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1992 Non-existence of non-compliant families: the influence of Humberto Maturana

Wright, Lorraine M.; Levac, Anne Marie C.

Blackwell Publishing

Wright, L. M. and Levac, A. M. C.. (1992). "Non-existence of non-compliant families: the influence of Humberto Maturana". Journal of Advanced Nursing, 17: 913-917. http://hdl.handle.net/1880/44463 journal article

Downloaded from PRISM: https://prism.ucalgary.ca Journal of Advanced Nursmg, 1992,17, 913-917

The non-existenc non-complianf eo t families: the influence of Humberto Maturana*

Lorrain WnghtRNPheM D Director, Family Nursing Unit, Professor,and Faculty of Nursmg, University of Calgary and Anne Mane C Levac RN MN Family Clinical Nurse Specialist, Calgary, Alberta, Canada

Accepted for publicatio nDecembe2 r 1991

WRIGH LEVA& M TL C A. M(1992C ) /OMfTW/ of Advanced Nursing , 913-9117 7 The non-existence of non-compliant families: the influence of Humberto Maturana Non-compliance is not only an epistemological error but a biological impossibility This profound statement arises fro influence mth Humbertf eo o Maturana's revolutionary meta-theor cognitiof yo definitione nTh d an s significant implication majoo tw f rs o theoretical concept thif so s meta-theorf yo cognition, namely structural determinis objechvity-in-parenthesisd man e ar , discussed These radical concepts challenge the approved North American Nursing Diagnostic Association's nursing diagnosi non-compliancf so e Maturana's theory reveals the impossibility of instructive interaction, leading the authors to conclude the non-existence of non-compliant families

INTRODUCTION hce nursine th , g diagnosi 'non-compliancef so t onl' isno y an epistemological error but a biological impossibility In the nursing of families, expectabons exist that families -^ revoluhonary theory mvjtes nurses to re^xainme w,U comply with ideas and advice that could promote, ^ assumphons about ^ ^^ of non

1983, 1985, 1988) offers an mtnguing meta-theory of M3n^5 ^.^Ty of cognition evolved from the cognition When this theory is applie nursino dt g prac- most ^^ of expenments expenments examinine gth structural mechanism of percephon in frogs Maturanaefa/ fbrffaw. t Ongon, May JWi ^ , (1960) discovered tha 'functioe tth n retin e ofth afroe inth g ComspanttiKt Praetor LM Wnght Faculty of Nmmg, Lhaveraly1 ofr Calgary, ^ » 2500 Unvtmty Dntit NW, Calgary. *&**« ™ J^4- Cana*L K not to t"11150111 information They further concluded that

913 LM WnghtandAMC Levac

'the transformation of the image {not transmission of the objects suc s 'truth'ha , 'mind', 'knowledge'n o o s d an , image] constitute fundamentae sth l functio retinae th f no ' These entitie usee sjustifar do t validat d yan e explanations Wha frota g perceives visuall bees yha n transformee th y db In this avenu explanationf eo come ,w believo et e thae tw retina i nmannea r that is specifi organizatioe th o ct e th f no have access to an objective reality frog's nervous Thus, perceptio pictura nt isno f eo Knowledge about the 'truth' by one person becomes a the world coming in and recording on the frog's brain demand for obedience by another, for example, a nurse's (Simon 1985) but rather it is the frog's structure which expectatio f compliancno familiey eb s Maturana (1987) determine realitsn itsow y claims that the view of an objective reality entails the Maturana et al (1968), when describing a biological possibilit conflicf yo mutuaa ( t l negahon) whic leay dhma theor f colouyo r coding pnmate inth e retina, concluded emotionao t l contradictio f 'violenceo t ac n 'A n whic h is that the activities of a do not reflect an 'holding one's opinion to be true such that another's must independent environment and therefore do not reflect change' (Maturana 1987) may result from conversation an absolute external world Maturan hid saan colleagues which is based on descriptions of 'truth' (1968) also concluded that an animal's interactions with an e labe f non-compliancTh o l e arises in this domaif no environment were best represente animal'e th n y db sow explanation Non-complianc e NANDth f o Aee ion s organization and not by an independent external reality approved nursing diagnoses unde e categorth r f o y Since the basic architecture of the nervous system is 'Choosing' (Carroll-Johnson 1989, Carpemto 1991) universal, Maturana extended his earlier ideas relateo dt Specifically s bee, iha t n denne s 'ada person's informed the visual perception of frogs to the perceptual process decision not to adhere to a therapeutic recommendation' of primates, which of course includes human beings What (Carroll-Johnson 1989) When nurses operat edomaie inth n is perceive n individuaa y b d l is alway a resuls f o t of objectivity or , they believe and behave as if transformation within the structure of the individual they have acces objectivn a o st e reality, that is, that their The revelation that all cannot refer to an observations/assessment of a family member's behaviours external, independent reahty becomes not onh/ a philo- are 'true' Consequently, within this domain, nurses can fall sophical reflection but a constitutive biological condition into the trap of believing that individuals and families are of humanity (Mende l a 1988 e uniquenest e zTh ) f o s non-complian thad an tt families should adher nurseso et ' Maturana's theory is that it reflect epistemologn a s y in advice and opinions They also invite the possibility of which individuals (living systems) draw forth reahty — conflict and violence between them and their patients they do not construct it nor does it exist independently of them (Maturana 1988) Therefore, change or learning occurs in humans from moment to moment, either as Objectivity-in-parenthesis a change triggered by interaction(s) or 'perturbations' coming fro environmene mth t in which ita exists a r so When objectivity is placed in parenthesis, nurses recognize resul internan f ito tsow l dynamic histore t isth I s d yan that objects do exist but are not independent of the living structure of the living system that determines which system that brings them forth The only truths which exist perturbation triggen sca r change statf so e are those drawn forth by observers, such as nurses Without observers nothing can be said, nothing can be explained, nothine claimeb n ca gd in fact, without observers EXPLANATION WORLR OU F DSO nothing exists because existence is specified in the operation of distinction of the observer' (Maturana 1988) Maturana offers the idea that there are two possible Distinctions made by an observer of what appears to be avenues for explaining our world objectivity and stimulus (input d responsan ) e (output e nervouth f o ) s objecti vi ty-in-parenthesis systems is not a property of the nervous system, but rather a propert domaie th f y o observationf no s Thus, braid nan Objectivity behaviour are only linked in the eyes of the observer As Maturana (1985) states, 'the min head e dit n th i sno , it is in This view assumes that ther eultimate ison e domaif no the behavior1 reference for explaining our world Within this domain, Drawing distinction sbasie isth c cognitive operatiof no entitie assumee sar exiso dt t independentl individe th f yo - the observe pror ro Cognitiot - ac define e e b th y s dna ma ual Such entities are as numerous and broad as imagination ces knowinf so g including both awarenes judgemend san t might allow and may be explicitly or implicitly identified as Cognitio representatioa nt isno worle th f ndo 'out there',

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rathet bu ongoinn ra g bringing fort worla f ho d througe hth Within the domain of objectivity-in-parenthesis, we proces f livinso g itself Therefore, it is alway sr co inou - cannot claim tha famila t y is non-compliant Therefore, existence with other bringine sar thae w tg forth reality nursing assessments are based on observer perspectives Humans literally creat worle eth d in which they live while co- ant ultimatdno e truths existing and co-dnfhng with other human beings It is human activity which brings forth and validates human activity Maturana (1988) claims that we exist in domains that THE IMPOSSIBILITY OF INSTRUCTIVE we bring forth through living and 'they are domains of INTERACTION realities, domain f explanationo s s thae presenw t r fo t explainin r experiencegou ,understandine inth g thae w t Instructive interaction implies that a living system is able to receive instructions from the environment, in the form of cannot claim anything about an independent reality' Every information to be processed (Aboihz 1985) It assumes that explanation is a reformulation of our experience Our individuals can specify structural changes in other indi- explanation conveyee sar d through narratives which embed viduals through instruction Maturana & Varela (1992) the meanings (beliefs) we have about our experiences It is mak e startlinth e g declaration that there cannon a e b t these beliefs that nurses' clients have about their experi- instructive interaction This notion emerges from the cen- ence sucs — chroni s ha life-threateninr co g illnes thas— t tral assumption that living system self-organizine sar e gTh are central to how they cope with them nervous system infonnationalln ia s operationalld an y y In applying thi nursinse ideth o at f families go , every closed system As a closed system, it is the nervous system family member has his or her own reality or perspective of that determines the changes of relative neuronal activity, his/her experienc illnesf eo s Nurses nee encouragdo t e eth it is not the perturbation that determines the state of expression of each family member's reality For example, if the nervous system Information or instruction cannot be each family member is asked, What is your point of view imported onto someone, it can only be offered as part of an youw ho r mothen o r is coping wit multiplr hhe e sclerosis?, interaction How an individual responds will be determined many different perspectives or realities will be drawn forth by their structure at that point in time If living systems e concepBaseth n f o structurado t l determinism, each were 'mstructable' they would all respond the same to a reality must be considered as 'true, valid and legitimate given perturbation It is the system in constant interaction e ideTh a that humans bring different perspectiveo t s with its medium that specifie itw wilsho l behavee th t no , their understanding of events is not new But Maturana's information or instruction perspective on observations is much more radical it is based Structural changes in living systems are unique and on biolog physiologyd yan t philosophno , y Maturana are dependent on the phylogemc history (genehc or states that not only do we have different views or perspec- evolutionary history r ontogemo ) c history pase (alth l t tives on a given event but that the event itself has no structural changes or history of interactions) in the life existence separate fror abilitmou o distinguisyt h it in of the organism Thus, changes in family members are words and symbols (Maturana & Varela 1992) One's view determine othery b theiy structuren db t ow srno d san distortioa t isno somf no e presumably correct interpretion Therefore, nurses are not change agents they cannot and Instead of one objective universe waiting to be discovered changt no o d e anyone or correctly described, Maturana proposes a 'mulhverse', where many observer 'verses' co-exist, each valid in its own right A scenario Mendezrfa/ (1988) state Consider the following scenario A cardiovascular clinical If we claim that the biology of the phenomenon of cogni- nurse specialist (CNS) conduct weeklsa y smoking cessahon tion demands that we operate with objectivity-in-parenthesis, clinic for cardiovascular patients and their families The then we can no longer keep the notion that we have a CNS provides relevant literature informing her cardiac legitimate transconsensual authonty of power to decide what patients abou nske smokintth f so promoted gan varietsa y happen anotheo st r human being ,deman e baseth n r do dfo of strategie patientr sfo decreaso st eliminatd ean e smoking obedience that the claim of objective knowledge entails behaviou ise puzzle Sh widre th ey d rangb responsef eo o st Indeed, putting objectivity m parenthesis entail explicie sth t recognition that the desirability or undesirability of any given her nursing interventions some patients stopped smoking behavior is socially determine tha cannod e dtan w claimo tg - almost immediately, others decreased their smoking behav- thag in t something is goo r baddo , health unhealthr yo y in iour, while still others remained firm in old smoking habits itself, as if these were intrinsic constitutive features of it Clients who fall into this latter category may be quickly

915 LM WnghiandAMC Levac

labelled as 'non-compliant' However, an implication of ask families what they would lik conservo et e rather than Maturan Varela'a& s (1992) theory recognizo ist e that what they wan chango t e This is als overa y useful inter- such t 'non-compliantclientno e sar t rathebu ' r havt eno vention on themselves as family nurse clinicians (Wnght selected a particular novel perturbation which invites them et al 1990) They attemp desigo t t n interventions which decreaso t e their smoking invite familie reflectiona o st (Wngh Nagt& y 1992, Wnght t Sunpson 1991, Wnght It Watson 1988) Interventions which invite reflection hav potentiae eth beinf lo g selected THE POSSIBILIT COLLABORATIVF YO E perturbations Family member respono swh particulao dt r INTERACTION perturbations (i e therapeutic interventions) do so because If instructive interaction cannot exist, how can we as of the fit between the perturbation and their structure nurses impart ideas about health promotion and health restoration? Maturana offere followine dth g suggestion. CONCLUSION

You will never be able to do instructive interaction The most One question still remains Are there nsks of being too that you can do is to talk to the patient and invite this person enraptured with Maturana's meta-theory of cognition? reflectioa o t n that will allo realizatioe wth n that there n isa The authors believe one nsk of embracing Maturana's illnes thad san t ther certaie ear o t ns actionha e sh sr thao e th theory with overwhelming enthusiasm is that nurses cannotaku eYo t forc otheunderstandine n a eth o rt g would behave with too much certainty If they are too (H R Maturana, personal communication, October 1988) enthusiasti certair co n about Maturana's theory, it becomes 'trueo to ' This 'truth' become tyrannsa y becausd en e ew Inviting individuals and families to a reflection can be up submittin externan a o gt l 'truth' whic hvere isth y idea accomplished by creating a context for change, creating an that Maturana is challenging However, there is one environment in which persons change themselves, offering occasion when nurses need wholeheartedl embraco yt e ideas, advic d suggestionan e s thaservn ca ts usefu ea l Maturana's theory, that is, whenever they encountee th r perturbations By remaining cunous about family mem- impulse to pathologize families as non-compliant bers' beliefs about their illness, nurse heln spca patientd san their families to discover which perturbations (ie interventions) will trigger structural changes which will References result in more effective responses to health problems Aboitiz F (1985) A antique of the modem concept of Through collaborative interaction with families, nurses localization Journal of Social and Biological Structure 8, can also eliminate what has been called the language of 307-312 loathing' (Szasz 1973 liberatd )an e themselve familied san s Carperuto LJ (1991) Handbook of Nursing Diagnosis 4th edn J B fro language mth f pathologizineo g Labels suc nons ha - Uppincott, Philadelphia compliant, resistan dysfunctionad an t l become irrelevant, CarroU-Johnson RM (ed) (1989) Classification of Nursing disrespectfu insultind an l g descriptors More importantly, Diagnosis Proceedings of the Eighth Conference North American Nursing Diagnosis Association LippincottB } , Philadelphia when applying Maturana's theor f meta-cogmhoo y n Maturana H (1978) Biology of language the eptstemology of to nursing practice, these behavioural descriptors are reality In Psychology and Biology of Language and Thought biologically impossible Essays m Honor of ErtcLemebergCMi&eT G kLennebergE eds), e assumptionth f o e f non-complianco On s e is that Academic Press, New York, pp 27-63 relationships between nurses and families are hierarchical Maturan (1983R aH ) What is seeo it t ? Archives of Biological (Staruh Rya& s n 1982 t woulI ) e morb d e respectful Mediant 16,255-269 mord an ethino t humbl f s ourselveko u r fo e s in non- Maturan (1985aH ) Commen Humberty b t o R. Maturane th a hierarchical collaborative relationships with families, mind is not in the head. Journal of Social and Biological Structure involvee ar tha e tw d in co-drifting with families creatinga 8,308-311 context for change rather than believing we can be change Maturana H (speaker) (1987) The Sm of Certamty (Videotape) agents University of Calgary, Calgary, Alberta. Maturan (1988aH ) Realit searce th y objectivitr hfo e th r yo quest for a compelling argument The Irish Journal of Psychology Conserve rather than change 9(1), 25-83 Maturana H fc Varela F (1992) The Tree of Knowledge The To move towards more collaborative relationships with Biological Roots tfHutnan Understanding 2nd edri New Science families, the authors often find it useful in clinical practice to Library, Boston

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Maturana H R, Lettvin J Y, McCulloch W S fc Pitts W H (1960) Wnght LM* Nagy J C (1992) Death the most troublesome and physiology of vision in the frog (Rana pipiens) family secret of all In Secreh m Families and Journal of General Physiology 43(6), 129-175 (lmber Black E ed), W W Norton, New York. Maturana H, Unbe G & Frenk S (1968) A biological theory of Wnght L M & Simpson P (1991) A systemic belief approach to relahvishc color coding e primatith n e retina Archives de epileptic seizure casa s f beineo g spellbound. Contemporary Btologta y MeAicma Expenmenlales (suppl 1), 1—30 Family Therapy An International Journal 13(2), 165—181 Mendez CL, Coddo Maturan& uF (1988H a e bringTh ) - Wngh t &LM Watson W (1988L ) Systemic family therapd yan ing fort f pathologho Inshe Th y Journal f Psychologyo 9(1), family development In Family Transitions Continuityd an 144-172 Change Over the Life Cycle (Falicov CJ ed), Guilford Press, Simon R (1985) A frog's eye view of the world Family Therapy New York, pp 407-430 Nehoorker9(3), 32, 34-35 Wnght LM, Watson WL & BeU JM (1990) The Family Stanitis M A & Ryan J (1982) Noncomphance an unacceptable Nursing Unit a unique integration of research, education, and diagnosis? American Journal of Nursing , 941-946 2 clinical practicCuttinge Th n I e Eage f Familyo Nursing (Bell Szas (1973S z SecondT e )AnchoTh m 5 r Press/Doubleday MJ , Watso fL cw Wnghn,W Ne eds)M L t , Family Nursing Unit York Publications, Calgary 95-11p ,p 2

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