Journal of Advanced Nursmg, 1992,17, 913-917

The non-existence of non-compliantfamilies: the influence of HumbertoMaturana*Lorraine M WnghtRNPhDDirector, Family Nursing Unit, and Professor, Faculty of Nursmg, University of Calgary

and Anne Mane C Levac RN MNFamily Clinical Nurse Specialist, Calgary, Alberta, Canada

Accepted for publication 2 December 1991

WRIGHT L M & LEVAC A.M C (1992) /OMfTW/ of Advanced Nursing 17, 913-917The non-existence of non-compliant families: the influence of HumbertoMaturanaNon-compliance is not only an epistemological error but a biologicalimpossibility This profound statement arises from the influence of HumbertoMaturana's revolutionary meta-theory of cognition The definitions andsignificant implications of two major theoretical concepts of this meta-theory ofcognition, namely structural determinism and objechvity-in-parenthesis, arediscussed These radical concepts challenge the approved North AmericanNursing Diagnostic Association's nursing diagnosis of non-complianceMaturana's theory reveals the impossibility of instructive interaction, leading theauthors to conclude the non-existence of non-compliant families

INTRODUCTION hce, the nursing diagnosis of 'non-compliance' is not onlyan epistemological error but a biological impossibility

In the nursing of families, expectabons exist that families -^ revoluhonary theory mvjtes nurses to re^xainmew,U comply with ideas and advice that could promote, ^ assumphons about ̂ ̂ ^ of non<ompliance

mamtainand/orrestoretheirhealthWhenfarruhesarenot ^ ̂ ^ North ̂ ^ Nursmg Diagnoshc

compliant with nursing interventions, nurses frequently A58003110n-,. ̂ A^D ̂ classification system It has radicalinterpret this behaviour as an unwillingness or a lack of ^^ ̂ ethjcal hcahons for nursmg prachcereadiness to change This linear view implies that problemswith adherence to treatment regimens reside within indi-viduals and families, not in the interactions or relationships THE CONCEPT OF STRUCTURALbetween individuals In the authors' opinion, it is arrogant, DETERMINISMinsulting and violent to label farruhes as non-comphant A major proposition of this theory is that all living systems,

However^fnurseschoosetoapplysomeoftheideasof ,̂̂ humang ^ structural]y detenruned It 1S theChilean biologist Humberto Maturana, such descnphons ^^j^ structure ̂ bstory of mterachons thatas non-comphant, resistant and unmofavated are ques- ^^^ dm^ m his/her state or a ̂ ^^ m his/herhoned Based on the science of biology, Maturana (1978 ^^ It „ nol nurses that determme or direct ̂ ^ge1983, 1985, 1988) offers an mtnguing meta-theory of M3n^5 ̂ .^Ty of cognition evolved from thecognition When this theory is applied to nursing prac- most ̂ ^ of expenments expenments examining the

structural mechanism of percephon in frogs Maturanaefa/. fbrffawt Ongon, May JWi ^1 r , (1960) discovered that the 'function of the retina in the frog

ComspanttiKt Praetor LM Wnght Faculty of Nmmg, Lhaveraly of Calgary, ^ »2500 Unvtmty Dntit NW, Calgary. *&**« ™ J^4- Cana*L K not to t"11150111 information They further concluded that

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'the transformation of the image {not transmission of theimage] constitutes the fundamental function of the retina'What a frog perceives visually has been transformed by theretina in a manner that is specific to the organization of thefrog's nervous system Thus, perception is not a picture ofthe world coming in and recording on the frog's brain(Simon 1985) but rather it is the frog's structure whichdetermines its own reality

Maturana et al (1968), when describing a biologicaltheory of colour coding in the pnmate retina, concludedthat the activities of a nervous system do not reflect anindependent environment and therefore do not reflectan absolute external world Maturana and his colleagues(1968) also concluded that an animal's interactions with anenvironment were best represented by the animal's ownorganization and not by an independent external realitySince the basic architecture of the nervous system isuniversal, Maturana extended his earlier ideas related tothe visual perception of frogs to the perceptual processof primates, which of course includes human beings Whatis perceived by an individual is always a result oftransformation within the structure of the individual

The revelation that all living systems cannot refer to anexternal, independent reahty becomes not onh/ a philo-sophical reflection but a constitutive biological conditionof humanity (Mendez et al 1988) The uniqueness ofMaturana's theory is that it reflects an epistemology inwhich individuals (living systems) draw forth reahty —they do not construct it nor does it exist independentlyof them (Maturana 1988) Therefore, change or learningoccurs in humans from moment to moment, either asa change triggered by interaction(s) or 'perturbations'coming from the environment in which it exists or as aresult of its own internal dynamics It is the history andstructure of the living system that determines whichperturbations can trigger changes of state

EXPLANATIONS OF OUR WORLD

Maturana offers the idea that there are two possibleavenues for explaining our world objectivity andobjecti vi ty-in-parenthesis

Objectivity

This view assumes that there is one ultimate domain ofreference for explaining our world Within this domain,entities are assumed to exist independently of the individ-ual Such entities are as numerous and broad as imaginationmight allow and may be explicitly or implicitly identified as

objects such as 'truth', 'mind', 'knowledge', and so onThese entities are used to justify and validate explanationsIn this avenue of explanation, we come to believe that wehave access to an objective reality

Knowledge about the 'truth' by one person becomes ademand for obedience by another, for example, a nurse'sexpectation of compliance by families Maturana (1987)claims that the view of an objective reality entails thepossibility of conflict (a mutual negahon) which may leadto emotional contradiction An act of 'violence' which is'holding one's opinion to be true such that another's mustchange' (Maturana 1987) may result from conversationwhich is based on descriptions of 'truth'

The label of non-compliance arises in this domain ofexplanation Non-compliance is one of the NANDAapproved nursing diagnoses under the category of'Choosing' (Carroll-Johnson 1989, Carpemto 1991)Specifically, it has been denned as 'a person's informeddecision not to adhere to a therapeutic recommendation'(Carroll-Johnson 1989) When nurses operate in the domainof objectivity or empiricism, they believe and behave as ifthey have access to an objective reality, that is, that theirobservations/assessment of a family member's behavioursare 'true' Consequently, within this domain, nurses can fallinto the trap of believing that individuals and families arenon-compliant and that families should adhere to nurses'advice and opinions They also invite the possibility ofconflict and violence between them and their patients

Objectivity-in-parenthesis

When objectivity is placed in parenthesis, nurses recognizethat objects do exist but are not independent of the livingsystem that brings them forth The only truths which existare those drawn forth by observers, such as nurses Withoutobservers nothing can be said, nothing can be explained,nothing can be claimed in fact, without observersnothing exists because existence is specified in theoperation of distinction of the observer' (Maturana 1988)Distinctions made by an observer of what appears to bestimulus (input) and response (output) of the nervoussystems is not a property of the nervous system, but rathera property of the domain of observations Thus, brain andbehaviour are only linked in the eyes of the observer AsMaturana (1985) states, 'the mind is not in the head, it is inthe behavior1

Drawing distinctions is the basic cognitive operation ofthe observer Cognition may be defined as the act or pro-cess of knowing including both awareness and judgementCognition is not a representation of the world 'out there',

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but rather an ongoing bringing forth of a world through theprocess of living itself Therefore, it is always in our co-existence with others that we are bringing forth realityHumans literally create the world in which they live while co-existing and co-dnfhng with other human beings It is humanactivity which brings forth and validates human activity

Maturana (1988) claims that we exist in domains thatwe bring forth through living and 'they are domains ofrealities, domains of explanations that we present forexplaining our experience, in the understanding that wecannot claim anything about an independent reality' Everyexplanation is a reformulation of our experience Ourexplanations are conveyed through narratives which embedthe meanings (beliefs) we have about our experiences It isthese beliefs that nurses' clients have about their experi-ences — such as chronic or life-threatening illness — thatare central to how they cope with them

In applying this idea to the nursing of families, everyfamily member has his or her own reality or perspective ofhis/her experience of illness Nurses need to encourage theexpression of each family member's reality For example, ifeach family member is asked, What is your point of viewon how your mother is coping with her multiple sclerosis?,many different perspectives or realities will be drawn forthBased on the concept of structural determinism, eachreality must be considered as 'true, valid and legitimate

The idea that humans bring different perspectives totheir understanding of events is not new But Maturana'sperspective on observations is much more radical it is basedon biology and physiology, not philosophy Maturanastates that not only do we have different views or perspec-tives on a given event but that the event itself has noexistence separate from our ability to distinguish it inwords and symbols (Maturana & Varela 1992) One's viewis not a distortion of some presumably correct interpretionInstead of one objective universe waiting to be discoveredor correctly described, Maturana proposes a 'mulhverse',where many observer 'verses' co-exist, each valid in itsown right

Mendezrfa/ (1988) state

If we claim that the biology of the phenomenon of cogni-tion demands that we operate with objectivity-in-parenthesis,then we can no longer keep the notion that we have alegitimate transconsensual authonty of power to decide whathappens to another human being, based on the demand forobedience that the claim of objective knowledge entailsIndeed, putting objectivity m parenthesis entails the explicitrecognition that the desirability or undesirability of any givenbehavior is socially determined and that we cannot go claim-ing that something is good or bad, healthy or unhealthy initself, as if these were intrinsic constitutive features of it

Within the domain of objectivity-in-parenthesis, wecannot claim that a family is non-compliant Therefore,nursing assessments are based on observer perspectivesand not ultimate truths

THE IMPOSSIBILITY OF INSTRUCTIVEINTERACTION

Instructive interaction implies that a living system is able toreceive instructions from the environment, in the form ofinformation to be processed (Aboihz 1985) It assumes thatindividuals can specify structural changes in other indi-viduals through instruction Maturana & Varela (1992)make the startling declaration that there cannot be aninstructive interaction This notion emerges from the cen-tral assumption that living systems are self-organizing Thenervous system is an infonnationally and operationallyclosed system As a closed system, it is the nervous systemthat determines the changes of relative neuronal activity,it is not the perturbation that determines the state ofthe nervous system Information or instruction cannot beimported onto someone, it can only be offered as part of aninteraction How an individual responds will be determinedby their structure at that point in time If living systemswere 'mstructable' they would all respond the same to agiven perturbation It is the system in constant interactionwith its medium that specifies how it will behave, not theinformation or instruction

Structural changes in living systems are unique andare dependent on the phylogemc history (genehc orevolutionary history) or ontogemc history (all the paststructural changes or history of interactions) in the lifeof the organism Thus, changes in family members aredetermined by their own structures and not by othersTherefore, nurses are not change agents they cannot anddo not change anyone

A scenario

Consider the following scenario A cardiovascular clinicalnurse specialist (CNS) conducts a weekly smoking cessahonclinic for cardiovascular patients and their families TheCNS provides relevant literature informing her cardiacpatients about the nsks of smoking and promotes a varietyof strategies for patients to decrease and eliminate smokingbehaviour She is puzzled by the wide range of responses toher nursing interventions some patients stopped smokingalmost immediately, others decreased their smoking behav-iour, while still others remained firm in old smoking habitsClients who fall into this latter category may be quickly

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labelled as 'non-compliant' However, an implication ofMaturana & Varela's (1992) theory is to recognize thatsuch clients are not 'non-compliant' but rather have notselected a particular novel perturbation which invites themto decrease their smoking

THE POSSIBILITY OF COLLABORATIVEINTERACTION

If instructive interaction cannot exist, how can we asnurses impart ideas about health promotion and healthrestoration? Maturana offered the following suggestion.

You will never be able to do instructive interaction The mostthat you can do is to talk to the patient and invite this personto a reflection that will allow the realization that there is anillness and that there are certain actions that he or she has totake You cannot force the other to an understanding

(H R Maturana, personal communication, October 1988)

Inviting individuals and families to a reflection can beaccomplished by creating a context for change, creating anenvironment in which persons change themselves, offeringideas, advice and suggestions that can serve as usefulperturbations By remaining cunous about family mem-bers' beliefs about their illness, nurses can help patients andtheir families to discover which perturbations (ieinterventions) will trigger structural changes which willresult in more effective responses to health problems

Through collaborative interaction with families, nursescan also eliminate what has been called the language ofloathing' (Szasz 1973) and liberate themselves and familiesfrom the language of pathologizing Labels such as non-compliant, resistant and dysfunctional become irrelevant,disrespectful and insulting descriptors More importantly,when applying Maturana's theory of meta-cogmhonto nursing practice, these behavioural descriptors arebiologically impossible

One of the assumptions of non-compliance is thatrelationships between nurses and families are hierarchical(Staruhs & Ryan 1982) It would be more respectfuland more humble for us to think of ourselves in non-hierarchical collaborative relationships with families,that we are involved in co-drifting with families creating acontext for change rather than believing we can be changeagents

Conserve rather than change

To move towards more collaborative relationships withfamilies, the authors often find it useful in clinical practice to

ask families what they would like to conserve rather thanwhat they want to change This is also a very useful inter-vention on themselves as family nurse clinicians (Wnghtet al 1990) They attempt to design interventions whichinvite families to a reflection (Wnght & Nagy 1992, Wnghtt Sunpson 1991, Wnght It Watson 1988) Interventionswhich invite reflection have the potential of being selectedperturbations Family members who respond to particularperturbations (i e therapeutic interventions) do so becauseof the fit between the perturbation and their structure

CONCLUSIONOne question still remains Are there nsks of being tooenraptured with Maturana's meta-theory of cognition?The authors believe one nsk of embracing Maturana'stheory with overwhelming enthusiasm is that nurseswould behave with too much certainty If they are tooenthusiastic or certain about Maturana's theory, it becomestoo 'true' This 'truth' becomes a tyranny because we endup submitting to an external 'truth' which is the very ideathat Maturana is challenging However, there is oneoccasion when nurses need wholeheartedly to embraceMaturana's theory, that is, whenever they encounter theimpulse to pathologize families as non-compliant

References

Aboitiz F (1985) A antique of the modem concept oflocalization Journal of Social and Biological Structure 8,307-312

Carperuto LJ (1991) Handbook of Nursing Diagnosis 4th edn J BUppincott, Philadelphia

CarroU-Johnson RM (ed) (1989) Classification of NursingDiagnosis Proceedings of the Eighth Conference North AmericanNursing Diagnosis Association } B Lippincott, Philadelphia

Maturana H (1978) Biology of language the eptstemology ofreality In Psychology and Biology of Language and ThoughtEssays m Honor of ErtcLemebergCMi&eT G kLennebergE eds),Academic Press, New York, pp 27-63

Maturana H R (1983) What is it to see? Archives of BiologicalMediant 16,255-269

Maturana H (1985) Comment by Humberto R. Maturana themind is not in the head. Journal of Social and Biological Structure8,308-311

Maturana H (speaker) (1987) The Sm of Certamty (Videotape)University of Calgary, Calgary, Alberta.

Maturana H (1988) Reality the search for objectivity or thequest for a compelling argument The Irish Journal of Psychology9(1), 25-83

Maturana H fc Varela F (1992) The Tree of Knowledge TheBiological Roots tfHutnan Understanding 2nd edri New ScienceLibrary, Boston

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Maturana H R, Lettvin J Y, McCulloch W S fc Pitts W H (1960) Wnght L M * Nagy J C (1992) Death the most troublesomeAnatomy and physiology of vision in the frog (Rana pipiens) family secret of all In Secreh m Families and Family TherapyJournal 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 torelahvishc color coding in the primate retina Archives de epileptic seizures a case of being spellbound. ContemporaryBtologta y MeAicma Expenmenlales (suppl 1), 1—30 Family Therapy An International Journal 13(2), 165—181

Mendez CL, Coddou F & Maturana H (1988) The bring- Wnght L M & Watson W L (1988) Systemic family therapy anding forth of pathology The Insh Journal of Psychology 9(1), family development In Family Transitions Continuity and144-172 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 407-430Nehoorker9(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, anddiagnosis? American Journal of Nursing 6, 941-942 clinical practice In The Cutting Eage of Family Nursing (Bell

Szasz T S (1973) The Second 5m Anchor Press/Doubleday, New J M, Watson W L fc Wnght L M eds), Family Nursing UnitYork Publications, Calgary, pp 95-112

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