If you work in the field of physical rehabilitation as an occupational, physical, or speech therapist in any setting, you have likely encountered a client with the debilitating effects of learned helplessness. These clients have a tendency to simultaneously break our hearts in compassion, and make our minds spin in an effort to progress them through our plans of care to reach their desired level of independence.
Learned Helplessness. What is it? The textbook definition from Oxford Languages is “a condition in which a person suffers from a sense of powerlessness, arising from a traumatic event or persistent failure to succeed.”
1. An 83 year old woman who was previously active in home-making, the care and company of her children and grandchildren, and volunteering in her community has had 3 falls in the past 6 months. Though not badly injured, she experienced extended soreness and some minor bruising. Initially, she returned to her daily living tasks without much modification. After the second fall, however, she began to experience a newfound fear of falling. She since has felt unsteady on her feet and has had several ‘near-falls’ from tripping or losing her balance while completing simple home-making tasks. After her third fall, her daughter stepped in to help. She now completes all of the grocery shopping, heavy cleaning, and meal preparation for her mother. She repeatedly reminds her mother to not get up without assistance and to stop worrying about her house cleaning and volunteer work.
So, 6 months after her original fall, the woman in our example has now experienced 3 traumatic events (falls), a decreased confidence in her ability to maintain her balance, and the voice of a loved one telling her she can no longer participate in the activities that bring her meaning. As a result, she has decreased self-efficacy, decreased opportunity to participate in meaningful occupation, fewer opportunities to maintain her physical abilities, and declining social participation.
2. A 4 year old boy is the only child of a mother who has chronic anxiety. Because of her constant concern over her young son’s safety, she has become somewhat of a “helicopter parent.” During playtime, the four-year-old hears repeated warnings. “Don’t climb on that!”; “You’re going to fall.”; “Hold mommy’s hand.”; “Don’t play in the mud. You’ll get sick.”; “No sticks!” An additional symptom of chronic anxiety experienced by his mother is a lack of patience. Because of this, she has difficulty allowing her son to practice self care skills--dressing, bathing, and grooming himself. At age 4, the child has just begun preschool. Many children experience separation anxiety as they transition to the ‘new normal’ of preschool, but with this young boy, the anxiety seems to be exacerbated. He has a hard time interacting with his new peers, and tends to cling to his mother’s leg at drop-off, even 6 months into the school year. He struggles with self cares at school including hand hygiene and toileting without verbal instruction to complete each step in the task. He must wait for the teacher to help put his jacket on before he can head outside to the playground. He will not climb on playground toys for fear of heights and now has aversions to many textures--including the dirt, grass, and ‘slime’ encountered at playtime. In the classroom, the boy needs constant encouragement to participate in classroom activities due to his lack of self confidence and attention. He often breaks down into tears at the start of a full-blown meltdown saying, “I can’t.” And he truly believes he cannot.
3. A 56 year old man experienced a stroke which affected the movement of his right arm, leg, and trunk. For about 3 months after the initial stroke, he was determined to regain his movement and strength so that he could return to his career, his responsibilities as the head of his household, and his favorite leisure activity of fishing. When he returned home from months of rehab, his wife went into ‘survival mode.’ She took on extra work to pay for the medical bills and became entrenched in the responsibilities of keeping the home running with cooking, cleaning, and doing what she needed for her children. Because of the added responsibilities to her plate, she didn’t have the patience or time to work with her husband on his home therapy program or to allow him the time needed to complete his self-cares as independently as possible. Over a short amount of time, the 56-year-old lost his motivation to return to his previous life. With his wife completing even his most basic self cares, he found very little meaning or purpose in day-to-day life. His colleagues and friends eventually stopped checking in. He became depressed, and as a result, spent most of his days watching TV and sleeping. His muscles continued to atrophy. Although during rehab, he was beginning to take steps with a walker, he now uses only a wheelchair for mobility. He is now very dependent on his spouse and his children to manage his medications, bring food and water to his spot on the couch, and assist him every place he needs to go. He is appreciative of all that his family does for him, but has lost the self-efficacy that made him feel that they needed him too. He continues to come for his outpatient therapy services, but shows little interest in learning rehabilitative or compensatory strategies to improve his independence. He has lost desire. He has lost the belief that he can improve. He has lost hope.
You can hear the echoes of your patients--past or present--right? Every therapist in every setting encounters the effects of learned helplessness. As a therapist who so badly wants to help people help themselves, navigating the care plan for a patient in a similar scenario is both heartbreaking and frustrating. So, what. do. we. do? How do we break through the psychological barrier so that we can make progress toward participation and independence in occupation?
You must have patient buy-in
I will by no means suggest that this is the first step you will complete, but it should be the first step you begin. Finding and maintaining patient buy-in is an ongoing, roller-coaster process. All of our goals and interventions should begin and end with the patient’s desired outcomes. Find what makes your client ‘tick.’ Underneath the fear of falling, does she desire to return to her volunteer work? Does your pediatric client have an undiscovered skill in which he excels? Does your adult-male client who has had a stroke have a sense of humor which has not been exercised lately?
Strive to make at least one small gain quickly. Show your client she can still walk without the assistance of another person. Allow the pediatric client to ‘show-off’ his new skill. Adapt a fishing pole to show your client he can participate in a beloved leisure activity.
Preserve your rapport. How many times have you had a patient scoff at your planned intervention that you thought was super inventive? I have many times. I came up with a new way to allow my client to reach her goals in a way that she may not have thought before, and she saw my idea as silly and child-like. People will appreciate your input and ideas when they like you and respect your opinion. Connect on a personal level. Educate your clients so that they can both understand the process and appreciate your high level of knowledge.
Check-in often. Use assessments to screen for depression. Identify occupations that they want to but are not completing. Ask difficult questions to inspire and motivate.
Address the environment
You can work one-on-one with your client for many months or years and make beautiful physical progress, but if you never address the environment that contributes to the learned helplessness, you will not have carry-over.
Take a step back so that you can see the full picture. You likely need to educate family and caregivers on the importance of repetition, participation in occupation, and progressively increasing independence. You may need to make modifications to the physical environment so that your patient can complete tasks with less assistance. You may need to address the families’ routine to allow the extra time needed for your client to complete a home program.
Refer out when needed
Know when the psychological impact of learned helplessness is outside of your skill-base or scope of practice. Our responsibility is to provide our clients with the highest level of care. Recognize when you are no longer the only profession needed or when you are no longer fit to provide the service you offer. Consider referring back to their primary care physician, a psychologist, or a psychiatrist.
Accept when a patient really does not want to improve
One of the most difficult cases for a therapist to accept. Sometimes, no matter the limitations that could be helped by your services, a patient has accepted their fate and has no desire to work to improve. I have worked with many clients who need assistance with their self care routine, and from either cultural or personal desires, actually find satisfaction in the disease or aging process in which their loved ones can care for them. This is a personal decision and though I have so badly wanted to step in and intervene and tell them about my wonderful knowledge that could help them, I have had to accept that I cannot change my client’s desired outcomes.
As rehab professionals, we are well aware that the patients who are the most pleasurable to work with are the ones who want to improve. For our clients who are dealing with the effects of learned helplessness, we are likely to discover that this desire to improve is buried under psychological, environmental, or self-efficacy limitations. Once we uncover these barriers, we will find a path toward improvement in occupational participation and independence--the great joy of our occupational therapy profession.
I encourage you to work to uncover that path. Work to help your clients live today. Live better tomorrow. And inspire others to do the same.
Your (fellow) OT,