o a l s " Elopements themselves  are c o n s i d e r e d i n a p p r o p r i a t e  60  behaviours and i t can thus e a s i l y be seen t h a t 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  s t r e s s e d i n t h i s s e c t i o n o f the paper i s the p a t t e r n o f normlessness which e x i s t s i n the l i v e s o f the p a r t i c i p a n t s . While t h e r e are v a r i o u s ways o f l o o k i n g a t the reasons coping behaviours are e s t a b l i s h e d 1976), to  i t i s g e n e r a l l y agreed a coping behaviour i s used  h e l p a person meet a need.  purpose  (Eaton, P e t e r s o n , & Davis,  The behaviour thus serves a  f o r the person who engages i n i t , though the purpose  may not be e v i d e n t to o t h e r people.  A r e p e r t o i r e o f coping  behaviours i s developed t o d e a l w i t h l i f e .  If a particular  behaviour has been u s e f u l t o the person i n the p a s t , " t h i s p a t t e r n i s l i k e l y t o be one o f the behaviors: c a l l e d  forth  from the person's memory bank and put i n t o o p e r a t i o n " (Grace, Layton, & C a m i l l e r i , 1977, p. 69). Though the behaviour i s not f i x e d and i t can be m o d i f i e d o r e l i m i n a t e d , i f o p p o r t u n i t i e s are not p r o v i d e d f o r the behaviour t o be changed i t usually persists  (Millon & M i l l o n ,  1974).  The behaviour o f elopement was the commonality which caused each p a r t i c i p a n t t o be i n t h i s study. the p a r t i c i p a n t s themselves  As some o f  s t a t e d , elopement i s a form o f  "running away" o r "escaping."  As the i n t e r v i e w s progressed,  i t became e v i d e n t t h a t "running away" was a p a t t e r n o r s t y l e of  behaviour f o r the p a r t i c i p a n t s : P':' You see, I've run away from a l o t o f p l a c e s when I was younger, and t h e r e ' s been a l o t o f d i f f e r e n t p e o p l e s p l a c e s , and j u s t t h a t I've run away f o r , a l l my l i f e , so i t ' s p r e t t y hard. 1  61  All  the p a r t i c i p a n t s  the p a r t i c i p a n t s had  left  related  identified  and f o u r o f the p a r t i c i p a n t s  hospitals;  juvenile  "escapes."  identified  s c h o o l s ; home; c o u r t ; f o s t e r  detention centres.  Another P:  psychi-  homes; and  For the p a r t i c i p a n t s ,  "running  a t hand:  I was h a v i n g p r o b l e m s , my p a r e n t s were h a v i n g p r o b l e m s , I was h a v i n g p r o b l e m s a t s c h o o l . . . . T h a t ' s what made me s t a r t r u n n i n g away f i r s t , my p a r e n t s , a n d j u s t l i f e i n g e n e r a l . participant explained i t this  way:  Why d i d I l e a v e ? Same r e a s o n . J u s t don't f e e l right. J u s t t h a t y o u h a t e i t so much y o u c a n ' t even t h i n k . . . . I j u s t h a t e d i t . J u s t the thought of being there.  Overall, away."  they  at least  These i n c l u d e d :  away" was a means o f d e a l i n g w i t h t h e s i t u a t i o n P:  Each o f  a t l e a s t one p l a c e w h i c h  t h r e e p l a c e s w h i c h t h e y had l e f t . atric  past  two r e a s o n s  The i n a b i l i t y  way was c i t e d  were g i v e n a s t o why p e o p l e " r a n  t o handle  the s i t u a t i o n  i n any o t h e r  a s one r e a s o n :  P:  You've g o t t h e same t r o u b l e , p r o b l e m s , and you haven't r e a l l y been d e a l i n g w i t h i t . I just t h r o w them o f f , r u n away, I d i d n ' t r e a l l y want t o d e a l w i t h my p r o b l e m s .  R:  So i t seems t h a t when y o u have p r o b l e m s ,  that  P:  — t o o stressful r u n n i n g away.  like  Another  participant  f o r me,  then  I just  feel  --  stated:  P:  I took  o f f on t h e l a w one t i m e , t o o .  R:  You t o o k  P:  On t h e l a w . I was s u p p o s e d t o a p p e a r i n c o u r t f o r undue c a r e a n d a t t e n t i o n , and I t o o k o f f f o r a y e a r . . . . I was s c a r e d t o s t a y .  The  second  off...?  reason  g i v e n a s t o why p e o p l e  " r a n away"  62  was  the  need f o r f r e e d o m , t h e  w h i c h the  A  participants come you  need to escape  from  constraints  perceived:  R:  How  u s e d t o do  that  P:  I j u s t wanted f r e e d o m , t h a t ' s a l l . . . . T h e y [parents] were work, work, work, a l l work, and t h a t ' s a l l t h e r e w a s — t h a t and s c h o o l . . . . I g o t nothing a g a i n s t work, b u t 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 t h e t r a c t o r by t h e t i m e I was about s i x .  second p a r t i c i p a n t a l s o l i s t e d  the  away f r o m home]?  same n e e d :  R:  Why d i d you l e a v e elopement]?  P:  J u s t b o r e d , boredom. I wanted t o g e t o u t , I , I l i k e t o w a l k a l o t , l i k e t e n m i l e s s o m e t i m e s , and I , I l i k e , r e a l l y l i k e t o w a l k a l o t t o keep me i n s h a p e , and my mind m e n t a l l y , i t h e l p s i t , h e l p s it.  R:  Okay—  P:  Just,  time  [from a  previous  f r e e d o m p u r p o s e , I t h i n k , more t h a n  Each o f the away" as  at that  [run  participants in this  a means o f c o p i n g  s t u d y had  anything.  used  "running  with d i f f i c u l t situations.  In-  deed, each p a r t i c i p a n t l e a r n e d  this  behaviour e a r l y i n l i f e ,  often  only  had  in met  during  their  adolescence.  respective  served  the  the  i t had  t i m e by  behaviour of  a u s e f u l purpose  been  successfully  either  s i t u a t i o n f o r a time or The  behaviour  allowing  allowing  the  " r u n n i n g away"  free-  had  f o r these i n d i v i d u a l s i n  past. Alcohol  of  the  they r e q u i r e d .  therefore the  r e p e r t o i r e s , but  a n e e d a t l e a s t some o f  them t o l e a v e dom  Not  the  a n d / o r d r u g m i s u s e was  participants.  intoxicated  w h i l e on  One her  of  the  also  patients  elopement.  The  a pattern stated  for  she  four  became  reasons given  for  63 the  substance  the  thing  avoiding a  to her  result.  pattern  misuse do  varied:  at the  problems;  Whatever  of  time; and  the  normlessness  in  As  society  were  otherwise"  for  one  person  His  terse  stated  he  might  (p. the  often.  This  though,  as  variation of  theme  the  i n the  i f the  of  better  reinforces  means  was  the  study.  stated, to  as  be  "To  some-  circumstances  53).  i t was  i n t e r a c t i o n with  be  i t  a means  felt  (1959/1972)  analysis,  ideally  was  misuse  Seeman  final  one  least  another  i t was  participants  than  occurred  stated  f o r the  less  Self-estrangement  one  the  s e l f - a l i e n a t e d i n the  thing  individual stated  reason,  Self-estrangement. be  one  was the  alienation  particularly main  reason  which  important  he  researcher requires  eloped. no  further  comment: R:  No. S o , i t was toward you t h a t  P:  Yeah.  R:  Anyone  P :  m a i n l y t h e way you eloped.'  the  staff  acted  in particular?  No.  R:  No. Okay. or a l l the  P:  A l l the  time.  R:  A l l the  time.  P:  Yeah.  R:  Do  P:  Yeah.  R:  Y o u do....How d o e s they i g n o r e you?  you  find  D i d t h a t happen j u s t time, or j u s t once?  that's  s t i l l  that  once  in a  while,  when  they,  happening?  make y o u  feel  64  P:  Not  too good.  Quite  R:  Yeah.  P:  I t j u s t doesn't f e e l r i g h t .  R:  Yeah.  P:  S o r t of a r e a l weird  R:  Mmhmm. Can you e x p l a i n a b i t more about t h a t weird f e e l i n g ?  P:  J u s t doesn't seem l i k e you're here.  Bad.  Subjective A l i e n a t i o n Within The has  bad.  feeling.  an O b j e c t i v e  i n t e r t w i n i n g o f s u b j e c t i v e and  been i l l u s t r a t e d i n the p r e s e n t a t i o n  the p a r t i c i p a n t s ' accounts.  Goffman  Context  objective alienation and  d i s c u s s i o n of  (1961) e l o q u e n t l y  sum-  marized t h i s i n t e r t w i n i n g : On the o u t s i d e , the i n d i v i d u a l can hold o b j e c t s o f s e l f - f e e l i n g — s u c h as h i s body, h i s immediate a c t i o n s , h i s thoughts, and some o f h i s possessions - - c l e a r o f c o n t a c t w i t h 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 v i o l a t e d ; the boundary between h i s being and the environment i s invaded. (p.  23)  Summary T h i s chapter has alienation. and  The  been concerned w i t h the concept of  review of the l i t e r a t u r e on both s u b j e c t i v e  o b j e c t i v e a l i e n a t i o n analyzed  a c r o s s - s e c t i o n of  i n g s which d i s p l a y e d how  d i f f e r e n t l y and  concept i s d e f i n e d .  accounts of the p a r t i c i p a n t s were  presented and  The  discussed  concurrently  t i o n o f a l i e n a t i o n as a framework.  how  widely  readthe  u s i n g Seeman's concepThe  major t h r u s t of  the  65  f e e l i n g s o f t h e p a r t i c i p a n t s was a s e n s e o v e r what was h a p p e n i n g see  little  t o and a r o u n d  meaning o r l i t t l e  value  of loss of control  them.  They t e n d e d  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  norms was a l s o  shown.  throughout lated  this  A sense  of separateness  c h a p t e r and t h i s  sense  hierarchy  e x p e r i e n c e s took  i n a hospital  was a t h r e a d  shown t o be r e -  control  was v i e w e d in clinical  amenable-to  place.  The  as l i m i t e d matters,  redistribution.  i n which  vertical  and t h e p a t i e n t ' s p o s i t i o n  h i e r a r c h y were shown t o be c r u c i a l .  quired  was  to s o c i a l  t o t h e o r g a n i z a t i o n o f t h e h e a l t h care system  the p a r t i c i p a n t s '  to  i n this  The p a t i e n t ' s a c t u a l  and, w h i l e  t h i s m i g h t be r e -  o t h e r a r e a s o f c o n t r o l m i g h t be  Chapter Summary, C o n c l u s i o n s ,  Five  and I m p l i c a t i o n s f o r N u r s i n g  Summary and C o n c l u s i o n s This  s t u d y was d e s i g n e d  how p s y c h i a t r i c hospital.  t o g a i n an u n d e r s t a n d i n g  p a t i e n t s v i e w t h e i r own e l o p e m e n t s  The l i m i t e d  amount o f i n f o r m a t i o n  of  from  available  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 worker. tant  A b e t t e r understanding  f o r nurses  o f the behaviour  b e c a u s e much t i m e  and e f f o r t  care  i s impor-  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  safety o f the p a t i e n t .  Because events  lation,  o f t h e p a t i e n t s were a l s o e x a m i n e d  in  the experiences  relation  t o the s o c i o c u l t u r a l  f o r the  do n o t o c c u r  context  i n which  i n iso-  they  occurred. To without  g a i n an u n d e r s t a n d i n g  o f those  the permission o f the s t a f f ,  who l e f t  an a p p r o a c h was u s e d  which emphasizes t h e importance o f i d e n t i f y i n g meaningful  the h o s p i t a l  what i s  f o r t h e s u b j e c t s from t h e i r p o i n t o f view.  a p p r o a c h complemented t h r e e o f t h e p u r p o s e s o f t h i s  This  study:  what l e d t o t h e e l o p e m e n t ; how t h e a c t u a l e l o p e m e n t was ceived;  a n d what p u r p o s e t h e e l o p e m e n t s e r v e d .  purpose o f t h i s  study,  per-  The f o u r t h  analyzing the perceptions o f the  subjects within the s o c i o c u l t u r a l  context,  with Kleinman s  framework w h i c h was u s e d  1  (1978) c o n c e p t u a l 66  was  congruent  67  in  this  study.  patients  In Kleinman's  are addressed  framework, t h e p e r c e p t i o n s o f  as w e l l  as the  f o r c e s which  influence  those p e r c e p t i o n s . I n t e r v i e w s were c o n d u c t e d had  returned to the h o s p i t a l .  the p a t i e n t  and  with five  s u b j e c t s once  Through the i n t e r v i e w s ,  t h e r e s e a r c h e r c o n s t r u c t e d an a c c o u n t  the experience.  they  T h r o u g h an i n t e r a c t i v e  of  p r o c e s s , the r e -  s e a r c h e r came t o an u n d e r s t a n d i n g o f t h e s u b j e c t ' s p e r s p e c tive.  From t h e c o n s t r u c t i o n  r e v i e w o f the  literature,  o f the accounts  an i n t e r p r e t a t i o n  i e n c e s o f t h e p a r t i c i p a n t s was A l i e n a t i o n was  the u n i f y i n g  tive  and  possible ceptual  T h i s concept objective  concept  in  The  of the accounts  of  the  as h a v i n g b o t h  To p r e s e n t t h e  treatment  w i t h Kleinman's  linked  were o c c u r r i n g ,  identifiable  were  t h e i r programme; and  t o t h e i r elopements. b u t t h e y had  subjects stated  t h e y had  no not  sought  of e x t e r n a l events or  t h e t r e a t m e n t s were f r e q u e n t l y sense.  The  events  Four  of  hospitalization,  The  o r n o t making  events  that  these.  because  meaningless  of  control  over  b u t were a d m i t t e d programme and  utilized.  hospital;  They f e l t  input into  con-  i n the case  over t h e i r entry i n t o and  subjec-  broadest  patients experienced a loss of  a v a r i e t y o f ways:  over t h e i r  the  the  congruent  a l i e n a t i o n was  exper-  by  framework, b o t h a s p e c t s o f a l i e n a t i o n  subject.  directly  t o be  o f the  ensuing  identified  viewed  components.  v i e w p o i n t and  Subjective each  c a n be  the  made.  r e s e a r c h e r t o e x p l a i n o r make s e n s e patients.  and  controls. viewed  p a t i e n t s were  as  asked  68  t o engage i n a c t i v i t i e s rect  which they  f o r them a n d t h e i r n e e d s .  a low v a l u e  to their  a "last  leaving.  as b e i n g  Thus, t h e p a t i e n t s  incor-  assigned  t r e a t m e n t , t o t h e i r programme, and t o  their hospitalization. fied  perceived  In each i n s t a n c e ,  the subject  straw" which caused h i s o r her  I n some c a s e s ,  t h i s was a c r i s i s  identi-  unsanctioned  situation  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 a n o t h e r 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 o f a p a r t i c u l a r e l o p e m e n t s u c h a s when a p a t i e n t f e l t listen  e l o p e m e n t was v i e w e d a s p o s i t i v e by e a c h  t h o u g h some p a t i e n t s d i d e x p e r i e n c e an i n c r e a s e  that  t h e - s t a f f d i d not  to h i s concerns.  The  or  concern a l s o l e d to  i n medications  as a r e s u l t  through t h e i r elopements they  control  a n d some f r e e d o m .  a reduction  This perception  This coping  when t h e y patterns  to regain  some  of health  care  i n the l i t e r a t u r e .  A pattern o f running subjects.  A l l stated  o f e l o p e m e n t as  a p o s i t i v e event c o n t r a d i c t s the perceptions workers as r e p o r t e d  i n privileges  of i t .  were a b l e  subject,  away b e h a v i o u r was t y p i c a l  p a t t e r n had h e l p e d  were e x p e r i e n c i n g  a stress.  f o r the  them i n t h e p a s t  Other  nonconforming  s u c h a s d r u g and a l c o h o l m i s u s e were a l s o  noted  amongst them. When K l e i n m a n s framework was u t i l i z e d 1  subjective cultural  experiences  context,  to place the  of the p a r t i c i p a n t s i n their  socio-  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  b u r e a u c r a c y was e x a m i n e d .  I t was s u g g e s t e d t h a t , due t o  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  less  to affect  this  feeling  what i s o c c u r r i n g .  i s inevitable;  health  To a c e r t a i n  c a r e w o r k e r s have an e x -  p e r t knowledge w h i c h p a t i e n t s do n o t h a v e . may o f t e n to  take c o n t r o l  the p a t i e n t s .  felt  formed about than For  the r a t i o n a l e s  them.  sense"  i n a low s t i m u l u s  felt  that  minutes  commented  notice  t h e y were n o t i n -  t h e r e were a r e a s  m a t t e r s where p a t i e n t s m i g h t  e x a m p l e , one p a t i e n t  room on f i v e  "make  f o r t h e d e c i s i o n s w h i c h were made  I t was s u g g e s t e d  clinical  staff  As an e x a m p l e , one p a t i e n t who was " h i g h "  The s u b j e c t s f r e q u e n t l y  about  As s u c h ,  and do t h i n g s w h i c h d o n ' t  she was b e i n g p u n i s h e d b y b e i n g k e p t  environment.  extent,  other  have more  control.  she h a d t o change h e r  and s h e had no c h o i c e i n h e r  new roommate. One  v e r y s t r o n g c o n c l u s i o n w h i c h emerged  s t u d y was t h a t t h e s u b j e c t s t e n d e d tively  w h i l e they tended  positively. the nurses nurses'  for  t o perceive nurses  nega-  to perceive doctors neutrally or  a s h a v i n g l e g i t i m a t e power a n d t h u s  attempts  to influence  f o r Nursing  nursing practice.  resented the  them.  Practice  findings of this  reiteration  this  I t was h y p o t h e s i z e d t h e p a t i e n t s do n o t see  Implications The  from  study suggest  several  directions  T h e y a r e n o t new o r u n i q u e  but a  o f i d e a s w h i c h have been t a u g h t i n n u r s i n g p r o -  grammes a n d w h i c h have been a d d r e s s e d  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 .  used,  the meanings a t t a c h e d  To.reach  then  have t o e x p l a i n  A process  the understanding  Teaching  done i n a d v a n c e o f t h e e v e n t understands, While  of negotiation  why  o f the p a t i e n t  the a c t i o n  about a treatment  i s not  should  i s being  necessarily  r e q u i r e e x p l a n a t i o n s on  taken.  so  be  evident to  rules  admission  and  i n a programme a l s o  Nurses should i n v e s t i g a t e w h i c h p a t i e n t s have u t i l i z e d or  powerless.  nurse  as  The to  nurse  The  require discussion.  previous patterns of  when t h e y  have  help  A l l o w i n g the e x p r e s s i o n o f  verbal participation  need  i t may  be  difficult  f o r the  f o r r e b e l l i o u s behaviour  the p a t i e n t . ment may  be  can  A l l o w i n g a sense  one  c o n c r e t e way  the  behaviours. as p o s s i b l e  feelings  can h e l p i n t h i s  when t h e a c t u a l d e c i s i o n s t h e p a t i e n t can make a r e While  coping  f e l t constrained  s h o u l d r e s t o r e as much c o n t r o l  the p a t i e n t .  encouraging  certain  They  different  A r e l e v a n t n u r s i n g a s s e s s m e n t may  to a n t i c i p a t e  the  f o r the p a t i e n t s .  a s p e c t s o f t h e programme a r e e x p a n d e d o r d e l e t e d . f o r the  be  so t h e p a t i e n t knows, i f n o t  t h e aims o f a programme may  this  reasons  greatly.  t e a c h i n g i f t h e t e a c h i n g i s t o have mean-  f o r the p a t i e n t .  will  will  vary  are  occur.  before they begin  staff,  words can  nurses  situation.  Nurses need t o a s s e s s  ing  to those  a mutual understanding,  t h e i r p e r c e p t i o n of the can  E v e n when s i m i l a r words  staff,  and  area  minimal.  acknowledging  help the  of control  of increasing  even  the  s e l f - c o n c e p t of over  the  environ-  the p a t i e n t ' s per-  71  ception  of  It  control.  i s imperative  e v e n t s c a n n o t be is  modified  i m p o r t a n t t o do  receive  this  the to  perceive  I f one their  n u r s e e x p l a i n why  suit  the  of  thing  the  i s s a i d and not  Again, i t  p a t i e n t does  a situation.  concerns are  This  being  the no  in this  treated  In  the  profession,  the  i n d i v i d u a l i s v e r b a l l y acknowledged. one  little  answer s u i t a b l e f o r a l l p a t i e n t s flexibility in policies  As ties. and  study.  a profession, I f we  i f we  truly  truly  nursing  believe  believe  a bio-psycho-social  and  patients  seriously.  administra-  uniqueness  yet  we  of is  permit  approaches.  needs t o examine i t s p r i o r i a patient  i n i n t e r a c t i n g w i t h the we  to  However, t h e r e and  i n a r o l e as  being,  not  relates  a n o t h e r done,  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 tion  certain  patient.  i n a d v a n c e so  a false perception  consistency. may  that  n e e d t o be  advocate  patient  congruent i n  as  our  actions. Nurses should  be  consumers so  involved  of  health  If  c o n s u m e r s band t o g e t h e r ,  moted t o i n f l u e n c e As  the  they can  organization  make i n f o r m e d  collective  organization  a profession, nursing  regarding  i n i n c r e a s i n g the  of  the  should  be  health  care  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 . fluence,  n u r s e s must have i n p u t  To  a t the  decisions.  a c t i o n can  of health  competence  be  care.  involved  in  s y s t e m and  have t h e  pro-  decisions other  greatest  decision-making  inlevel.  72  Implications  for Nursing  Education  N u r s i n g c u r r i c u l a need t o p r e p a r e different of being  views o f  of  health the  skill  of  the  care  patient  techniques.  e l i c i t the  i n the  an  of  is crucial.  the  patient  more s e n s i t i v e t o w a r d s t h e  Health  i m p a c t on  their  patients of  needs  b e h a v i o u r can  professionals  have t h e  are  casual  of  affect  frequently  r e p l i e s or  obviously  I f n u r s e s do  patient's  advocate,  operationalize  this  s y s t e m and  the  and  requires accept  the  to  the  un-  un-  skills  fellow health  a sense o f  to  care  professional  r e s p o n s i b i l i t y of  s t u d e n t s need t o  l e a r n ways  being to  role.  C u r r i c u l a must f o s t e r an  students are  knowledge and  r o l e to patients  This  identity.  u n d e r s t a n d i n g o f the  f a c t o r s which i n f l u e n c e  t o u n d e r s t a n d how  the  decision-making  the  system a l s o heed t o It  role of  interpersonal  actions.  workers.  care  of  perspective  sophisticated  a w a r e n e s s o f how  Students should  the  use  students i n the  side."  present  the  t o promote e f f e c t i v e c o m m u n i c a t i o n ,  "the  explained  that  To  Placing  the  part  professional.  them t o be  aware o f  r o l e , must r e a l i z e  a  d i f f e r e n t from t h a t  and  Instilling  S t u d e n t s , as  be  might help other  examine  p a t i e n t may  i s required  others  reality.  s o c i a l i z e d i n t o a new  perspective the  clinical  students to  level.  is particularly  be  The  t h e y can  the  make an  political  skills  health  system i f impact  at  to a f f e c t  provided.  important  to note  t h a t , w h i l e we  as  73  nurses  b e l i e v e we  practice, tent  address  implementation  as we  might  Implications  these may  i s s u e s i n both  n o t be  as e f f e c t i v e  f o r Nursing  the elopement o f  identified.  could heighten  spect,  psychiatric  knowledge o f t h i s  a s i m i l a r m e t h o d o l o g y were u s e d , o t h e r  jects  or c o n s i s -  Research  p a t i e n t s would produce a broader  m i g h t be  and  wish.  S u b s e q u e n t s t u d i e s on  If  education  subject.  concepts  or  A d d i t i o n a l i n t e r a c t i o n s with the r i c h n e s s o f the data.  themes  the  In  sub-  retro-  i t w o u l d have been u s e f u l t o i n t e r v i e w t h e p a t i e n t s  once t h e y  had  left  when t h e y were w o u l d be  the h o s p i t a l  "free."  An  obvious  their  perceptions  extension of t h i s  t o e x a m i n e t h e p e r c e p t i o n s o f p a t i e n t s who  from n o n - p s y c h i a t r i c u n i t s o f a As  to assess  a direct  r e s u l t of t h i s  study elope  hospital. study,  some q u e s t i o n s  have  been r a i s e d w h i c h w o u l d b e n e f i t f r o m 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 ferently? ment and the  were o l d e r p e r c e i v e  a previous  dif-  between  elope-  coping pattern of running  s t a f f p e r c e i v e the  subsequently  had  eloped  o f a p a t i e n t who  initially  wanted t o be  perceive their  e l o p e m e n t i s p e r c e i v e d as one  of  alienation,  identified? same time  away?  behaviour  If  the  situation  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  Would p a t i e n t s who and  their  in  situation  How  elopes? hospital differently?  behavioural manifestation  a r e t h e r e o t h e r m a n i f e s t a t i o n s t h a t can  How  can  p a t i e n t s be  t h a t s a f e and  do  allowed  effective  more c o n t r o l  care  is  be at  provided?  74  An the be  unexpected  finding of this  role of the staff  was u n c l e a r  s t u d y was t h e f a c t t o the subjects.  u s e f u l t o know how p a t i e n t s p e r c e i v e  staff  w o u l d be u s e f u l t o know what e x p e c t a t i o n s of health useful  care  professionals.  This  more r e s p o n s i v e  information  This  the parts  strengthening  information  could  as i t have  w o u l d be patients.  a s an e x a m i n a t i o n  of this.hierarchy i s indi-  be u s e d a s a b a s i s  o f the system which c o u l d those  I t would  o f t h e h o s p i t a l c o u l d be  t o p a t i e n t s ' needs as w e l l  the e f f e c t s o f the f l a t t e n i n g  cated. ing  patients  t o e s t a b l i s h a basis f o r negotiation with  R e s e a r c h on how t h e h i e r a r c h y  of  just  that  f o r chang-  be i m p r o v e d o r  features which are b e n e f i c i a l  f o r patient  care. In c o n c l u s i o n , the  fact  then, t h i s t h e s i s w i l l  that continued  research  into this  have made field  obvious  i s neces-  sary.  The r e a s o n s f o r t h e p a t i e n t s ' e l o p e m e n t s have b e e n  viewed  from t h e i r  perspective  and i t i s c l e a r t h a t t h e  patients perceive  justifiable  rationales f o rthis  Through f u r t h e r examination o f these workers w i l l  reasons, health  care  expand t h e i r u n d e r s t a n d i n g o f t h e elopements  of p s y c h i a t r i c p a t i e n t s . practitioners  behaviour.  cope w i t h  This an a r e a  continued  research  will  help  o f s e r i o u s ..concern b o t h f o r  them and f o r t h e 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 n u r s i n g process i n p s y c h i a t r i c c a r e . Nursing Times, 1977, 73, 1412-1413. Aspy, V i r g i n i a H. 6_8, 690.  Are p a t i e n t s people?  Nursing Times, 1972,  B a i l e y , Janet T. The problem behavior r e p o r t sheet and coding t o o l . In M.J. Ward & C A . 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London: SAGE P u b l i c a t i o n s L t d . , 1982. Vousden, M a r t i n . Times, 1979,  The one t h a t n e a r l y got away. 75, 1642-1643.  Nursing  Wilson, H o l l y S., & K n e i s l , C a r o l Ren. Psychiatric nursing. Menlo Park, C a l i f . : Addison-Wesley Pub. Co., 1979.  81  Appendix I n f o r m a t i o n and  A  Consent  Form  82  I n f o r m a t i o n and Consent My name i s K a t h y is  c u r r e n t l y working  Mclndoe.  I am a r e g i s t e r e d  on a M a s t e r ' s  the U n i v e r s i t y  of British  learning  p e o p l e who have l e f t  about  Columbia.  the p e r m i s s i o n o f the s t a f f . when I was w o r k i n g about  this  who  Degree i n n u r s i n g a t I am i n t e r e s t e d i n the h o s p i t a l  My i n t e r e s t  and I c o u l d f i n d  nurse  without  i n this  developed  out l i t t l e information  matter.  I would l i k e recent  Form  leaving  t o meet w i t h y o u t w i c e t o d i s c u s s y o u r  o f the h o s p i t a l .  While  y o u may n o t b e n e f i t  f r o m my s t u d y , o t h e r t h a n h a v i n g t h e o p p o r t u n i t y t o d i s c u s s the matter, benefit. record  i t i s hoped t h a t o t h e r p e o p l e  I f you g i v e your  the conversations.  consent,  the tapes o r i n the t h e s i s .  I would l i k e  The t a p e s w i l l  my t h e s i s h a s been f i n i s h e d .  i n the future  You: may r e f u s e t o answer a n y q u e s t i o n s .  ment i n any way.  not a f f e c t  after  n o t appear  Your p r i v a c y w i l l  tion or non-participation w i l l  t o tape  be e r a s e d  Y o u r name w i l l  on  be e n s u r e d . Your  your  will  participa-  care o r t r e a t -  I f y o u do e n t e r t h e s t u d y , y o u may w i t h -  draw a t any t i m e . If  y o u have any q u e s t i o n s , p l e a s e f e e l  I understand participate.  free  t o a s k them.  t h e n a t u r e o f t h e s t u d y a n d g i v e my c o n s e n t t o  Date : Patient's signature: Researcher's signature:  Appendix Interview  B Guide  84  Sample o f Interview 1.  Questions  What t h i n g s made you decide t o leave 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 ?  2.  What was i t l i k e  f o r you while you weren't here?  (How  did i t feel?) 3.  Do you f e e l i t was a p o s i t i v e o r a negative event f o r you, o r both?  In what ways was i t  ?  4.  What stands out most i n your mind about the experience?  5-  What purposes affected  d i d the elopement serve f o r you?  your h o s p i t a l i z a t i o n i n any way?  Has i t  

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