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We can all dish it out, but how many of us can take it?

Raj Persaud
BSc MSc MB BS MPhil FRCPsych
Gresham Professor for Public Understanding of Psychiatry and Consultant Psychiatrist The Maudsley Hospital London

Nurses may advise about dressings, taking medication and lifestyle choices. Yet it's odd and intriguing that how to give advice is not something that actually appears to be a significant part of the training of nurses (or doctors for that matter). It may seem that giving advice - particularly if the advice is coming from an authority figure or an expert - is a bit of a no-brainer - surely most people follow advice if it's good advice?
Actually it's pretty clear that, in fact, so many people don't follow excellent advice that quite a large amount of resources have to be thrown at the problem. Take the small matter of advising people to give up smoking or to take their medication. Research in these areas suggests that in fact it's probably more the norm to ignore advice given by health authority figures such as nurses and doctors. Why is this?
The tendency for most people to rebel against advice and do the opposite is termed "reactance" - a well-known psychological phenomenon that has been identified and studied for approaching 30 years now. Despite this fact, it remains a psychological effect that seems mysterious to those in healthcare professions who stubbornly persist in giving advice that is not going to be taken - at best it is politely ignored, at worst the way the advice is given is probably increasing the chances that the patient will do the opposite. So the advice is not just neutral in its effect - it's actually counterproductive.
Since psychologists believe that "reactance" is a response to the way the advice is given, this has dramatic implications for those burdened with having to give advice - such as doctors and nurses.
Psychologist Tanya Chartrand and colleagues from Duke University have just published a fascinating study examining the psychological phenomenon of reactance in the Journal of Experimental Social Psychology.
These psychologists have reviewed the literature on "reactance" and point out that often we feel compelled to act in opposition to those trying to influence us. For instance, previous psychology experiments have established that interest in viewing violent films and videos is actually increased by labels on the packaging that warn of violent content, which might have been thought to discourage viewing. We are more, not less, likely to choose unhealthy foods if presented with recommendations for healthier alternatives.
The psychological theory to explain this puzzling but widespread phenomenon is the idea that we behave in oppositional ways to those giving out advice because we perceive the advice givers as trying to circumscribe or restrict our personal freedom and autonomy. We are motivated instinctively, and perhaps even at an unconscious level, to fight to preserve our freedom and react negatively to a sense of restrictions being imposed upon us. Another way of putting this is that we are constantly striving to increase our freedom, not restrict it, so we instinctively rebel against "do-gooders" who appear to be stifling our liberty.
This leads to a key lesson for anyone tasked with handing out advice. Always frame any advice in such a way that it looks like your main intention is to increase the patient's freedom, not reduce it. So, advice about giving up smoking should be framed not in terms of "you won't get cancer", but more like "think of all the things you could do if you weren't so breathless - like play with your kids". Advice is more likely to be taken seriously if it's seen as a means of increasing our freedom, not reducing it.
Another problem with the way many doctors and nurses give advice is that they explicitly or implicitly focus on the idea that they know more than the patient about the area being discussed. The problem is that (a) no one likes a clever clogs, and (b) it's actually quite threatening to be in the presence of someone who knows more than you and is ramming this fact down your throat. There is a natural tendency to dismiss advice given from experts by finding flaws in the notion of expertise in order to reassure us that the expert is really no better than us. Instead, experts should not focus on their superior knowledge, but rather draw attention to the sincerity with which they hold their beliefs and how much they care for the patient and are concerned for them, and that it is in this context that the advice arises.
Patients are more likely to follow advice that they believe has been given because you care for them rather than because you know more than them.

Reference

  1. Chartrand TL, Dalton AN, Fitzsimons GJ. Nonconscious relationship reactance: when significant others prime opposing goals. J Exp Soc Psychol 2006. In Press.
    Available online 6 October 2006 from: http://www. sciencedirect.com