A Cognitive and Emotional Theory
Claudia Baird, Amy Ingmire, Miriam Itzkowitz, John Marra, Erin Smith, Kelli Tabit, Amanda Thomas
Origin of Control Theory
Control Theory is the classification and examination of systems to create a certain output or behavior and has been around since the days of Plato. Most recently it has been identified with Norbert Weiner’s 1948 Cybernetics (PSU, 2013). Originally his theory was used in the mathematical and engineering field but has become widely accepted in the field of industrial/organizational psychology. There is an obvious parallel shown between the ideas connected with machines and ideas connected with human behaviors related to how systems are able to function as a whole (PSU, 2013). Machines are made up of complex systems that must work together to produce a wanted output or function. Humans are made up of similar systems working together to produce a desired behavior or action- systems explained by cognitive psychology.
Three ideas must be assumed so that the theory can be applied to human beings. First, belief that humans are a system in and of themselves. Secondly, society is also a system (PSU, 2013). The third assumption is that all systems are self-regulating. Accepting these ideas helps us understand how individual behavior will ultimately affect a bigger system and how it all pieces together (PSU, 2013). Control Theory is comparable to Goal-Setting Theory because many of their concepts are intertwined. A major concept of Control Theory is that people seek feedback on behaviors and actions when goals have been set for them. Feedback can then generate a specific reaction that could either help or hinder individuals from accomplishing the set goal. In Control Theory a feedback loop breaks down the behaviors and cognitive processes into rudimentary parts. These parts consist of sensing, comparator, feedback, goals, and individual behavior (PSU, 2013).
On a cognitive level, a person in the feedback loop may be using problem-oriented acquisition; that is, they encode information in their based on how it will be used later (Reed, 2010). If the person sets out to begin a process with the parameters that define success/failure in mind they will encode the information for later usage based on its importance. If they have encoded this way they will apply what they encoded with the same considerations of importance as they did when they encoded the information. In other words, if a person effectively learns about a disease they have and what it means for their life, they will likely encode the information about it in a way that will ensure that they apply what they have learned in a way that is helpful. It is important for the person teaching about the disease (such as the doctor) to convey the possible courses of the disease in such a way that the person learning will be able to comply with the doctor’s orders.
When the person is inside the feedback loop, their cycle through the loop will be influenced by how they encode the information. A sensor (a person) can go beyond just hearing the doctor’s orders- the person can put into action what the doctor tells them. If the person encodes (listens and remembers) properly they have the best chance of reaching the retirement link in the loop. If the information was never coded properly (not given its proper weight) the person may cycle endlessly due to their lack of understanding of the importance of what they are dealing with. This is a cognitive link to why Control Theory has validity. The brain can be thought of as a circuit board with millions of processors. The way information is routed in the first place can have significant effect on the way it is used by the person.
Part of the locus of control a person has can come from how well they committed (cognitively) the importance of information about their disease initially. Attitude has an effect on well-being; therefore, a person with a better attitude will likely encode information as having higher importance, subsequently paying more attention to detail when it comes to treatment regimen. Przybylski (2010) wrote an article about locus of control in diabetic patients. He suggests that arming a patient with the knowledge of what needs to be done will give them greater control of the disease. The effect that control has on well-being will affect the outcome of the disease. If their cognitive processes support the importance of the treatment ,they can eventually exit the art of the feedback loop that keeps them out of line with the improved outcome.
The following case is about a 40 year old named Susan who is experiencing negative physiological symptoms. When she goes to speak with her doctor, she gets diagnosed with a medical condition. The case emphasizes an open feedback loop as well as a closed feedback loop and many other Control Theory mechanics.
Introduction and Setting
Susan is a 40 year old woman who has been experiencing symptoms of dry mouth, fatigue, weight fluctuation and frequent urination for the last few months. She hasn’t really put much thought into these symptoms because her exercising and training for an upcoming marathon could serve as an explanation. She is convinced that the training is what is causing her to experience these symptoms. Despite this, her husband has been pressuring her to go to the doctor to get evaluated just to prove nothing is wrong. Reluctantly, Susan makes the appointment and sees her family doctor.
At her appointment, Susan explains to the doctor what she has been experiencing. The doctor recognizes the symptoms and decides to test Susan’s blood sugar. The results of the test revealed that Susan’s blood-sugar levels were very high. The doctor explains that Susan’s symptoms are indicators of diabetes, but he would like to run more tests in a few days. Susan is appalled and argues with the doctor. She expresses to him that it is not possible that she is diabetic because she works out regularly and is not overweight. The doctor tries to educate Susan about her symptoms and how they are related to diabetes. Susan is in shock and disbelief, but agrees to take the additional tests.
Susan participated in the additional testing, and a few weeks later, she attends her follow-up appointment with the doctor. She is informed that she has Type 2 diabetes. Susan is scared, angry and still can’t understand how this is possible. The doctor explains how changing her diet will help alleviate the symptoms that she has been having, and will help control her diabetes. He also informs her that if the diet changes do not help, then they have to look into pharmaceutical treatment options. Susan hears the doctor’s suggestions, but she has a difficult time digesting the information. Her family offers support, and encourages her to make changes to her lifestyle.
The following diagram serves an an explanation for the cognitive process that go along with a patient’s feeling of control regarding a prognosis. A patient who feels he or she has control will adhere to treatment more steadily than one that does not.
Feedback Loop One
Susan has been diagnosed with diabetes and has been given the goal of reducing her symptoms. To this end she has been set to the task of changing her diet and has been given specific parameters for eating. She is shown where she is now and where she needs to be after changing her diet. She agrees readily externally, but internally is resistant to change as she is not ready to admit she has a real problem. While the doctor hears her agree to the plan verbally, she has no real plan for changing her diet. She is frightened by the diagnosis and unsure of her ability to stick to a diet to lower her symptoms, the main goal. This is explained by the Subjective Expected Utility of Goal Attainment, where people are more likely to commit to a goal when they think that they can achieve the goal (Klein, 1989). In her case she does not think she can do it and so it affects her actions (suggesting an external locus of control). As a result, she goes into denial and does not take the doctor’s orders seriously. The end result is her poor performance towards her new goal of reducing symptoms via diet. Her effort toward this end is essentially non-existent. At her next appointment the doctor asks her how she is faring with her diet. Susan lies to appease him and says she is doing well. As a result of her dishonesty the doctor is not providing real feedback. Her symptoms and her poor diet continue unabated.
Susan does not adjust her lifestyle to the include diabetes into her way of life. This ends in her refusal to change her diet for the better and the open loop of unchanged dietary behaviors continues. The emotional aspect of Control Theory applies to the evaluation of process (PSU, 2013). In her case she is not getting honestly evaluated by anyone. Susan is not approaching the process honestly; thus, she is circumventing any real feedback by her doctor. She is stuck with feelings of fear and denial towards her disease and the process of change that goes along with it. She knows deep down her behavior is doing her no good, but cannot seem to face it. She even feels a little guilty as she is lying to her friends and family while keeping up a front of effort. They have been so supportive and say they are proud of her changes when in reality there are none. The doctor remains happy with her on a personal level but is unaware she is lying about her results. From the doctor’s point of view, even if she is trying, there is no change in her condition and so alternative methods will have to be pursued. Her denial and refusal to deal with her condition openly leaves her with no real feedback from her doctor and so leaves the feedback loop open.
Feedback Loop 1 Example: This is an open loop, showing no feedback. Image by Erin Smith.
Feedback Loop Two
In Klein’s (1989) simplified approach (figure below), Susan visits the doctor for a follow up on her diabetes management. A new Comprehensive Metabolic panel, weight measurement and stress inventory (input functions) are taken to asses her blood chemistry, weight, and emotional state. Her results are compared to normal ranges (referent Standard) as well as Susan’s previous readings (comparator). At this point, if the test results fit the standards then the goal is met and the loop closes. A later visit is scheduled for further comparison. However, if the results of the Comprehensive Metabolic panel, weight measurements and stress inventory (input functions) have not changed in comparison the standard measures (referent standards) or Susan’s previous results (comparator), it will be determined that Susan may need some adjustments. For example, if Susan shows significant weight gain, adjustments need to be implemented in her diet and exercise plan. Now that she is facing her disease she is ready to take on the new diet regimen that her doctor had initially wanted. A visit to a nutritionist and a fitness trainer may help keep her on the right path now that she is willing to accept help. In addition, the evaluation shows significant changes in her emotional state. An appointment with a counselor should be scheduled to evaluate her emotions and determine what form of therapy is needed. She is doing well facing her illness and visits to a psychologist can help keep her on track. A follow-up doctor visit will be scheduled at a later time to reevaluate the effectiveness of the changes. Until then, the loop will stay closed.
Feedback Loop 2 example. Image by Erin Smith.
Cognitive Emotional Link
Susan had trouble adhering to her prescribed diet in part due to her core self-evaluation. In Susan’s case, she was battling a negative view of her abilities in the wake of her diagnosis. Self-evaluations about goal attainment become critical information (conditions) to inform future cycles of goal-setting and future self-judgments of confidence that goals can be achieved (Hadwin & Webster, 2013). This self- perception was negatively affecting her goal-setting behaviors because her main cognitions about her diagnosis were of denial, disbelief, and low confidence in her ability to maintain the diet. When she focused on her diet, and on the thoughts and feelings that coincided, she gave herself negative feedback. In addition, she chose to lie to her doctor about her success in dieting, so she received no further feedback from him. This resulted in her failure to adhere to her diet goals, thus directly affecting her behavior towards achieving that goal (PSU, 2013).
The health locus of control (HLOC) theory, a psychological theory concerning patients' perceptions of how much control they have over life events may be of use in Susan’s case. It has been suggested that concordance with treatment is improved when patients have a high internal HLOC, which aligns with the belief that they have greater control over their health (Przybylski, 2010). Knowing that she is in control of her diabetes, can regulate her insulin, has the ability to maintain treatment and receives positive feedback for doing so can help her to adhere long-term. In time, this can alleviate confidence issues and depression as she learns to cope, re-evaluate her self-perceptions and rely on her support systems in times of need.
Susan becomes depressed because she feels she has lost control of her life since being diagnosed with Type 2 diabetes. She stops exercising and secretly eats foods she knows are bad for her condition. Her husband and friends urge her to seek help for her depression, but she insists that she is fine. The behaviors brought on by the stress and depression (lack of exercise and poor food choices) are beginning to cause other health concerns because she is not controlling her blood glucose (blood sugar) levels. She hides these symptoms from her doctor and husband. She knows that if she does not begin to take care of herself that Type 2 diabetes can have an effect on her kidneys, eyes, circulation, cause nerve damage or she could even go into a coma. The depression is making it harder for her to come to terms with her diagnosis and make better choices to improve her health.
The fact that the insulin is helping Susan physically does nothing to alleviate the mental anxiety and depression she has been experiencing. Her initial reaction to being diagnosed was denial, shock, and anger, but depression is now the main psychological battle she is facing. She feels guilty about lying to her doctor about making dietary changes. She has lost interest in exercising which intensifies her depression. She is looking for a therapist or psychologist to help her find a way to deal with all the new changes in her lifestyle. The control theory is both a cognitive and emotional theory (Pinder, 2008) and all the changes Susan’s life will need to be dealt with on both levels. She will be better equipped to process these changes with the help of a mental health professional. Susan comes to terms with her diagnosis of Type 2 diabetes with the help of her psychologist and therapist. This mental health treatment lessens her stress and depression. She begins to exercise again and eats better. The positive changes alleviate her depression and help her keep her diabetes under control.
MBO (Management by objectives) can be organized in a Control Theory framework, to describe and organize the feedback loops between the manager, the employees and the goals they need to accomplish as a team(PSU, 2013). In similar process to the chart above this paragraph, MBO can be applied to the treatment of Diabetes. Where the patient team up with a team of professional advisors with the objective of controlling the disease.
Susan, with family history of Diabetes, should follow a (MBO) Management by Objective plan. Part of the problem with diabetic patients is the lack of information about the disease, individuals with family history of diabetes need to take a proactive approach to the disease; early pre screening using a Comprehensive Metabolic Panel to measure not only the glucose in the blood but also other anomalies such as kidney and liver damage, that can alert the doctor and the patient of symptoms of pre-diabetes, such as; blood glucose levels that are higher than normal but, not yet high enough to be diagnosed as diabetes (American Diabetes Association, 2013) Early detection of Pre Diabetes, can potentially de-accelerate the damage that diabetes causes to the body.
Susan, with family history of diabetes, should consider consult with a doctor on a yearly basis to check the blood sugar levels or if one or more of the following symptoms are occurring; Frequent infections, blurred vision, cuts/bruises that are slow to heal, tingling/numbness in the hands/feet, and recurring skin, gum, or bladder infections (American Diabetes Association, 2013).
Susan needs to learn that she is not alone, she needs to take a proactive role in the management of her disease, there are many resources available to cope with the disease, the American diabetes association is a good source of information and support. Patients should take a management approach using all the resources available to decelerated the progression of the disease, a team of specialist will be the ideal approach to Diabetes management. It should include a Primary Care Physician, a psychologist, a dermatologist, a nutritionist and a fitness manager.
While Control Theory has it’s roots in math and engineering, it is also relevant on a human level. It becomes relevant to humans through it’s association with Goal Setting Behavior as well as it’s assumptions about people and society as systems in and of themselves. Through the case study of Susan it is shown how her medical issues ebb and flow through goal setting, feedback from her doctor, and her own emotional responses. From an emotional standpoint she was locked in a cycle of denial and guilt. Instead of opening up to her doctor and allowing honest feedback, her fear provided negative self-feedback forcing her into denial. Her denial over her condition led to constant stopping and starting of her diet with no real adhesion and so no real progress. She also felt guilty over what her condition was doing to her family. On a cognitive level she eventually saw how directly dealing with her disease can improve the quality of her life and those around her. She reached a point where she set goals, received positive feedback, and was able to be proud of herself on an emotional level.
People with life-altering diagnoses such as diabetes should seek help with a mental health professional in dealing with the reality of their diagnoses so they can avoid putting themselves through the self inflicted hurdles Susan did. Through this process people will be able to feel as though they can be honest with their doctors. Without honest doctor/patient communication it is hard to make progress in setting goals and achieving them. It’s only when people allow themselves to face their problems head on can the process move forward. Using MBO, management by objectives, can also help streamline and organize the process. It can do this by treating the disease as something that can be managed in a logical and organized fashion focusing on the feedback loop, in this case between doctor and patient.
American Diabetes Association. (2013). Retrieved from American Diabetes Association: http://www.diabetes.org/?loc=logo
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Pinder, C. C. (2008). Work motivation in organizational behavior. New York: Psychology Press.
Przybylski, M. (2010). Health locus of control theory in diabetes: A worthwhile approach in managing diabetic foot ulcers? Journal of Wound Care, 19(6), 288-233.
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