Of the two dimensions I usually assess with people not working because of chronic pain, lack of importance given to returning to work is often identified by ‘onlookers’ as the main reason someone hasn’t yet returned. I don’t know how many times I’ve heard about ‘secondary gain’ getting in the way of people making progress – and yet when I look in to research into returning to work, it’s self efficacy, or confidence to successfully return to work, that has more press than any other aspect (oh, apart from physical ability vs job demands).
I’ve blogged about self efficacy several times now because it seems to be one of those factors that pops up all over the place – as Bandura himself puts it ‘Self-efficacy beliefs determine how people feel, think, motivate themselves and behave.’
I mainly look at self efficacy in terms of confidence to achieve a desired result. When I’m looking at the process of returning to work with someone, the two facets I review first-off are importance and confidence. Using the Prochaska and DiClemente transtheoretical model, both of these elements can be used to determine the stage that someone might be in terms of their readiness to take action.
Let me unpack that a little. If you recall the stages of change model, there are several stages before someone is ready to actually do something to achieve a goal. At these pre-action stages (Precontemplation, Contemplation, and Preparation), people have yet to decide whether action is the right thing to do, let alone work out how to do it.
At the Precontemplation stage, action is nowhere on the scene.
At both Contemplation and Preparation, the person is often ambivalent and maybe not yet ready to even learn what to do.
To help people work out whether they want to take action, it’s worth exploring these questions:
(1) Have they thought about returning to work at all? (Precontemplation)
(2) How important is returning to work at this stage in the person’s rehabilitation? (Contemplation)
(3) How confident is the person about actually returning to work at this point? (Contemplation)
(4) If importance is high, but confidence is not, what things are concerning the person about returning to work? (Factors that influence Preparation)
A study by Shaw & Huang (2005) showed that the areas that people are concerned about (ie, the things that reduce confidence) are divided into two main areas –
- concern about resuming physical activity, and
- concerns about resuming work.
The concerns about resuming work were divided into three main areas –
- meeting job demands,
- obtaining help, and
- coping with pain.
In fact, out of 348 statements that were coded in this study, 253 were about self efficacy, while the remaining 95 were expectations about returning to work. Expectations were around financial security, re-injury, workplace support and self-image.
So, some of the areas that may be contributing to low confidence for returning to work may be:
– can I do what I have been employed to do at work?
– can I do these tasks to the standard that my employer wants?
– can I do them as well as I want to?
– can I be reliable at work?
– can I (or do I want to) ask for, and get, help?
– can I change the physical environment at work so I can do the job?
– can I cope with the pain?
– can I prevent the pain from taking over?
– can I avoid injuring myself?
This list isn’t exhaustive, but based on Shaw & Huang’s work, covers many of the factors that people think about when they are concerned about going back to work.
Once the areas of low confidence, or concern, are identified, our job is about helping people develop confidence in those areas.
Often it is simply problem-solving ways around their concerns. Things like ensuring there is a clear description of the task demands (especially during any work trial or gradual return to work), clarifying quality requirements, ensuring reporting lines are clear, and arranging for physical environment alterations and any adaptive equipment to be available from the outset.
Other times it’s much more difficult – especially where there is a mismatch between what the client has been able to achieve in the past and what he or she can do now (this especially holds for people who push themselves to achieve well, or previously worked at 110% and now can ‘only’ manage 98%).
This may mean working through some cognitive therapy to reframe or challenge automatic thoughts, (eg ‘I’m working at this level because it’s part of my rehabilitation’ rather than ‘I must always work incredibly hard’, or ‘Most people work at 90%, and that’s all I need to achieve’, or ‘It’s OK to work at 90%, it means I can keep going for longer and be reliable the next day’).
The process of building confidence through cognitive therapy can be very challenging, especially if the person hasn’t had any exposure to CBT during their pain management rehabilitation. In fact, I often find that people may have had some CBT-based pain management, but until they reach the work environment, the real objections or core beliefs haven’t been explored, and the real ‘work’ of cognitive therapy begins only once those objections are raised.
Shaw, W., Huang, Y. (2005). Concerns and expectations about returning to work with low back pain: Identifying themes from focus groups and semi-structured interviews. Disability & Rehabilitation, 27(21), 1269-1281. DOI: 10.1080/09638280500076269
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