Fig. 4.1
An intentionalist model of adherence
Schematically, desire is the pro-attitude that leads to an action : For instance, Jane wants a beautiful baby, so she begins to adjust her insulin dose correctly. Beliefs play an instrumental role: She does it because she believes that correctly adjusting her insulin dose will make it more likely that her baby is beautiful (she had the same belief before she was pregnant, but it didn’t motivate her to adjust her insulin dose). Desire can also be caused by another belief. For instance, Irene believes that she will be happier if she weighs 10 pounds less, and this causes her desire to lose weight . Similarly, an emotion can cause a new desire: Thomas wants to take care of himself because he fears complications. Skill also plays an instrumental role in action. Jane must know how to adjust her insulin doses, although this is not why she does it.
In this model, emotions play a major role in inducing revisions of beliefs , expectations, and preferences of patients’ various desires . It is obvious that non-intentional factors (contentless states), such as pain or pleasure , can have a motivational role—indeed, sometimes overwhelmingly so. Events can also intervene as a substratum of new beliefs, or by provoking the emergence of emotions. Exogenous factors, such as the presence or absence of resources , for example, can intervene in encouraging or limiting patient adherence. Finally, to follow Searle , the different mental states listed here are inscribed in a Background of competence and presuppositions (not represented in this graphic) which allows those mental states to ‘function’. One notes that patients’ desires are a driving force in this model (it is clear that the modules representing, for instance, beliefs and desires, must be seen as generic. In particular, the so-called secondary order mental states certainly play a very important role: Beliefs about beliefs, desires about desires. I will come back later to this important concept).
Events, mental states , and exogenous factors can each have a positive or a negative effect on patient adherence. Some factors may influence actions in a predictable way, but have the opposite effect in some patients, or at some times. For example, physicians know that a medication given once a day is more likely to be taken as prescribed than a medication given four times a day—yet a few patients want higher frequency dosing, and respond better on such a regimen.
4.3 The Pivotal Role of Emotions in Patient Adherence
Emotions were barely present in the various models of adoption of a health behavior described in the first part of this book (Leventhal ’s Self-Regulation Model is the exception). Leventhal explicitly suggests that a patient ’s evaluation of her own behavior is partly cognitive and partly emotional (Leventhal et al. 1997). In the other models, emotions are seen as a nuisance which divert a “susceptible” patient from the path of rational treatment adherence.
However, just what do we mean really by emotion? For our purposes here, we may think of emotions as affective (i.e., felt) states which are about something. Emotions may be distinguished from visceral states—which are certainly felt—but which are not directed at anything (they are non-intentional , to use our earlier language). Elster gives the following groupings:
Among the states that unambiguously qualify as emotions we may first list various social emotions: anger , hatred, guilt , shame , pride , pridefulness, admiration, and liking. Second there are various counterfactual emotions generated by thoughts about what might have happened but didn’t: regret , rejoicing, disappointment, elation….Third, there are emotions generated by the thought of what may happen: fear and hope . Fourth, there are emotions generated by good or bad things that have happened: joy and grief. Fifth, there are emotions triggered by the thought of the possessions of others: Envy, malice, indignation, and jealousy. Finally, there are cases that do not fall neatly into any special category, such as contempt, disgust, and romantic love …borderline or controversial cases include surprise , boredom, interest, sexual desire , enjoyment, worry, and frustration (Elster 1998).
Pierre Livet defines emotion somewhat differently, emphasizing the generative role played by the never-ending flux of experience:
[Emotion is the] affective, physiological and behavioral resonance of a differential between one or two perceived (or imagined, thought of) traits of the situation and the continuation of our thoughts, imaginings, perceptions or actions currently under way (Livet 2002, 23).
Livet implies that, as with the five senses, emotions are driven by contrast. But unlike the senses, which are more tightly grounded in the present, emotions may arise from a variety of differences: The present versus the anticipated future ; the present versus the past; one’s self-perception versus the perception of others; desire versus what the environment has to offer; and so forth. Each of these differences—imbalances, if you will—gives rise to emotional states. These states may be transient, enduring, or even unnoticed (skilled psychotherapists, for example, are adept at picking up transient/ignored emotions as a way to understand the patient ’s trouble, for example). Except for strongly felt emotions, or ones which are enduring, much of our emotional life is seamlessly experienced—just as our sensory experience is.
Livet ’s concept of emotion enables us to understand how the announcement of a chronic illness (even if it were expected and no great surprise ), generates diverse emotions . It is the difference between the immediate past and the new—very new—present which produces the fear , anger , anxiety , dread, regret , guilt , disgust, even relief, felt by patients who are diagnosed with a long-term illness.
On first examination, Livet ’s idea may seem to be mere common sense dressed in fine language. But as with Davidson , it is the ramifications of the idea which reveal its profundity. If emotion is about difference, it means that emotions never arise sui generis: Every emotion has an origin. And because the differences which give rise to emotions are so diverse, it helps us to understand how someone experiences conflicting emotions. In a purely rational model of human experience, conflicting emotions are not supposed to occur—how can one person be of two minds? But Livet opens the door to explaining something everyone experiences: We have conflicting emotions when we have multiple differences in play. For example, a patient newly diagnosed with a chronic illness may feel guilt (“I knew I wasn’t taking good care of my health , and now I’m being punished”) and relief (“I was having mysterious pains before, and now at least I know what’s causing them.”). Relief may then give way to fear (“I was relieved to know what ails me, but now what’s going to happen?”); and so forth.
Livet also helps us understand both the fragmentary nature of our experience—differences arise and fade away all the time —and how such fragments nevertheless form into a coherent experience of our life . Because emotions never arise from a vacuum, they remain connected to previous emotions and experiences. Over time, patterns recur—fostered in part by the many regularities in our physical and social environments—and these form enduring elements in our mental world. It is not unlike the puzzle metaphor discussed earlier.
Emotions are by no means passive responses to “difference.” Emotional states motivate action , often in fascinating ways. In the simplest cases, an emotion such as envy might lead a person to take a friend’s coveted possession; or anger may lead to aggressive behavior . However, that same envy may lead to avoidance of that friend, lest the envious party be constantly reminded of what she doesn’t have. Or, envy may lead to an attempt to not desire that which is envied: If the desired “possession” is, say, a boyfriend, the envious friend may dwell on his deficiencies to make him seem less desirable. Or, even more complexly, she might make a sexual advance towards her friend’s boyfriend, so she can imperiously reject him if he reciprocates, or—if he doesn’t—she can dismiss him as unmanly.
What is important to understand is that our emotional lives are complicated in a way which is part and parcel of being human. Our attempt to better understand adherence will necessarily involve the patient ’s emotions , and all the actions driven by them. If our goal is to understand a real world issue—rather than a theoretical one—then emotions must be given their proper place in explaining human action .
When it comes to making treatment decisions, emotions play an especially big role, as illness and health are of existential concern to the patient . In anger , Juliet comes to believe that the doctor doesn’t know anything—he’s a complete moron. The truth that John has cancer motivates him to believe the very opposite, that he is in perfect health. John is so afraid of being sick that, despite all available evidence (the weight he has lost, the X-rays and the lab exams that he has seen), he believes that he is healthy. The announcement of one’s illness can be scary; and so it is no surprise , then, that it can, on occasion, result in denial and unhealthy behaviors.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
