self efficacy

Always look on the bright side of life!

Anyone who is older than, say, 40 years old, should be whistling right now…

For some time now I’ve been interested in how people who cope well with pain go about their daily lives. What makes this group of people different from the ones we more often see? While I know from my own research that there’s a process to get to where living life outweighs putting all the emphasis on finding a cure (note: this doesn’t mean giving up on a cure, it just means it’s a different priority), there is some research showing that how we view a situation (either as a challenge – or not) plays a role in how well we deal with it (Lazarus & Folkman, 1984).

The theory goes something like this: resilience people view pain as a challenge and believe that they have the resources to cope with it, and as a result they experience less disability and distress.

There has been a reasonable interest in resilience in coping with persistent pain since Karoly and Ruehlman (2006) found that a small but reasonable-sized group of people report moderate to severe levels of pain intensity, but don’t report high levels of interference or emotional burden. It’s thought that instead of avoiding movements or activities that are painful, this group of people may feel fear – but go on to “confront” or at least willingly experience pain as part of their recovery. What hasn’t been as well-understood is whether resilience is associated with perceiving pain as a challenge, and therefore people are more likely to do things that may hurt, or whether people believe they can face the demands of experiencing pain (ie they have self efficacy for managing pain) and this is the path by which they get on with life.

This study was carried out in mainland China, and is for this reason alone, is an interesting study (most of our understanding about pain comes from the US, Canada, Australia and the UK). China also faces an enormous burden from people being disabled by chronic pain, so this is a good step forward to understanding what might support living well with pain in this highly populated country.

The study is by Shuanghong Chen and Todd Jackson, and published last year in the journal Rehabilitation Psychology. The authors recruited 307 Chinese adults with chronic back pain (189 women, 118 men), and asked them to complete a batch of questionnaires: Connor-Davidson Resilience Scale (Chinese); Pain Appraisal Inventory (Short-form) Challenge; Pain Self-Efficacy Questionnaire; The catastrophising subscale of the Coping Strategies Questionnaire, the Chronic Pain Grade; The Multidimensional Pain Inventory-Screening (Affective Distress) subscale; and the Center for Epidemiologic Studies Depression Scale. Participants were recruited from large residential settings close to the university and two local hospitals, and participants needed to be at least 18 years old with back pain of at least 3 months duration. All the questionnaires were translated into Mandarin using back-translation. This was a cross-sectional design, so all the measures were taken at one time, and analysis performed across the group. It’s not possible, therefore, to determine causal relations, and all the calculations were carried out using structural equation modeling, therefore correlational relationships only.

What did they find out?

High resilience levels were related to elevations in primary appraisals of pain as a challenge, and in turn, higher resilience and challenge appraisal scores were each related to higher scores on the secondary appraisal measure of pain self-efficacy beliefs. Those with high scores on resilience and pain self-efficacy tended to score lower on the secondary appraisal measure of pain catastrophising. When analysing the path it was found that challenge appraisals didn’t reach significance with catastrophising or pain-related disability (such as scores on Chronic Pain Grade, Affective Distress, or Depression). Higher scores on resilience and pain self-efficacy as well as reductions in pain catastrophising were associated with lower overall dysfunction scores (Chronic Pain Grade, Affective Distress, and Depression).

Interestingly, the authors tested to see whether pain self-efficacy and pain catastrophising had a bidirectional relationship with one another – they found that yes, this did have a good fit with the data but the resilience-catastrophising path was strong than the path in the original model, while the bidirectional self-efficacy-catastrophising path was slightly less strongly associated compare with the other model.

What does all this mean for us?

Well it seems that while we attend to negative features of a person’s presentation, from this study it looks like the relationship between positive aspects (such as not thinking of pain as an incredibly negative thing (catastrophising) and believing that yes I do have resources sufficient to cope with pain) is more predictive of outcomes than simply looking at catastrophising alone. However – pain self-efficacy and pain catastrophising and poorer coping have been found significant, while general resilience (appraising pain itself as a challenge, or not) and appraising pain itself as a challenge is less strongly associated. What this suggests is that increasing a person’s beliefs that they have the capability to cope (ie self-efficacy) despite pain needs to be a priority in pain rehabilitation.

To me this is an important finding. When we as therapists attribute change in function to either less pain, or to our efforts (or the treatments, eg injections, pills, special exercises, super-duper techniques that we use), we fail to foster or support self-efficacy. Self-efficacy is a slippery concept: the measure indicates confidence to engage in activities despite pain. If our treatments focus on reducing pain intensity and don’t support the person being able to do things despite their pain, we’re likely not helping them become more confident, especially in the future.

This doesn’t mean we should tell people to “suck it up, Buttercup”. It does mean we should help people identify the strategies they have (or can develop) to be able to continue with activity in the face of pain fluctuations. Of course this means we need to be comfortable with the idea that it’s OK to do things despite pain! If we still hold a sneaky suspicion that it’s not OK to be sore and do things, we’re likely to inadvertently (or perhaps overtly) encourage people to ease up, back off, or generally stop when they’re sore. Asking people how sore they are at each treatment is likely not to increase confidence that it’s OK to move. Commiserating over how painful it is and how tough it is may be unhelpful!

What can we do instead?

I think we can draw a lot from motivational interviewing. No, not the stages of change, but the part where we acknowledge that despite it being difficult, the person did something that moved them towards a more positive choice. What this might look like is “Hey you had a tough week, but it’s fantastic that you made it here today so we can look at what you carried on with”. It might include “While it’s been a flare-up week for you, you were still aware of your goals and had a go”. Or “Look at how you stayed the course despite the bumps in the road”.

Sticking with the idea that actions, or habits count more than results can be useful, because we’re helping people build long-term lifestyle changes that will sustain them over time. Yes, results are really cool and we want to see them (so don’t stop recording wins!), but at the same time, it’s vital we celebrate the daily choices a person makes to keep going and doing.

I think we can also help build self-efficacy by drawing on pain heroes. People who have maintained a good lifestyle despite their pain. Celebrating those who are grinding through, even though they have tough times. Perhaps other people in the clinic who are also managing pain. From self-efficacy research we know that vicarious learning (watching how others perform in the same situation) is one of the ways we boost our confidence to succeed. Group-work may be a useful approach for encouraging people to know they’re not alone, they can make progress, and that they’re doing OK.

So…. looking on the bright side of life doesn’t mean ignoring challenges, but it does mean viewing them as challenges rather than insurmountable obstacles. Our approach to pain – is it something to get rid of, or is it something to learn from and something we can manage – may give people encouragement to persist, or it may undermine coping. What’s your view?

Chen, S., & Jackson, T. (2018). Pain Beliefs Mediate Relations Between General Resilience and Dysfunction From Chronic Back Pain. Rehabilitation Psychology, 63(4), 604–611.

Karoly, P., & Ruehlman, L. S. (2006). Psychological “resilience” and its correlates in chronic pain: Findings from a national community sample. Pain, 123, 90–97.

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer.

Each time we face our fear, we gain strength, courage, and confidence in the doing – Theodore Roosevelt

I’m not certain Theodore Roosevelt actually said that – but who cares?! It’s a great statement. For the person living with persistent pain, though, it can be the last thing you want to hear. After all, it’s tough enough getting up and just doing the normal things let alone challenge yourself! So… how can a health professional help?

Let’s briefly recap. Self efficacy is the confidence I can do something successfully if I wanted to. It’s a robust predictor of many health behaviours including exercise, stopping smoking, eating healthily and coping well with persistent pain (Jackson, Wang, Wang & Fan, 2014; Williams & Rhodes, 2016). It was first introduced as a concept by Bandura as part of his theoretical model of behaviour change, and further discussed in an experimental study in a paper investigating systematic desensitisation processes, arguing that this approach to treatment created and strengthened expectations of personal efficacy (Bandura & Adams, 1977). Bandura argued that people develop a sense (expectation) of self efficacy from their own performance, watching others succeed, being persuaded by someone that yes indeed you have the skills to achieve, and also awareness of physiological arousal from which people can judge their own level of anxiety.

Self efficacy is more than a simple “general confidence” construct, however. It’s far more selective than this. For example, although I believe I can successfully dance in my lounge with no-one there and the curtains closed, this does not translate to me dancing on a stage on my own in the spotlights with an audience watching! Self efficacy refers to confidence to succeed and produce the outcome I desire in a given context – and that’s extremely important for pain management, and in particular, exercise for people experiencing pain.

How does self efficacy improve outcomes? There are at least two ways: (1) through the actions taken to manage or control pain (for example, gradually increasing activity levels but not doing too much) and (2) managing the situations associated with pain (for example, people with low self efficacy may avoid activities that increase pain, or cope by using more medication (Jackson, Wang, Wang & Fan, 2014).

To examine how self efficacy affects outcomes, Jackson and colleagues (2014) conducted a meta-analysis of papers examining this variable along with other important outcomes. Overall effect sizes for relationships between self efficacy and all chronic pain outcomes were medium and highly significant. This is really important stuff – we don’t find all that many studies where a single variable has this much predictive power!

As a moderator, the adjusted overall effect size (r=.50) of self efficacy and impairment was larger than the average effect sizes of meta-analyses on relations between disability and fear-avoidance beliefs, and pain as a threat for future damage and challenge for future opportunities. Self efficacy has stronger links with impairment than cognitive factors such as fear-avoidance beliefs and primary appraisals of pain (Jackson, Wang, Wang & Fan, 2014).  Age and duration of pain were the strongest moderators of these associations and suggest that reduced self-efficacy can become entrenched over time. In other words – as time passes, people experience fewer opportunities for success and begin to expect they won’t ever manage their pain well.

An important point is made by these authors: how we measure self efficacy matters. They found that self efficacy measures tapping “confidence in the capacity to function despite pain” had
stronger associations with impairment than did those assessing confidence in controlling pain or managing other symptoms.

Bolstering self efficacy – not just about telling people they can do it!

Given that self efficacy is domain-specific, or a construct that refers to confidence to do actions that lead to success in specified situations, here are a few of my questions:

  • Why are most people attending pain management programmes provided with gym-based programmes that don’t look at lot like the kinds of things people have to do in daily life? It’s like there’s an expectation that “doing exercise” – any exercise – is enough to improve a person’s capabilities.

    BUT while this might increase my confidence to (a) do exercise and (b) do it in a gym – but does it mean I’ll be more confident to return to work? Or do my housework?

  • How often are people attending gyms told to “push on”, or to “stop if it hurts”? And what effect does this have on people?

If their confidence is low, being told “just do it” is NOT likely to work. People need to experience that it’s possible to do things despite pain – and I think, to be able to handle a flare-up successfully. Now this is not going to happen if we adopt the line that getting rid of all pain is the aim, and that flare-ups should be avoided. If we want people to deal successfully with the inevitable flare-ups that occur, especially with low back pain, then we need to (a) be gentle, and grade the activities in an appropriate way (b) have some “ways of coping” we can introduce to people rather than simply telling them they can cope or reducing the demands (c) have other people around them also coping well (and that includes us health professionals)

  • Ensure we attribute change to the person, not to us.

That’s right: not to our sparkling personality, not to our special exercises, not to the machines we use, not to the techniques we have – you get the drift? Progress must be attributed to the person and his or her skills and perseverance. Because, seriously, all this arguing over which exercise regime is best doesn’t stack up when it’s actually self efficacy that predicts a good outcome.

And for case managers who may read this: just because someone has successfully completed an exercise programme, or a vocational programme with exercise as a component, this does not mean the person can manage successfully at work. Well, they may manage – but they may utterly lack confidence that they can. Context matters.


Bandura, A., & Adams, N. E. (1977). Analysis of self-efficacy theory of behavioral change. Cognitive Therapy and Research, 1(4), 287-310.

Estlander AM, Takala EP, Viikari-Juntura E., (1998). Do psychological factors predict changes in musculoskeletal pain? A prospective, two-year follow-up study of a working population. Journal of Occupational and Environmental Medicine 40:445-453

Jackson, T., Wang, Y., Wang, Y., & Fan, H. (2014). Self-efficacy and chronic pain outcomes: A meta-analytic review. The Journal of Pain, 15(8), 800-814.

Williams, D. M., & Rhodes, R. E. (2016). The confounded self-efficacy construct: Conceptual analysis and recommendations for future research. Health Psychology Review, 10(2), 113-128.

Accentuate the positive
How often do we spend most of our assessment time looking at people’s problems, deficits, functional difficulties? I know that much of my time in assessment involves looking across a range of domains and experiences – and whooops! by the time we come to an end I’ve hardly looked at what this person has continued doing despite their pain and distress. After reading this 2005 paper by Tedeshi and Kilmer I’m ready to re-orient myself and review the structure of my assessment interview to see how I can integrate the resources and strengths that a person brings into the situation.

There are three main areas that Tedeshci and Kilmer identify as useful to explore when looking at the positives of an individual:

Strengths – ‘the measurement of thos eemotional and behavioural skills, competencies and characteristics that create a sense of personal accomplishment; contribute to satisfying relationships with family members … enhance ones ability to deal with adversity and stress; and promote one’s personal, social and academic development’ (Epstien and Sharma (1998).

Resilience‘attributes or characteristics that might include positive temperament,  self efficacy, positive self worth; problem solving skills; internal locus of control’ along with ‘a warm family environment, sound relationships’ and ‘good supports within the community, connections to school and work’ (Tedeschi and Kilmer, 2005).  In other words, things that help people ‘bounce back’ under adversity.

Growth – this area refers to ‘positive changes in individuals that occur as the result of attempts to cope in the aftermath of traumatic life events…become transformed by their struggles with adversity’ (Tedeschi and Kilmer, 2005).

Something I have emphasised in my work with people living wih chronic pain is that everything they have ever done to cope with or manage their situation has both positive and not so positive aspects to it.  We need to remember that people don’t deliberately set out to fail or have negative consequences. Typically the short-term consequences, if not helpful or positive, at least avoid the immediate negative emotional impact of a situation.  It’s the longer-term consequences that often cause the problems!  Something I can readily appreciate is how a person can choose a course of action believing that it is the ‘right’ path, such as resting or over-using medication or avoiding certain movements – it does stop pain! But of course, we know what happens over time…

So in looking at strengths, perhaps some of what we might view as a negative – for example, the ‘boom and bust’ pattern of activity – could in fact be a strength.  The person who does this may well be very good at task persistence, sticking to a quite difficult activity until it’s done, perhaps even have very high standards and values, but simply be misapplying this to the activity, and failing to manage the long term consequences.

I’m sure we can all appreciate how recognising and affirming strengths might help develop rapport, increase the person’s sense of personal competence, and improve ‘motivation’.  It may help move us from trying to ‘fix’ a problem to building a solution or enhancing a characteristic that already exists.

A couple of questions that might help us assess strengths (and I’ve modified these from Tedeschi and Kilmer):

  1. Let’s talk for a while about what you’ve managed to keep doing despite your pain.
  2. Tell me what you’re good at and what makes you proud
  3. How do you keep doing important things when your pain is bad?

Resilience can act as a protective factor when people are exposed to stress, it’s often described in terms of flexibility, and can reflect the interaction between the individual, the family and the community.  Tedeschi and Kilmer suggest that ‘rather than viewing a goal of evaluation as assessing resilience per se, it may be more appropraitely framed as seeking to assess factors associated with positive adjustment, competence in core domains, and healthy outcomes under adversity.’ (Tedeschi and Kilmer, 2005).

In pain management, we’re most often looking at self efficacy for managing pain – something like Mike Nicholas’ Pain Self Efficacy Questionnaire can be helpful to establish ‘what can you still do despite your pain’.  Some other questions based on those suggested in this paper are:

  1. How do you go about doing things when times are challenging?
  2. What do you do to figure out something by yourself?
  3. What do you do when you’re faced with a problem or stressful situation? How do you handle it?
  4. What is getting you through this tough situation?

These questions might highlight areas to draw upon when extending the person’s coping framework – do they have certain people or agencies that help? Do they have a core set of problem solving strategies that could be extended to deal with chronic pain? Do they already have skills they use in a helpful way?

Growth – it’s not often that we hear about how chronic pain can help a person grow and develop. I know I’ve heard about the positives from having depression, and I know I’ve experienced this myself, but I can’t say I’ve heard many people talk about the good things they have experienced or the way they have been transformed by their pain.  However, if we take a good hard look at what can happen as a result of facing tough times, I think it’s clear there are some good things – like knowing you do have strength, like valuing time out and family, like recognising vulnerability and appreciating the ‘little things’ in life.  Some people have told me that by stopping work they’ve lost their sense of self identity as a worker – but gained a sense of being a person within a community or family.

Tedeschi and Kilmer note that people who report positive growth after adversity ‘may not be able to leave all of their distress behind.’  They go on to say ‘many indicate that they are still suffering from the aftermath of trauma.’  There are, however, five domains of possible growth after trauma that can be assessed – improved relationships, new possibilities for one’s life, a greater appreciation for life, a greater sense of personal strength, and spiritual development.  And yes, some of these are areas that people I’ve worked with have said they now appreciate more deeply – and don’t take for granted any more.

I hope this brief tour through areas of positive psychology might tantalise – perhaps we’ll stroll through the sunny side of the street this week.  Let’s accentuate the positive today!

Tedeschi, R., & Kilmer, R. (2005). Assessing Strengths, Resilience, and Growth to Guide Clinical Interventions. Professional Psychology: Research and Practice, 36 (3), 230-237 DOI: 10.1037/0735-7028.36.3.230

The gap between pain management – and returning to work

One of the most satisfying experiences I have in my job is seeing someone who has been off work for ages finally return to work.  It’s like seeing the person open up and bloom again. 

I often see people who have been off work for several years – most of them don’t have jobs to return to, and most of them have experienced a couple of attempts to return to work that have, for some reason or another, failed.  Often pain is given the blame for this, and the remedy is thought to be ‘develop pain management skills’ – and I guess in part that’s true.  But not completely.

There is a difference between using pain management skills at home, where for the most part, activities can be picked up and put down as needed, and at work where other demands are present.  There’s an element of discretion about when and how things are done at home.  People can, if they want to, take it a bit quietly on days when their pain is worse, and fit things in more readily on days when they’re feeling better.  Not so at work!  At work we have to do things to fit into an external timetable – deadlines exist! There are jobs we have to do that are not so forgiving – we have to do them in a certain way, or at a certain time whether we’re feeling great or not.

And therein lies the one of the reasons I think there is a gap between pain management and returning to work.  There’s a whole lot more riding on being able to keep going at work.

Let’s take a case like Allan.  Allan has been off work for three years now.  Before his accident he’d been working for two years as a night supervisor in a food production factory, and before that he’d been the primary caregiver for his wee girl who is now 8 years old.  And before that he’d been a professional athlete.

When he hurt his back he thought it would resolve quickly – but after a series of unsuccessful nerve blocks attempting to ‘find and obliterate the cause’ of his pain, and after two multidisciplinary physical rehabilitation programmes, he finally had to accept that his back pain wasn’t going to just go away.

He lost his job after he tried to return to work for about six weeks on a graduated return to work programme.  Allan had an occupational therapist visit his work place and was advised that he could do X, Y and Z tasks – but this wasn’t practical given the nature of the work, not even as a supernumerary.  Like many employers, his employer didn’t have any ‘selected duties’, and needed to employ someone else to cover Allan’s shift, and eventually told Allan that he couldn’t come back to work until he could manage certain tasks.  Allan’s employer terminated his employment after both of them decided that he wasn’t going to make it back in the next two or three months.

Allan was finally referred for pain management, and attended a three week interdisciplinary pain management programme.  He struggled with many of the concepts, particularly activity regulation (pacing was his least favourite word!), and he experienced panic when trying to use relaxation techniques.  He had been using a walking stick, and although he tried to stop using it during the programme, shortly afterwards he fell, and the stick became an ongoing fixture.  Allan was trying very hard to learn how to do things differently – but needed another twelve week programme of pain management using a cognitive behavioural approach before he could consistently maintain even his normal home activities.

Work was out of the question initially.  Allan’s confidence was shot – he knew he could do ‘some’ pain management, but much of what he did involved minimising fluctuations in pain, and when he did have an increase in pain he’d either push himself very hard to ‘get the job done’, or he’d use medications or rest to get through the tough patch.

Let’s make one thing clear, Allan really wanted to go back to work.  He told me he felt worthless, not a ‘real man’ because he wasn’t providing for his family and he felt trapped in his own home.  His confidence though, was at rock bottom.

The specific issues he saw as obstacles to going back to work were:

  1. Managing his pain without resorting to prn medication
  2. Coping with the side effects of his medication
  3. Confidence to tell an employer that he would be reliable
  4. Confidence he could be reliable and work consistently
  5. Confidence to be assertive and let others know what he could and could not do
  6. Worry that he would increase his pain and the other important aspects of his life would be under strain
  7. Feeling out of touch with the technology and specific skills in the workplace
  8. Not knowing how to present himself positively in a job interview – how would he answer those tricky questions about the time he’s had off work and about his health?
  9. Knowing his own functional abilities – he knew what he couldn’t do, but not what he could rely on doing consistently
  10. Identifying specific job options now that he couldn’t work the way he used to

You can see that the gap is not just about job seeking skills, although that’s certainly a part of it, but it’s also about how to use his skills to be reliable at work – to experience pain but persist and be consistent with his output.

How confusing it would be for Allan to be seen by a vocational provider who had a limited knowledge of chronic pain management.  How scary would it be for Allan to start to return to work after having failed in the past.  How demeaning to feel inadequate about his own skills and lack confidence to ask for help not only with every day work technology, but also with his pain (after all, that’s what lead to his loss of job early on).

The literature on returning to work after illness or injury is clear.  It’s not simply about coping with pain, it’s not simply about coping with disability, it’s not just about finding work, it’s not just about the person with the pain problem.  Vocational management is anything that helps a person remain at work or return to work – and it includes all of us on the team, including the employer.

For the most extensive review on vocational management that has been published recently, go to here for the executive summary of the report into vocational rehabilitation ‘What works for Whom’ by Waddell, Burton & Kendall (2008). 

Go here for a great set of downloadable documents about work and health (Working for Health, UK government)

And of course, RTW Matters  (Australasian) and ACC (New Zealand) Return to Work search page

“I thought if I held out long enough, someone would find a cure”

I’ve written about acceptance before (here) , (here) oh and (here) – it’s one of those topics that seems to come up again and again (or is that ‘cos I’m looking for it?!).

I have been reading about self efficacy beliefs especially relating to beliefs about returning to work, and the thought crossed my mind that people can hold contradictory beliefs about their condition and their confidence to do things despite pain, but that it probably has some sort of emotional cost. Not sure that I’ve found any specific literature to support that, but hold the thought in your mind!

Anyway, today I was reading an article by Busch, Goransson & Melin (2007) about self-efficacy beliefs predicting sustained long-term sick absenteeism in individuals with chronic musculoskeletal pain. In it they describe the results of a survey of 233 people with chronic pain, aged under 60, who had jobs to return to and had not taken early retirement – the long-term sick leave people. The group were divided into those who had been considered ‘work capable’ (they had been removed from the sick leave register in Sweden in the previous 6 months), or currently sick listed. All participants were given an initial questionnaire which included questions on:
(1) demographics
(2) perceived physical and psychological health
(3) working conditions
(4) involvement in rehabilitation
(5) individual factors including beliefs and mastery
(6) perceived consequences of long-term sick leave

The specific questions and questionnaires used are described in the actual article, so I’ll cut to the chase and get on with the results…
After this initial survey, four follow-up surveys were conducted 6 – 12 months after the initial one. The outcome measures of interest at these follow-ups were sick leave days.

Using regression analyses, five significant predictors were found:

  • psychological health,
  • mastery,
  • mental demands at work,
  • recovery beliefs, and
  • sick absenteeism earlier in life.

The strongest predictor was beliefs about recovery, and the next strongest was a sense of mastery.

Once again, it seems that the physical characteristics of work and the physical capacities of individuals are less useful for predicting return to work than whether the person thinks they will recover. The actual question used was ‘A year from now, do you think your health will be better or worse?’

I’m not entirely sure that this is a question of self-efficacy, however that aside, it seems that the person’s own opinion of whether they are ‘well’ or not has an incredibly powerful effect on whether an individual will or won’t meet the challenge of the workplace.

As the authors in this paper say ‘beliefs about one’s recovery can be interpreted in different ways. They can reflect medical ‘facts’ about one’s disorder, communicated by medical staff or others.’

The person I quoted in the headline today said to me, ‘I thought I shouldn’t go back to work because then they wouldn’t think I needed to have my hand fixed, and if I held out long enough, someone would find a cure’.

He had been told that he shouldn’t risk his hand in a work situation because ‘it might make your recovery slower’.

If only someone had said to him that staying off work would likely mean he would lose his job and make eventual return to work much more difficult!

How does this fit with acceptance? The man I’m working with is slowly moving to a place where he accepts that his hand doesn’t perform exactly the way it used to – and that this doesn’t mean an absolute disaster for him.  Neither does it mean he needs to give up hope that things will be different in the future.  Or that someone might find a ‘cure’.

In the meantime he has a life to live, and he is gaining confidence (self-efficacy) that if he starts to take steps to regain control in his life, he’ll begin to ‘live’ a fuller, more ‘normal’ life.

Self efficacy is about being confident that one can achieve success in a given situation. Acceptance is about giving up a resentful struggle against things being the way they are, and getting on with life – I think they may be linked. It’s very hard to feel confident if you are struggling against the reality of life being different from the way you want it to be.

As for our role as health providers? Well it seems to me, if we instill in people the belief that they shouldn’t return to work in case they delay their recovery, or that we don’t believe they can cope with hearing that their problem may be chronic, we’re undoubtedly contributing to the negative effects of low self-efficacy. If instead we work hard to instill in our patients that we believe they have the ability to do ‘normal’ things in life, like return to work, and that recovery is more than pain reduction, we may contribute to their confidence. I hope we do this!

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Busch, H., Göransson, S., Melin, B. (2007). Self-Efficacy Beliefs Predict Sustained Long-Term Sick Absenteeism in Individuals With Chronic Musculoskeletal Pain. Pain Practice, 7(3), 234-240. DOI: 10.1111/j.1533-2500.2007.00134.x

Self efficacy for returning to work

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

Goal setting: A critical skill for change

Pain management is many things to many people, but most of us would agree that if life hasn’t changed in some way after pain management, then it hasn’t really been effective.  For change to actually happen and be maintained, Prochaska and DiClemente and others (eg Miller, Rollnick and colleagues) identify that people must believe the change to be important, and that they have the ability to make it happen successfully.

I’ve posted earlier on self regulation (eg this reading, and this post), making the point that it is made up of several components, one of which is goal setting.

When I went to Google to search the words ‘goal setting’, 13,200,000 hits came up in 0.16 seconds, so goal setting seems to be rather popular – and yet it’s often the most difficult session to facilitate in the three week pain management programme I work in, and some of the ‘goals’ I’ve seen written for patients just don’t look anything like the kind of goals that can actually be measured! So perhaps goal setting is both popular but not easily carried out in ‘real life’.

So, how do we set goals?
It sounds easy if you’ve learned to set goals early in life, but for so many of the people I see it’s not a familiar activity. The research literature in psychology abounds with various models and influences on goal setting and achievement, which doesn’t really help a busy practitioner who may well be drawing on knowledge from first year professional training! And unfortunately, the information readily available online is often of variable quality.

I’m going to start with some random thoughts, mainly based on conclusions drawn from a motivational approach – tomorrow I’ll fill in with some literature!

Firstly, goals need to be relevant to the person. That means that the person believes that the goal is important. Importance is predicated upon things that the person values (see the New Zealand School Curriculum definition here)- these are usually abstract beliefs that, through action, become evident. The same action can represent many values (eg daily exercise can represent ‘time out’, ‘commitment to my wellbeing’, ‘a way to keep my partner/husband/dog happy’). And similarly, values can be fulfilled or operationalised in many different ways (eg ‘caring for my family’ can be achieved by ‘being in a high paid job’, ‘being home when they get home after school’, ‘always going to sports activities with the kids’).

Sometimes, the values appear to conflict with each other – it’s quite common for someone (perhaps yourself?) to value ‘being healthy’ while at the same time valuing ‘relaxing’ – how those values are played out in the real world may mean the person eating healthily in one part of the day, then drinking alcohol as a primary way to relax! I’ve seen this in people who say on the one hand that they’d like to return to work, but on the other, they don’t think they can – because they can’t continue working in the way that they’re used to. There is a conflict between two different values: the values that constitute ‘being a good worker’ (which is operationalised as ‘always doing a job at 120%’) and ‘being able to cope’ (which is operationalised as ‘never allowing my pain to fluctuate’).

The second is that goals need to be achievable.
That is, the person needs to feel confident enough that they can actually succeed in making the goal happen. When pain becomes chronic, confidence to achieve goals can often be eroded, especially if pain is feared or avoided. Successive failures to achieve goals only serve to confirm that taking a risk by setting a goal should be avoided. And this seems to be much more the case if the goal is particularly important – and of course, if it’s not important at all, it just won’t happen!

It almost goes without saying that goals need to be specific and measurable
– exactly what is it that the person has to do, and how will they know they’ve achieved. This is much more difficult if the area of goal development is complex, or requires sub-goals to be achieved in order to attain a longer-term goal.

Tomorrow: some readings on goal and goal-setting, and over this week – tools to use to help people set and maintain goal-directed behaviour.

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Work and disability

It’s taken me some months to finally put something down about my favourite topic – work! I’m a fervent believer in the value of work as an incredibly important component of life, and one of the really telling ways to identify whether pain management skills have become embedded in the coping repertoire of an individual.

A model of work disability that I’ve found useful is based on Lent, Brown and Hackett’s social cognitive career theory, which is in turn based on Bandura’s work on motivation. This model suggests that people determine their work options based on self efficacy, outcome expectations and personal goals. Self efficacy is, in turn, based on personal performance and accomplishments; vicarious learning; social persuasion; and physiological and affective states. Outcome expectations are beliefs about the outcome of various behaviours, and personal goals are the determination to engage in a particular behaviour or achieve a certain outcome. In addition to these core areas, interests and values and contextual conditions influence opportunities and choice.

As a result of disability, individuals belief in their own self efficacy, and outcome expectations are changed. Many people find previous performance and accomplishments no longer count, anxiety about performance, as well as outcome expectations that they are ‘no longer reliable’ mean that they feel anxious about seeking work. Given the lack of knowledge about self that most teens have when choosing a career, it’s not surprising that people who experience work disability have a great deal of trouble identifying exactly what they can offer an employer.

Some of the basic predictions of the SCCT are: Some people eliminate possible occupations due to faulty self efficacy beliefs or outcome expectations, especially when they experience changed ability to perform tasks, without appropriate ways to test their strengths.
The greater the perceived barriers to an occupation, the less likely individuals are to pursue those careers So, if they’ve never been job seeking, they have trouble managing their home-based responsibilities, and there are no role models with disabilities in their employment history, it’s very difficult for them to consider a new work option.
Modifying faulty self efficacy and outcome expectations can help individuals acquire new successful experiences and open their eyes to new career occupations – and this is the work of a vocational specialist counsellor.

In our work as therapists, we all encounter situations in which we are directly or indirectly influencing the work choices of someone with a disability. It may be helpful to remind both ourselves and the person we’re working with that although their function may have changed in some domains, the majority of domains remain unchanged despite pain. So, although self efficacy for ‘lifting heavy things’ or ‘working physically’ may be changed due to poor biomechanics and difficulty tolerating increased pain, this doesn’t affect the global ability to ‘be a good worker’. We may need to support the person to become much more aware of their work style, and particularly their beliefs about what constitutes ‘a good worker’ – if their belief that ‘a good worker’ depends on ‘working 100% and not taking any breaks’, this will conflict with our suggestion that they break a task up into time contingent quota, and we may need to help them consider that ‘good workers’ come in many flavours!

Career decision-making tasks include evaluating career-related abilities and skills, gathering occupational information, selecting occupational goals, and making plans to implement a career goal (Betz & Taylor, 2001). Thus, career self-efficacy reflects an individual’s confidence in performing a self-evaluation, gathering occupational information, selecting a goal, and making implementation plans. We can help with each of these four areas within our therapy, by providing accurate self-evaluation, ensuring occupational information is gathered from as broad a range of job options as possible, helping realistc goal-setting to occur, and ensuring implementation plans are supported and monitored.

Helping people return to productive lives is an integral part of pain management – and one I hope we all can be part of.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W. H. Freeman.

Lent, R. W., Hackett, G., & Brown, S. D. (1996) A social cognitive framework for studying career choice and transition to work. Journal of Vocational Education Research, 21(4), 3-31.