Which of these refers to the concept that much of what happens in ones life is either under or outside of their own control?

Locus of control

Locus of control (Rotter 1966) refers to an individual's beliefs about the extent of control that they have over things that happen to them. The more anxious or depressed a person is, the more external their locus of control tends to be and a greater external locus of control is associated with a greater vulnerability to physical illness. Over the course of a psychotherapeutic intervention, the locus of control tends to become more internalized.

Stress management interventions incorporate parts of the theories described above. Biofeedback aims to change the physiological state directly, as does progressive muscular relaxation. Cognitive restructuring changes the way individuals think, which then leads to alterations in emotions and behaviour (the basis for cognitive behavioural therapy).

2 Self-efficacy, Mastery, and Competence

Locus of control is only one type of control belief. Other psychological constructs that are similar to locus of control are self-efficacy (Bandura 1977), mastery (Pearlin and Schooler 1978), and competence (White 1959). Self-efficacy, or the belief that one can do a specific behavior in a specific situation, is much more predictive of actually engaging in that behavior in that situation than is an internal locus of control orientation (see Self-efficacy and Health). Both mastery and competence are more generalized constructs than self-efficacy, and they encompass control over the situation and outcomes as well as control over behavior. Individuals with a sense of self-efficacy, mastery, or personal competence (and also those with an internal locus of control orientation) generally feel very good about themselves (i.e., have high self-esteem and psychological well-being) and are receptive to learning about and engaging in new behaviors. An internal locus of control orientation coupled with a high degree of self-efficacy, mastery, or personal competence is a potent resource for helping individuals cope with health-related stressors.

HEALTH LOCUS OF CONTROL

The Health Locus of Control model is based on Rotter’s Social Learning Theory (Rotter 1954). It proposes that health behaviours are predicted by the extent to which an individual believes they can perform the behaviour and that it will be effective. Individuals with an internal locus of control (LOC) are more likely to take action to manage their symptoms than an individual with more external LOC who believes their symptoms are a result of chance and looks to other sources, such as the doctor, to manage their symptoms. However, this model has been tested in a wide range of therapeutic areas with conflicting results.

The most widely used measure is the Multiple Health Locus of Control (MHLC) Scale (Wallston et al 1978), evaluating beliefs about health behaviours in general, and the variance in results might relate to individuals holding different beliefs depending on the situation. For example, an individual might have a high internal LOC for weight loss (i.e. they believe they are responsible and have the ability to reduce their weight) but a high external LOC for managing their arthritis, believing this is the doctor’s responsibility. Ryan et al (2003) found that within a medical consultation, contrary to the HLC model, an external LOC increased the patient’s perceived control over their ability to live with their arthritis. This may be because patients view their condition as too unpredictable and mutifacted to manage without external professional support and view the consultation as a partnership where their issues could be voiced and management appropriate to their needs provided.

In an attempt to make the HLC a stronger predictor of health behaviour it has been adapted to include: the value the individual places on their health and the extent to which an individual is confident in carrying out behaviours they believe will be effective. In other words, for an individual to engage in health behaviour, such as exercise, they need to value their health, believe they are responsible for it, be confident they can exercise and believe exercise will be effective.

Definitions of Perceived Control

Beyond locus of control and self-efficacy, other classic concepts such as mastery, agency, and self-determination emerged that are all generally subsumed under the umbrella term ‘perceived control.’ Skinner developed a taxonomy that helped to differentiate the subtle variations between these concepts. Each can presumably be classified in relation to its emphasis on the ‘agent–means–end’ sequence, in particular whether it describes an ‘agent–means,’ ‘agent–ends,’ or ‘means–ends’ relationship. The ‘agent’ refers to beliefs about the agent of control (the role of the self); the ‘means’ refers to beliefs about the way in which control is exerted; and the ‘end’ refers to the desired outcome over which control is exerted.

Despite the different emphases in the classic concepts, the definitions share a common core: each focuses on beliefs about influence. The focus might be on a belief that certain actions will generally influence an outcome (running fast will allow one to escape from an attacking bear) or on whether one believes he/she possesses the essential qualities to influence his/her actions (I believe I have the strength and endurance to run fast) and/or whether this allows for one's influence over outcomes (running fast will allow me to escape from an attacking bear).

Some researchers continue to use the perceived control label in the classical way to refer to beliefs about influence; whereas, others use it more liberally to describe a psychological state of control, that is, whether one feels ‘in control’ or ‘out of control.’ Beliefs about influence are tied to specific outcomes, but the psychological state of control is broader. Just as people can report whether a specific outcome produces happiness, they can also report a broader, overall state of happiness that extends beyond the outcome.

To avoid confusion in this article, when it is useful to distinguish perceived control from the broad psychological state of control, we adopt sense of control as a label to refer to the psychological state. We subsequently use the perceived control label in its narrowest, classic manner (i.e., beliefs about influence), not as an endorsement of this classic view, but rather, to avoid confusion.

Locus of Control

The “locus of control” is a personality construct referring to an individual's perception of the locus of events as determined internally by his/her belief that an outcome is directly the result of his/her behavior. This contrasts with the perception of external circumstances, by which control is in the hands of powerful others (doctors), or outcomes are due to the vagaries of fate, luck, or chance. Some research suggests that what underlies the internal locus of control is the concept of “self as agent.” This means that our thoughts control our actions, and that when we apply this executive function of thinking, we can positively affect our beliefs, motivation, and performance. We can control our own destinies and we are more effective in influencing our environments in a wide variety of situations.

A health-related Locus of Control Inventory developed in the mid-1970s was derived from social learning theory. This tool was a one-dimensional scale containing a series of statements of people's beliefs that their health was or was not determined by their own behavior. A further development was the three 8-item Likert-type “internal, powerful others, chance” (IPC) scales, which predicted that the construct could be better understood by studying fate and chance expectations separately from external control by powerful others. The locus of control and IPC approaches were combined to develop the Multidimensional Health Locus of Control (MHLC) Scale. The MHLC Scale consists of three 6-item scales also using the Likert format. This tool is used to measure quality of life in patients with diseases or disabilities such as breast cancer, irritable bowel syndrome, chronic leg ulcer, and traumatic spinal cord injury. The second aspect is medical outcomes as assessment for quality of treatments (for example, for cervicogenic headache, after cardiac surgery; treatment outcome in subgroups of uncooperative child dental patients; outcomes of parent–child interaction therapy). The last aspect is efficiency of health services or planning a new service. Examples of application include prediagnostic decision-making styles among Australian women, relating to treatment choices for early breast cancer, intention to breast feed, and other important health-related behaviors and beliefs during pregnancy; predicting the ability of lower limb amputees to learn to use a prosthesis; and planning a program of awareness in early-stage Alzheimer's disease.

Control Beliefs

Julian Rotter's locus of control idea has initiated some studies that map stability and change in control beliefs over the life span. This research tradition goes back to learning theories that postulate the existence of generalized expectancies concerning behavior possibilities, based on reinforcement. Thus, the individual's feelings of outer control from the caregiving parents would be typical of the childhood years, whereas feelings of increasing inner control in young adulthood will grow out of newly gained independence. Decreased internality of control beliefs is postulated again in old age, when advancing frailty might lead to an increased need for assistance and care.

The research group led by Margy Gatz has generated most of the longitudinal data concerning this issue. In a cross-sequential study with a follow-up of 20 years there seemed to be strong evidence for continuity of internality over the adult years. The mean levels of personal control actually became more internal in all the young, middle-aged, and old-age groups followed in this study, a finding that probably reflects changing contextual factors in the culture. At the same time, the oldest women showed more outer control, most probably a cohort effect. In addition to the gender difference, the researchers point out the great individual differences found concerning this attribute.

According to some researchers, the inconsistency in some other longitudinal research projects on this issue can be explained by the unidimensional way of defining control (as inner or outer control). Multidimensional approaches might thus be needed. The European researcher Jochen Brandstädter has shown in a cross-sequential study of developmental goals that self-perceptions of autonomous control became more pronounced in middle and late adulthood. This control concerned the domains of health and physical well-being, assertiveness, self-assurance, intellectual efficacy, self-development, mature understanding, and wisdom. Recently, researchers have started to stress the need for studying personality-linked concepts such as control, self-efficacy, or autonomy as transactional processes rather than as personality traits. Where these concepts are studied as processes, the relation between the aging individual and his or her environment will be the focus of the research.

Validity

Locus of control

Related to notions of self-efficacy is locus of control[131], also important to perceived quality of life. It is a psychological concept describing the extent to which individuals see themselves as having personal (or “internal”) control over events in their lives or to which control lies in others (“external”). In health-related research, the concept is often used to understand the extent to which people think that their health status and future health outcomes are achievable by their own actions. Locus of control is now generally considered to be one of four psychological “core self-evaluation” concepts, along with neuroticism, self-efficacy, and self-esteem, through which individuals judge their worth as people and the general quality of their lives. They may also be considered as being among the predictors of resilience [132].

As with self-efficacy, studies of associations between dementia-related outcomes and locus of control have focused on caregivers rather than on people with dementia themselves. The results have been somewhat varied. Nordtug et al. [133] studied the influence of neuroticism and external locus of control in caregivers of people with dementia and found that while neuroticism was predictive of increased burden and mental health problems, external locus of control was not. But Bruvik et al. [134] reported that locus of control was the main predictor of burden in caregivers of people with dementia, with greater internalized control associated with lower burden and greater externalized control associated with greater burden.

Some support for loss of control as a perceived cause for behavioral and psychological symptoms of dementia is provided by Polenick et al. [135], who applied attribution theory in an analysis of focus group data. Caregivers attributed such symptoms in people with dementia to their fear at their expected loss of control.

Research about “control” in persons with dementia has frequently been less focused on the psychological concept of locus of control and more on perceived autonomy. As will be seen in subsequent chapters, the extent to which persons with dementia have control of, or input into, decisions about their lives varies. Autonomy and control influence transition experiences. Those with dementia often feel that decisions about their lives are made for them rather than with them [136].

Health-Related Behavior

Health motivation, health value, and health locus of control have a strong influence on compliance with medical care5 and orthodontic treatment.20,27 Recent studies suggest a beneficial influence of excellent dental appearance and of past orthodontic treatment on oral health attitudes and oral health-related quality of life of young adults.29,30 It is believed that health-related behavior in general and patients' attitude to orthodontic treatment in particular might considerably influence orthodontic compliance. Health behaviors comprise personal efforts aimed at reducing behavioral pathogens or health-compromising behaviors, as well as increasing the practice of behaviors which act as behavioral immunogens or health-promoting behaviors.27

Of particular relevance in this respect are patients' attitudes toward dental esthetics, perceived severity of malocclusion, desire for orthodontic correction and expectations from orthodontic treatment in the sense of an anticipated self-efficacy.25,31,32 The latter may be defined as the individual's belief in their ability to function competently.32 Favorable compliance seems to be related to perceived severity of malocclusion13,20,33,34 and to internal control orientation.21,26,35 According to the locus of control theory, internal control orientation implies that patients attribute treatment outcomes to their personal efforts without relying primarily on chance or endeavors of others.36 It is likely that those orthodontic patients who make fewer external attributions will retain some sense of responsibility, and possibly control, over treatment outcomes and believe that their participation and cooperation can facilitate treatment progress.21

Endocrinological Evidence for the Role of Self-esteem and Locus of Control in the Perception of Stress

Evidence for the impact of self-esteem and locus of control on stress perception emerged when subjects were exposed to repeated psychological stress, using the Trier Psychosocial Stress Test (TSST). In this paradigm, subjects have to give an impromptu speech and perform serial subtraction tasks in front of an audience, usually for about 10 min. The audience consists of two to three persons who are instructed to maintain a neutral expression, being neither explicitly rejecting nor confirmative in their facial expression or gestures. During the speech, the audience interacts with the subject only to indicate the amount of time that is left to talk or to ask specific questions. In the case that a subject stumbles, they encourage the subject to continue the speech. During the serial subtraction task, the subject is interrupted only when making a mistake. The subject is then corrected and instructed to start the task over. The task was designed to represent a significant social-evaluative threat and indeed has been shown to be a powerful stressor, stimulating the hypothalamic-pituitary-adrenal (HPA) axis and leading to significant free cortisol increases within 15 to 30 min following the onset of the task. This first study aimed to validate the long-standing hypothesis that in humans, repeated exposure to the same stressor would lead to quick habituation of the stress response. In order to test the habituation of the stress response, 20 young healthy male college students were exposed to the TSST on five subsequent days. For this purpose, the TSST was modified using different speech topics and serial subtraction tasks on each day. Interestingly, only 13 of the 20 subjects showed the typical habituation pattern, with a normal stress response on day one being significantly reduced on day two, and no longer present on the subsequent days. In the seven remaining subjects, however, the cortisol stress response continued to be present on all days and only showed a tendency to decline toward the end of the testing (Figure 1). When analyzing the available psychological variables, it became apparent that low internal locus of control and low self-esteem were the best predictors of failing habituation of the cortisol stress response to repeated stress exposure. This can be interpreted as a sign that these personality variables interact with the evaluation of a situation during repeated exposure. The absence of differences in the stress response between the two groups of subjects on day one was at the time attributed to the effect of novelty – the novelty of the situation might have made it unpredictable and uncontrollable for everybody on the first exposure and might thus have masked the impact of personality variables on stress perception and response. One conclusion at the time was that in order to reveal the effect of personality variables on the stress evaluation and response, one would likely need repeated exposures to the same stressor in order to reveal the influence of personality variables on stress.

However, it is known that personality variables tend to have relatively weaker effects when situational factors are very strong. In a second study, the threatening aspects of the situation were reduced, and self-esteem and locus of control had an impact on the perception of stress on the first exposure to a stimulus. Here, computerized mental arithmetic was combined with an induced failure design to invoke stress. In the setup used in this task, 52 students performed the task on computer terminals in front of them. Half of the students were exposed to a difficult version leading to low performance, compared to an easy version of the task with high performance for the other half. The students played the task in three 3-min segments and had to announce their performance score after each segment to the investigator, who wrote the scores down on a board for everybody to see. Saliva sampling before, throughout, and after the task allowed the assessment of the cortisol dynamics in relation to this paradigm. Interestingly, this task triggered a significant cortisol release only in the subjects who were in the low-performance group and had low self-esteem and low internal locus of control. Neither low performance alone nor low self-esteem and internal locus of control alone were significant predictors of cortisol release, supporting the notion that these personality variables produce effects only in interaction with a potentially stressful situation (Figure 2). The evaluation of the situation is suggested to be at the core of this interaction.