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Making Treatment Work

How to Make Treatment Work for You: Agency is Important

Jon G. Allen, PhD - Senior staff psychologist at The Menninger Clinic; Helen Malsin Palley - Chair in Mental Health Research and professor of psychiatry in the Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine.

 

Taking agency for your illness includes active efforts to recover. By the time you arrive at The Menninger Clinic, you’re likely to deserve credit for taking a great deal of agency:

  • you might have tried many medications as you put up with their side effects and endured frustration with their limited effectiveness;
  • you might have sought psychotherapy, perhaps a number of times;
  • you might have given a history of your illness repeatedly and made arrangements to provide records of your prior treatment; and
  • while you looked for a suitable inpatient setting, you might have grappled with dauntingly complicated financial and insurance matters.

Participating in hospital treatment requires a great deal of agency; there’s much you must do, including educating yourself (e.g., by reading about agency). To benefit from treatment at Menninger, you’ll need to establish a therapeutic alliance, that is, collaborating with your treatment team in formulating and working toward goals. More generally, the alliance entails actively making constructive use of treatment as a resource for change (including addressing your resistance to change).

 

The upshot is this: the most important determinant of the outcome of treatment is you. Being in treatment is like going to school: what you get out of it depends on what you put into it. Catch-22: your illness will limit what you can put into treatment. Thus you’re likely to move forward slowly.

 

Why is agency important?

Dr. Richard Munich, former vice president and chief of staff of The Menninger Clinic, proposed that the patient’s willingness to take agency for the illness is a foundation of effective treatment. What does this mean?

 

Agency is the capacity to initiate action for a purpose.

 

Agency implies will, autonomy, freedom and choice. As an agent, you make things happen; the opposite of agency is passivity, letting things happen to you. All animals are agents, but we humans are rational agents: we are able to reason about what we’re doing. We are self-aware and able to think, plan and deliberate before we take action; and we are self-correcting when things don’t go as planned. Thus agency gives us control and flexibility. But agency is a matter of degree: we’re potentially intelligent agents but we also can act impulsively or thoughtlessly and thereby diminish our agency.

 

Illness constrains agency.

For example, you can be so depressed that you can hardly move. Generally, however, your agency is not reduced to zero; you have some remaining agency. Even when you’re depressed, you might have enough energy to force yourself to sit up in bed, and then put your feet on the floor, and thus get yourself going to some degree. You need to use whatever elbowroom you have. And when you’re ill, one of the most important ways of exercising agency is asking for help.

 

Here’s a potential trap with taking agency for your illness: being a free agent, you make choices; making choices implies responsibility; being responsible opens you up to being blamed; and blaming is destructive. We can make two serious mistakes: taking responsibility for things we can’t control, and failing to take responsibility for things we can control. You walk two tightropes:

  • taking responsibility for exercising your agency while fully appreciating how you’re hampered by illness;
  • employing criticism constructively while avoiding destructive blaming.

Taking agency for your illness includes recognizing whatever active, if unwitting, role you’ve played in the development of your illness. For example, depression stems from unmanageable stress pileup; although much stress is unavoidable, you also play some contributing role to the extent that you actively generate additional stress in your life (e.g., through overwork, perfectionism, or contributing to relationship conflicts). Substance abuse is another prime example of self-generated stress (and addictive behavior exemplifies the knotty intermingling of agency and illness). Understanding your active role in the development of your illness can help you get out of it and stay out.

 

Taking agency for your illness also includes recognizing whatever active, if unwitting, role you’re playing in perpetuating your illness. Conscious and unconscious resistance to change is common. For example, a depressive retreat might feel relatively safe in its sheer familiarity, even though it’s a painful state. Avoiding pain and obtaining pleasure through addictive behavior also can be extremely difficult to give up. Any form of substantial change—even though it’s for the better—will bring considerable anxiety.

 

Recovery begins here.

You’re not done with taking agency for your illness when you leave the hospital; you’ll need to make a discharge plan and use it. Our treatments for psychiatric disorders are not curative, and many disorders tend to be recurrent. Thus you’ll make use of agency not only in recovering but also in remaining well—taking care of yourself over the long haul, including obtaining whatever treatment you need at any given time. Fortunately, after you’ve recovered, your full agency is restored, and you’ll be in a better position to take care of yourself.

 

Agency is a foundation of hope.

Psychiatrist Karl Menninger, one of The Clinic’s founders, construed hope as involving a motive force for a plan of action. With increasing agency to overcome the constraints of illness, you’re freer to move forward along this path. A key point in treatment is when you discover something you can do that helps, for example, finding tools that work. The most important ingredient of hope is the feeling, “I can do something about this!” That’s agency.

Further reading

Copyright © 2005 The Menninger Clinic.