Give Up or Gear Up?
Teaching Internal (vs External) Locus of Control
Michael Watts, MSW, RSW
Medical Social Worker: (formerly of) Diabetes and Endocrine Clinics, Alberta Children’s Hospital
Assistant Professor: Mount Royal University
Imagine a scenario in which a 14-year-old is forced to care for a cat. This is no ordinary cat! This particular cat has multiple ailments to which the teen is expected to tend on a daily basis: the cat requires three drops of eye ointment on a daily basis, needs to be given liquid oral medication four times a day and the cat must have it’s hind legs massaged ten minutes per day for arthritis pain relief. And to top it all off, this young person will not be helped in caring for the cat, but will be monitored closely by and given negative feedback each time they miss a pet-care task.
As you can imagine, after several weeks the teen becomes increasingly apathetic towards the management of the cat’s ailments, and the relationship between adult and teen becomes strained. As more time goes on, the teen begins to use his apathy as a means to justify his thoughts about caring for the animal:
“I didn’t ask for this cat!”
“This cat was forced upon me, caring for it should be someone else’s problem.”
“Taking care of this cat is controlling my life!”
As the weeks progress, the teen’s commitment toward managing the cat’s ailments becomes increasingly sporadic. The cat’s health is at risk.
This scenario may sound ridiculous. You may be saying, “Who would give a teen a sick cat to care for?!” But this decline in commitment towards managing "the cat"is reminiscent of the decline in commitment towards managing diabetes in some of the adolescent patients I work with. Some of them often feel as though they “didn’t ask to be diagnosed with diabetes”, or that diabetes was “forced upon them, and it should be someone else’s problem to manage.” They often feel (perhaps accurately) that “diabetes is controlling my life!”
Like the 14-year-old in the cat story, some of my adolescent patients grow increasingly apathetic towards their diabetes management and have shared that they often experience patterns in which their unhealthy thoughts, perceptions, and beliefs about their condition influence their sporadic lack of commitment towards self-care. They may also feel alone in dealing with the associated responsibilities.
I often wonder if the unhealthy thoughts, perceptions and beliefs validate the adolescent’s views that diabetes was forced upon them, that diabetes should be someone else’s problem and that diabetes is controlling their life and they can do little to stop it.
The aforementioned pattern is worrisome for me. I have witnessed adolescent patients slowly begin to lose the high level of commitment, accountability and responsibility towards their diabetes management that they once had when initially diagnosed, while moving toward a more sporadic level of commitment, accountability and responsibility. What could be the reasons for this shift?
Locus of Control
Locus of control (Rotter, 1966) is the extent to which individuals believe that their life circumstances are a function of either their own actions OR external factors beyond their control.
People who believe that they are in control of their own lives and that effort and ability determine their future have an internal locus of control.
In contrast, individuals with an external locus of control believe that fate, luck, chance, or other people’s behaviour determines what happens to them (Rotter, 1990).
The adolescents I work with who typify an external locus of control often struggle with their diabetes self care, namely due to feelings of helplessness and hopelessness (a reasonable, though not helpful, response to what may be an overwhelming situation to them). In my view, these feelings, combined with the perception on the teen’s part (which may be accurate or inaccurate) that family members and/or medical professionals are judging them for “poor management”, nurtures their unhealthy thoughts that diabetes controls their lives and that there is little they can do about it.
Tip from the Trenches
One of the most helpful things we can do as parents and health care providers is to take the blame out of the equation. Even the most educated and diligent person will find it impossible to master diabetes! Our children and teens with diabetes need support to develop healthy management patterns. If we view diabetes as the common enemy, relationships will be strengthened and everyone will be happier and healthier. ~Danielle
Like their peers, adolescents who typify an internal locus of control dislike the disease and all the associated responsibilities just as much as adolescents who typify an external locus of control, however those with an internal locus of control tend to be more accountable and diligent about managing their diabetes. In my experiences, adolescents with this mindset tend to be mentally, emotionally and physically healthy and subsequently tend to respond well to the day to day expectations and rigors of a busy teenage life.
Can We Change Our Locus of Control?
Absolutely! In an attempt to support adolescents who typify an external locus of control toward more of an internal locus of control, I have worked closely with them to assist them with the following interventions:
1. Educate About the Stages of Change
Without exception, all of my adolescent patients who typify an external locus of control could benefit mentally, emotionally and physically from positive changes to their diabetes management. In my view an important initial step is to teach them about the dynamics of the stages of change. I believe this is important to allow them to understand that change is a process, that change is not linear and that it is okay to make mistakes (slips in the change process). It’s also important to understand that the key is to continue to commit to the change until the maintenance/termination levels are achieved. In my view, educating the adolescents on the stages of change is a normalizing and validating process which equips them with tools to navigate (with support) the process of change.
2. Short Term Goal Mastery
I advocate that the adolescent set small, realistic, short-term goals with the expectation of achieving the goals within a reasonable time frame. Having a reasonable timeframe in which to achieve a goal provides perpetual motivation to works towards the goal if the individual experiences small episodes of success during the journey toward goal attainment.
The Child and Youth Care Counsellor literature suggests that when a young person’s need to be competent and successful is satisfied, the potential for more competence and success is enhanced. In other words, when a young person feels like they’re “getting it”, they experience feelings that they wish to continue feeling, and they understand that to re-create those feelings (in the context of this article) they need to continue to work towards the goal of effective diabetes management.
Tip from the Trenches
Motivation is also increased when our kids can see the positive aspect of meeting those goals. Parents can support their children and teens through this process of change by pointing out to them how much the interventions are helping. Going back to the cat example, we could highlight how much better the cat is doing in specific ways: “Look at how much better he’s walking now because of how often you’re massaging his legs.” “He’s so playful now that he’s getting his medication every day.” In terms of diabetes care, it’s also important to discuss with your teen the reasons why the required diabetes tasks are so important. For example: “It’s important to check your blood sugar regularly before meals so that we can tell if you’re getting enough insulin at that time of day, and change the dose if we need to.” “It’s important to bolus before you eat so that your blood sugar doesn’t go so high.” ~ Danielle and Michelle
3. Parental Validation and Praise
Parents of adolescent patients who typify an external locus of control can support their kids in developing a healthier mindset through validation and praise. For example, when the adolescent has a slip in diabetes management (eg. forgot to test, forgot to administer correction insulin after grazing in the pantry, etc), rather than "talking at" the adolescent and pointing out what he did wrong, we can support them by "talking with" him. That is, we can discuss what got in the way of effective management and make a plan to protect against it happening again.
I hold the view that adolescents who feel validated are more likely to be honest and willing to admit mistakes because they know the mistake is an opportunity to learn and grow, versus an opportunity to be scolded and not heard.
In combination with validation, adolescents with an external locus of control MUST receive praise for a job well done. Praise is the “icing” on the validation cake, and praise intensifies the adolescent’s sense of competence and success.
Tip from the Trenches
As parents it’s easy to slip into expecting our kids to “just do it” without complaining. But if we shift instead to praising them for taking such good care of their “cat”, then they will shift into doing more with fewer complaints. ~Michelle
Some Final Thoughts
These factors -- education, short term goal mastery, parental validation and praise --are, in my view, the starting points for supporting adolescents who typify an external locus of control.
In closing, I must mention that I routinely remind my patients (and their parents) that counselling only works to the extent that the relationships between the patient, the parents and the counsellor are strong, and to the extent that the patient and the family are willing to commit to improving diabetes management with support from the counsellor. Once a therapeutic plan around navigating the change towards a more internal locus of control attitude regarding diabetes management is agreed upon and consistently applied, the adolescent creates protective factors for himself which will ultimately improve his mental, emotional and physical health.
Tip from the Trenches
We can best support our kids if we all view caring for diabetes as a shared responsibility between parents and children/teens, with a gradual increase in responsibility as our kids get older - more and more responsibility is systematically transferred to them, until the teen becomes an adult. It’s tempting to be hands-off when it comes to diabetes care – especially when our teenagers are pushing for independence. But it’s important to remember that just because they are teenagers, doesn’t mean that they can do it all by themselves. Even if they think that they can. ~Danielle
Even if we, as parents, have developed an internal locus of control, we need to be patient with our kids if they’re not there yet. It’s natural for them to feel like “I don’t want this”… after all, we probably feel the same way! But what we may have learned as adults is that sometimes things in life are “forced” upon all of us, we all have to do things we would rather not have to do (like go to work, household chores, care for an ailing parent, live with the diabetes dragon). However, we still do the things we’d rather not do because we want the associated positive results (money to pay for our home to live in, having a clean house and good food to eat, seeing our parents comfortable and happy, keeping our kids healthy and happy). Our kids will learn about this exchange of effort for positive results, too, over time and with our support and guidance. ~Danielle and Michelle
Why not start by sitting down together and brainstorming what sorts of things need to happen for effective diabetes self-care? Then decide together who will take responsibility for what, in a way that is manageable and attainable for your teen. In the following weeks and months, hold her accountable for the things that are her responsibility. Keep touching base to discuss how things are going. If she’s ready for more responsibility, hand over another d-task, or part of one. If she’s not ready, pause for a bit. In this way we can be actively and effectively involved in our teen’s diabetes management, without doing it all for them, and with a plan to fade that support over time, according to our kids’ individual abilities and needs. ~Michelle
Rotter, J. B. (1966). Generalized expectancies for internal versus external control of Reinforcement. Psychological Monographs, 80, 1-28.
Rotter, J. B. (1990). Internal versus external control of reinforcement: a case variable. American Psychologist, 45, 489-493.
The above information was adapted from an article written by clinical staff of the Alberta Children’s Hospital Diabetes Clinic.