I had a patient in Karwany-e-Hayat, who is 57 years old male with diagnosis of Drug-induced psychosis. Admitted with aggression, irrelevant talk, paranoid delusions and insight absent. He is living alone, divorced 30 years back, one daughter who got married 2 years back. He was addicted of Cannabis (chars) from the age of 20 and continues it till his forties and then left it and started taking nicotine cigarettes 3-4 per day. Patient stated that “I want my share in property but now I do not have control on situation. I do not have any support who can help me or can fight for me because of lack of strength to cope. Physically I also feel powerless as I am getting older and unable to fight for my rights. I feel lack of control due to which I could not be able to get my share from step-brothers and their wives always behave negatively with me. They consider me as a substance abuser and mentally ill which is actually I am not”. Patient further stated that “I am thinking to go in court but I feel that they have power in society which I do not have that’s why I can’t get my share by any means”.
Anne Lee (2006) defines drug-induced psychosis as “Psychotic symptoms that arise during drug intoxication… The reaction may… re-exposure to the drugs occurs” (p.353). According to WHO report “It is estimated that about 04 million people in Pakistan… abusing different substances… is heroin)” (para.4). This data predicts, on-going crisis on mental health of the people.
I took the concept of powerlessness on the basis of my patient scenario. It is important to first understand the concept of power. Larsen and Lubkin (2009) describe power as “A personal resource inherent in all individuals, and is the ability to influence what happens to one’s self” (p.256). Erikson’s second stage of psychosocial development, autonomy versus shame can relate with the feelings of powerlessness as it involves the struggle for personal control and separation from others. Lacking in this stage, might lead to feelings of powerlessness in later life also.
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Power reflects person’s ability to achieve and struggle for desired outcome. Powerlessness, as defined by Wilkinson (2005) is “the perception that one’s own action will not significantly affect an outcome; a perceived… ” (p. 386). Every individual experiences powerlessness in their life in some point in time. Although people with physical illness experience powerlessness in their daily life activity but, mentally ill client experience more than others because of stigma associated with mental illness and not accepted by society and disturbances in their thoughts process make this feeling worse. As my patient has no control over his own situation rather control by people around him.
Concept of hopelessness and powerlessness consider similar but both are different. Carpenito-Moyet (2004) clarifies theses two concepts as “A hopelessness person sees no solution…. A powerless person may… because of perceived lack of control and resources” (p.207). Persistent powerlessness can lead to hopelessness, which is more risk taking behavior in which person do not see any options and consider self as worthless and this might lead to self harm.
Powerlessness can be associated with physical, psychological or/and social lack of control. Feeling of powerless due to any reason, strongly link with the poor health outcome since it develop fatigue, grief and hopelessness. People feel powerless due to their chronic physical illnesses; some feels due to lack of psychosocial control and threatened to their autonomy. There are factors or resources which lead to power and lacking in any of these lead to powerlessness. Resources which retain individual power discussed by Larsen and Lubkin (2009) that “Individual power resources include physical strength and physical reserve, psychological stamina and social support, positive self-control, energy, knowledge, motivation, and hope” (p.258). If these power resources affected, individual experience feelings of powerlessness. As my patient’s physical endurance decreased, no family support present and less motivated and positive to deal with situation around him. Failures of these internal and external resources make him feel more powerless.
Feeling of lack of control over situation is so much personal to individual and people are consider low when they feel powerless that’s why they hide their actual feeling because of fear of label as ‘powerless’. Powerlessness can be assessing through subjective and objective findings. To assess patient’s feeling of powerless and contributing factors, nurse should clearly assess client’s strength, resources and take time to listen and observe patient’s objective and subjective feelings which lead to powerlessness. To identify strengths of a client White and Roberts in (1993) given Personal Control Model that links personal control with powerlessness. This model is comprehensive and covers all aspects of powerlessness. It gives four types of loss of control, associated with powerlessness. One is physiological loss of control which is associated with biological changes, second is cognitive loss of control which describe the inability to correctly interpret the effects of a chronic illness and is categorized as sensory and appraisal loss of control, third is environmental loss of control when individuals are unable to control where they are and what they are experiencing and fourth is decisional loss of control, is when person unable to make decisions for themselves or for their care. After critically assessing patient’s feelings, I come to know that he has loss of biological, environmental and decisional control because he has no control and power over situation and people around him and wasn’t able to take any decision for himself and his brothers are imposing their power on him and he can’t even argue. My patient also feels physically powerless whereas, cognitive ability was intact as assess through mental status examination. From this, I analyze that it was also observable that people who can’t access their power and unable to show it, develop feeling of frustration and showed their aggression. Vogel-Scibilia, et al. (2009) talking about Erikson’s stage 2 as “Anger externalized or internalized is a prominent feature of this stage and may lead to the person coming into conflict with others or engaging in self-damaging behavior” (p.408). My patient was also become aggressive when he felt powerless. By analyzing and integrated scenario and concept of powerlessness with the model and Erikson’s theory, I come to know that powerlessness can poorly affect individual’s overall health.
Braga & Cruz (2009) develop powerlessness assessment tool and stated that “The Powerlessness… to assess… for the selection and evaluation of interventions” (p.1062). Although it was used in western culture but, we can also use it in our context with some modifications. As, this tool will help deepen understanding, identifying and evaluating interventions of powerlessness. Unfortunately, I was unable to implement this tool on my patient because he was discharged.
On the basis of assessment findings of powerlessness in my patient, planning phase come in which my goals are to explore patient’s feelings of powerlessness, then motivates him towards developing autonomy to take decision and sense of control over situation and environment.
Strategies for powerlessness divided into individual, group and institutional level. Basic aim of all level of interventions is to make patient empower enough to deal with the own situation and situation around him effectively. Increase in power makes individual powerful enough to live in environment with more abundant resources and rewards, able to attain their goals and feel unrestrained by others.
Client and family level intervention plays crucial role in regaining power. Diversional activity like music can be used as therapeutic manner for diversion. This help patient clearly identify their feelings and foster discussion of feelings. I involved patient in musical play activity with other patients, through this I also utilized group level strategy. Empowering can be done through focusing on other supports and resources rather than on feeling overwhelmed by deficits. In my patient he has no family support but still I try my best to explore other internal and external resources which can help him to be independent and enhance empowerment. In second week, I explore that he can do job if he gets and his uncle who has business and might help him for job to earn for himself. Through this, I was able to develop my patient’s strength to get back to his usual life in society. Though he previously confesses lack of physical power but now motivated towards autonomous. Other interventions are listening to individuals; asking them to describe their experience, displaying kind and helpful attitude and being approachable, respecting and fostering individualized decision making. Sense of mastery is important to overcome client’s powerlessness by developing sense of control over threatening situation, finding new sources of satisfaction and problem solving measures to prevent similar stressful event. It is also important for individual to analyze own response at the time of intense feeling of powerlessness and exploring own positive strength rather only focusing on things which can’t be handle.
Taw (2006) stated that “For many people, the mutually supported and co-ordinated exercise of power may have greater potential impact than isolated and competitive instances of power to” (p.38). Interventions for both institutional and group level can be done by using self-determination theory. This theory is base on three basic psychological needs; these are competence, relatedness and autonomy. The need for competence help individual to adapt new challenges. It stimulates adaptive and flexible functioning in the context of changing demands. Relatedness is the integration of the individual with the social world to develop sense of belonging. For this I involved my patient in all group activities to motivate towards power. Family should involved, as environment outside hospital also matter but in my patient I was unable to implemented family level interventions because nobody involved in his care, nor come to meet him. Autonomy better helps to regulate own actions according to their needs and capacities. Autonomous people will not develop powerlessness, which can be achieved through supporting and acknowledging initiative, providing choices for treatment and minimizing control environment around patient. I had worked on this theory to help my patient empower enough in society. At institutional level, health care team should follow these interventions which I haven’t observed there. It is overall lacking in our health sector that less attention is giving to mental health by government and by health care settings.
Fewer researches are conducted for mental health in Pakistan; so I have not found any relevant research on concept of powerlessness. I found a study done in Israel by Ronel and Claridge (2003) said “Violent behavior as a sign of powerlessness and of being out of control, much resembling the symptoms of substance abuse” (p.62). Further stated that “It is accepted and even expected that men never admit to powerlessness or lack of control” (p.62). These words not only represent the culture addressing in this article but also applicable to Pakistani culture where showing powerlessness is not allowed in society and considering it disgraceful so, feeling of powerlessness must come out in form of aggression, violent behavior or going towards substance abuse.
Previously, I believed that powerlessness is only link with physical weaknesses and only faced by patients but after reading this concept in depth my prejudice become clear. I was able to integrate model and theories which help in dealing and improving my patient control over situation and regain their power back in society. I am glad after analyzing my efforts that my patient realized his feelings of powerlessness and try to cope with it by taking decision for him as he admitted that he will do work after discharge. During writing this paper, I realized that most of the interventions which I already implemented on patient are base on model and theories.
Power is important aspect of a person’s life without which survival become difficult for individual. Powerlessness can be faced by everyone in any point in life. Persistent feeling of powerlessness greatly affects not only mental but also physical health. It should be deal at early level for better mental health outcome. More researches is needed to assess the peoples’ perspective and feeling of power and powerlessness and on evidence based interventions.
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