ANNOUNCEMENTS

Diary Study write up due today. Hand in at end of class.

Remaining classes:

4/22: Stigma/Being a patient

4/24: Patient / provider communication

4/29: Movie: Let There Be Light

5/01: Review session

5/13: Final Exam; 11:45-2:45

Instructor Evaluation: http://sakai.rutgers.edu

Hypervisible: Everyone notices you because of the mark—the facial disfigurement, the radiation-treatment hair loss, the wheel chair.

Invisible: But people still seem to not see you.

I am invisible, understand, simply because people refuse to see me. ...it is though I have been surrounded by mirrors of hard, distorting glass. When they approach me they see only my surroundings, themselves, or figments of their imagination—indeed, everything and anything except me. Ralph Ellison, Invisible Man, 1947

Being at Once Hyper-visible and Invisible

One of the most direct effects of stigma is threat to self-esteem. -- Defined in terms of stigma-- Avoided, shunned, ostracized-- Non-stigmatized features are overlooked

Self-stigmatizing—internalizing other's negative view of oneself.

Not just that one is fat or gay or blind or alcoholic, but rather that one is therefore fundamentally flawed as a person—sick, weak, immoral, or evil. In Goffman's terms, one has "a spoiled identity".

Stigma Corrodes Self Esteem: The Darkened Looking Glass

How Disability Can Change Self Schema

Popular

SELF

Athletic

Runner Biker

Busy

Many Opportunities

XX X

X

X

Popular

SELF

Athletic

Runner Biker

Busy

Many Opportunities

Paraplegic

Dependent

Avoided

Anxious

X

We depend on other's reactions to make sense of things, and of ourselves, when there is no other source of info.

Stigmatized don't get this info. Why not?

Stigma Deprives Person of Vital Information:The Absent Looking Glass

a. Shunned, so don't see how others respond.

b. Get a constant reaction to selves, either constantly (and falsely) positive or constantly negative.

Stigma becomes a wall that blocks social information.

After acquiring a stigma (cancer, AIDS, paraplegia, etc.) it can help to develop ties to others with similar condition. Why?

a. Social comparison

b. Recognition of one's own non-stigmatized features.

c. Recognizing difference from others who share stigma.

Creating New Reference Groups

BUT, important to not belong ONLY to community of stigmatized. Why?

a. Need to re-enter mainstream.

b. Need to get feedback from "markers", which may be more realistic

Some people are not fully stigmatized, not fully "normal"

* Partially deaf, partially blind* Loss of one limb, but otherwise can walk

These people are not fully accepted by mainstream, but also not fully accepted by the stigmatized group.

The "unblinded"--and their unexpected social challenges.

In-Between Stigma Status

GUESS THAT PERSONMystery Person #1: Assigns readings

Grades examsConducts lectures

The person is a: _____________________

Mystery Person #2: Works with a variety of woodsUses hammers, nails and sawsBuilds cabinets and frames houses

The person is a: _____________________

Mystery Person #3: Confined to small spaceRequired to follow instructions or face severitiesLittle control over meals or socializing

The person is a: _____________________

Teacher

Carpenter

Hospital patient

Class 23: Being a Patient

Experience of Being a Hospital Patient

Emotional State

Anxiety over condition

Nature of problem? Pain Loss of functioning Will I die?

Real world worriesJob Family

Etc. House, car, pets, bills

First Encounters with Hospital

Patient enters hospital scared, hurt, anxious. What does he want to hear upon admission?

What does he hear upon admission?

“Do you have insurance?”

Hospital garb: Why?

Ease of access

How do you look to others?

Childish, infirmed, low-status

How does garb affect how you feel about yourself?

Weak, embarrassed, dependent

Who’s the Fighter?

How does garb affect “fighting spirit” and morale of patients?

How does this relate to psychosocial resources, stress, and coping?

Could there be an alternative?

Hospitalization from Patient’s PerspectiveFragmented care

Many different staff, doing different tasks Minimal contact

Patient transformed from person to object

A broken arm to be X-Rayed A Body due its pain meds.

Information is often withheld from patients. Why?

You wish!

Staff too busy to answer questions Staff, specialists, don’t communicate Staff deliberately withhold information: Pat. won’t understand; pat will freak-out, require more care Lack of information one of patients’ biggest complaints. Why?

Reactions to Being HospitalizedMain points of hospital situation

Strong negative emotions: fear, worry, pain, confusionStripped of authority, dignity, identity

Lose clothes, bossed by nurses & MDs, become a “thing” Reminded of 1000 ways fate depends on kindness of strangers

Deprived of vital informationExpected to be cooperative, passive—seen but not heard

Dependent, needy, controlled, ignorant is like being a: ________Child

Leads to regression: attempt to get needs met by pleasing others

Stockholm Syndrome, Patty Hearst, cults

Hospital Patient RoleHospital wants patients to do as told:

a. Reduce chances of things getting worseb. Increase chance of recoveryc. Reduces demands on over-taxed staff

Patients often want to be “good patients.” Why?

a. Appease “powerful” staff, MDs1. Staff dictate daily life2. Staff have power of life and death.

b. Curry favor, to get more/better attention

c. Superstitious faith in power of medical institutions and providers1. Healers have god-like power to heal, save life2. Variant on “just world” beliefs

Is There Truth to “Good Patient” Beliefs?

You are hospitalized, feel staff is not fully attending to you. Should you be a “nice” patient or a strongly assertive patient?

Patients report, and there is some evidence to suggest, that “troublesome" patients are:

-- Overmedicated-- Ignored-- Discharged prematurely

http://www.youtube.com/watch?v=RGRD6JBnHrU

Reactance

What percent of patients fall into “good patient” role?

____ Good patient ____ Average patient (minor complaints) ____ Bad patient: seriously ill and complain, not ill but complain anyway

25%

25%50%

Very bad patients: harass nurses, violate hospital rules, self-sabotage (don’t take meds, risk own health). Why?

Reactance: People have basic need for personal freedom. Work to regain freedom taken in ways that appear unfair. Hospitals can induce reactance by being arbitrary, withholdng info, treating pats. like children.

Why Hospitals Demoralize

Hospitals want to help patients. Why do they cause patients to fall into “good patient” role, or reactance?

Biomedical Model: Body is a machine—fix the parts, the body is OK, job is done. "Person" is irrelevant.

Real world constraints: Hospitals forced to do more with less. HMOs, cost cutting, related pressures.

Improving the Patient ExperienceIrving Janis “ideal anxiety” approach (1958)

Hospital hires Janis (social psych) to reduce patient stress

Janis redefines situation: Some anxiety is good. Why?

No anxiety – person not prepared for difficult outcomes. Too much anxiety – person is flooded, can’t take in information. Recommends providing pats. with enough info to emotionally prepare.

Egbert study (1964): Works with pats. undergoing abdominal surgery

Patients either told / not told what to expect post-surgery (pain, recovery, severity, etc.)

Result: Informed pats need less narcotics, leave hospital sooner. Highly replicated finding.

Social Support and Surgical RecoveryYou are about to undergo surgery. Would you prefer your hospital roommate to be someone:

____ About to undergo same surgery

____ In recovery from same surgery

Kulik & Mahler study (1996)

Patients pared with roommate who is:

* undergoing same / different surgery * Pre-operative / post-operative

What matters in terms of patients’ recovery?Pared with post-op roommate: Less anxious pre-op, more ambulatory post-op, released sooner,

___ No Roommate

___Same/Pre-op ___ Diff/Pre-op

___Same/Post-op ___Diff/Post-opXX

Effects of Responsibility and Care-Giving on Patient Outcomes

Rodin & Langer, 1977

Ss are nursing home elderly.

Cond. 1: Reminded of their own responsibilities, and given a plant to care for.

Cond. 2: Reminded of staff responsibilities to them, and given a plant that staff care for.

18 months later: Staff ratings, mortality

Cond ___ : * More positive staff ratings (happier, more sociable * Lower mortality (more likely still alive)

1

Animal Assisted Therapy (AAT): Specially trained animals plus handlers visit hospitalized patients.

Dog lies on patient's bed, is petted.

Cute, but does it work?

Experiment by Kathie Cole, RN, UCLA Medical Center

77 heart-failure patients (ave. age = 57) receive 12 minute visit from either:

a. Dogb. Human volunteerc. No visit

Animal Assisted Therapy

Anxiety:Dog: Down 24 ptsHuman: Down 10 pts

EpinephrineDog: Down 17%Human: Down 02%Control: Up 07%

Blood pressureDog: Down 10%Human: Up 03%Control: Up 05%

Results of AAT Study: The Paws that Refreshes

Elephant-Assisted Therapy: South Africa

Dolphin-Assisted Therapy: Israel, Florida, Ukraine

Children in HospitalsHospitals are frightening to children.

a. Place associated with pain b. Weird looking peoplec. Sad/Scary looking patients d. Parents are not in control

Emotional reactions

a. Fear, anxietyb. Anger, rebellionc. Shame (esp. at adolescence)

Being left overnight in hospital esp. upsetting. a. "Setting" anxiety b. Age 3-6: fear rejection

c. Age 4-6 develop new fears (e.g., darkness) d. Age 6-10 free-floating anxiety e. Separation anxiety: deserted? punished?

Social-Psychological Tx for Hospitalized ChildrenSocial Support

a. Parental visits study (Branstetter, 1969)Cond 1. Mom at visiting hours onlyCond 2. Mom for extended periodsCond 3. Surrogate mom

b. Kids in Cond 2 & 3 do better than Cond 1c. Hospitals now let parents stay with kid all timesd. Story telling

Psychological Control

a. Kid in hosp. movie --> less anxietyb. In gen., informed kids show less anxietyc. Encourage kids to ask questionsd. Provide kids with coping skills * Self-talk

* Relaxation skills