While the internal locus of control has been widely championed for its role in personal growth and patient empowerment, it is only one side of the story. Equally important, though often viewed more critically, is the external locus of control, the belief that outcomes are shaped by forces beyond one’s direct influence. Whether attributed to fate, luck, powerful institutions or spiritual forces, the orientation toward the world has profound implications for behaviour, especially in the area of health.

Understanding the external locus of control is essential for healthcare professionals, caregivers and policymakers alike. While it can pose challenges to the adoption of self-directed health behaviours, it can also offer meaningful psychological and cultural value. The key lies in recognising when external orientation becomes a barrier and when it provides essential coping strategies.

What is the External Locus of Control?

An external locus of control is the belief that life’s outcomes are dictated by forces outside one’s personal influence. People who lean towards an external locus of control might say:

·       It is out of my hands.

·       I will leave it in the hands of the doctor.

·       If it is meant to be, it is meant to be.

·       Bad things just seem to happen to me.

The statements are fatalistic, but they also reflect a psychological stance rooted in external attribution, such as the idea that luck, fate, powerful others or uncontrollable circumstances determine outcomes.

This worldview often develops in response to life experiences. People who were raised in environments with little personal agency, due to poverty, trauma or oppressive systems, may come to believe that effort does not change results. Similarly, within a culture, there may be values that favour the external locus: destiny, spiritual surrender, communal will, individual autonomy being quite an alien concept. These also shape the external orientation.

When the External Locus becomes problematic

In the context of healthcare, a strong external locus of control can sometimes lead to passive behaviour, especially when patients assume that their health is controlled entirely by forces beyond their control. This can reduce personal responsibility. It can diminish the motivation to consider and adopt proactive health behaviours.

Here are a few of the key challenges associated with a dominant external locus in health settings:

·       Learned Helplessness

When people repeatedly face negative outcomes despite their efforts, they may internalise the belief that nothing they do matters. This is known as learned helplessness. This is a condition associated with depression, anxiety and reduced problem-solving ability.

In healthcare, learned helplessness might manifest in patients who give up on managing chronic illness because previous attempts at change had poor results. A patient with obesity who has tried multiple diets and failed may stop trying altogether, believing that their health is predetermined.

·       Passive Patient Behaviour

Patients with a strong external locus may become over-reliant on authority figures, such as doctors or family members, to make decisions for them. While trust in healthcare providers is important, excessive passivity can undermine patient autonomy and be an obstacle to shared decision-making.

A typical pattern might emerge as follows: a doctor recommends a treatment plan and the patient agrees without asking questions, expressing concerns or fully understanding the implications. Later, confusion or non-adherence may arise because the patient never internalised the decision as their own.

·       Reduced Treatment Adherence

Believing that one’s actions do not matter can lead to poor adherence to medications, appointments and lifestyle recommendations. If outcomes are viewed as inevitable or arbitrary, there’s little incentive to stick with challenging regimes.

For example, a patient with hypertension who believes their condition is genetic or unchangeable might skip medications, fail to adjust their diet or ignore medical advice, believing nothing they do will alter their fate.

When the External Locus can be adaptive

Despite these challenges, it is a mistake to dismiss the external locus of control as inherently harmful. In some contexts, especially those where the challenges are out of a person’s control, the external orientation can serve important psychological and social functions.

In situations like terminal illness, progressive neurological disease or sudden traumatic loss, efforts to assert control can feel futile or even cruel. Here, an external locus can help people surrender to what they cannot change, reducing anxiety and emotional distress.

For example, this could help a person with advanced cancer find peace, rather than blaming themselves for treatment failure. Placing the locus externally can encourage meaningful reflection on life’s remaining moments.

Strength in Community and Spirituality

In many cultures, external control is not associated with weakness, but with connection to something larger. This could be a divine force, the will of the ancestors or collective decision-making. In collectivist societies, decisions are often made in consultation with family or community elders, and individual control may be seen as less relevant or even inappropriate.

In addition, spiritual frameworks that place value on surrender, such as in Hinduism, Islam or Christianity, can provide a sense of coherence and meaning in the face of uncertainty. This is different to promoting helplessness. This idea of surrendering oneself and the locus of control can encourage resilience, humility and compassion. This is especially so when integrated with supportive care systems.

Navigating the Tension in Medical Practice

Healthcare professionals often find themselves navigating a delicate balance between promoting patient autonomy (the internal focus) and respecting patients’ cultural or personal inclination towards external control.

This tension raises important questions, such as:

·       How can patients be empowered without undermining their beliefs and worldviews?

·       How can action be promoted while validating the need for acceptance?

·       When should self-direction be encouraged and when should surrender be supported by the health system?

A culturally sensitive approach would require healthcare professionals to assess what patients believe and, crucially, why they believe it and how those beliefs can be aligned with effective care.

Is a middle path possible?

Rather than trying to shift every patient towards an internal locus, a more nuanced goal is to integrate both perspectives. For instance:

·       Healthcare professionals could educate patients on areas where they can exert control, such as medication routines and nutrition, while acknowledging areas where control is limited, such as disease progression.

·       Shared decision-making could offer autonomy in ways that fit the patient’s worldview.

·       Health behaviours could be framed in terms of duty to community or family, rather than only self-responsibility.

Control is contextual

The external locus of control is not inherently disempowering. It depends on context. In some situation, it poses barriers to engagement, while in others it offers a lifeline of meaning and comfort.

Health systems need to recognise the complex interplay between belief and behaviour, especially in pluralistic societies. Supporting patients means not only encouraging agency but also respecting the diverse ways in which people make sense of illness and the limits of control.

Empowerment is not about forcing everyone to believe that they are in charge. It should be about helping each person to find strength in the place they are standing, whatever that context may be.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, May 2025