I grew up with a mom who is an occupational therapist and who has chronic pain. She began having low back pain in high school. She did what she was advised to do back then, she rested for weeks. After the initial bout of low back pain, her course continued episodically as it often does for people. She had wanted to go into physical therapy but was advised against it because she was told that she “wouldn’t be able to handle all the lifting.” Twenty years ago while working in a pain program, with unfortunate irony, she developed a knee injury which eventually led to CRPS. My experience growing up with her example, has greatly shaped my practice today. When we talk, our roles vacillate between parent, child, and clinician. They often intertwine in ways that aren’t clear to us. And in our discussion, you can hear how we morph between them. I want to highlight my mom’s story to introduce the topic of self efficacy.
I cannot recall many days when she didn’t hurt. She hurt, and we knew she hurt. But she also exercised, had hobbies, worked full time, and was a phenomenal parent. Her self efficacy empowered her to reduce pain interference on function, maintain independence, and improve her life satisfaction. All constructs that are well supported by research. Some hearing my mom’s story might conclude that it doesn’t appear that fear played much of a role for her. I think fear was present as a natural response to hearing a surgeon tell her that without surgery she would end up in a wheelchair. Fear was present when reading an MRI report identifying every level of her spine had a finding and at other points throughout her narrative. Certainly fear played a role for her practitioners. Darlow et al unsurprisingly found that fear avoidant clinicians promoted fear avoidant treatments such as inactivity. However, I believe her story highlights what the evidence supports. Miles et al’s systematic review, sought to discern the predictors, mediators, and moderators of self-management programs. They found strong evidence that high levels of self-efficacy at baseline, predicted function, irrespective of treatment. Self-efficacy mediated and predicted outcomes when it was the target of treatment. Costa et al., Woby et al,, Lee et al. Foster et al., and Martinez-Calderon et al., and many more, all establish that self efficacy mediates and moderates the pain/disability relationship and that self-efficacy predicts outcomes. If self-efficacy is high, then elevated fear won’t decrease function.
Bandurra is noted to have established self efficacy theory in 1977 (read it here) and defined self efficacy as one’s belief in their ability to perform a given task in a given context. Perceived disability is true disability. If you think you can’t, then you are unlikely to try. Bandurra’s definition is context and task specific. I believe that today, this definition is too limiting. Devan et al describe self-efficacy as a “resilient belief system” to reduce disability and suffering. This broadened definition of self efficacy is useful. Defining self-efficacy as one’s belief in their ability to remain engaged in valued roles allows us to clinically move beyond a vigilance on task specific parameters. It creates a path towards a patient’s skill set that would give them flexibility to engage in a variety tasks and roles. This isn’t to say that we abandon task specificity. But rather that we consider the necessary self efficacy beliefs and skills more broadly first.
And while my mom’s self efficacy was present early on, it is not so for everyone. Self efficacy can be learned. Damush et al. emphasize that skill development can increase confidence to manage symptoms. And there are many studies that address strategies for self management (next blog, I promise.) It is understandable that someone would seek relief by exploring options and seeking out practitioners. But perhaps they aren’t considering their own expertise and skill in this quest. But really, this is the most important. This is where I focus my early efforts with people who are experiencing persisting pain. I aim to help them build a skill set that will enable them to feel that they are able to reliably manage not only their current life, but also new experiences. With the development of a successful strategy, a person can encounter a sense of control over how they feel, reduce a sense of helplessness, boost activity tolerance, and experience repeated success with an internal locus of control. Shifting self talk from “I can’t do anything to help my pain” to “There are things I can do to help me feel better.” Features of self efficacy include self confidence, accurate self evaluation, willingness to take risks, and sense of accomplishment.(Martinez-Calderon) My mom talks about her interpretation of her pain as not being harmful. She is also able to differentiate her sensations. She can confidently identify that certain pain related sensations aren’t harmful. She will still seek medical care if she doesn’t think what she is feeling was part of her normal pain profile which itself is variable. We don’t want people ignoring important care because they believe their pain sensations are completely unreliable. This area can be confusing. For the person experiencing pain, it is an ongoing conversation with themselves and care providers. Repeating patterns of success with strategies, and feeling more predictable sensations can help. Accurate self evaluation can also mean a person’s understanding of why a fluctuation may have occurred. I’ve had patients who experience consistent flares in response to specific people and situations. Learning this gives the opportunity to understand that symptoms may not be random, which itself may be a relief. This knowledge also creates the opportunity to intervene with a strategy. Self efficacy can be protective, as it is for my mom. It boosts resiliency, it helps people adapt. For my mom, it gives her freedom to engage without worry.
It would be easy to identify persistence as being related to my mom’s continuation of valued tasks. Persistence and self-efficacy are not the same. Persistence can be unhelpful if it is the result of endurance coping that doesn’t necessarily reduce suffering. Persistence that is the result of shame related to worry over the perceptions of others that a person isn’t “trying,” doesn’t reduce suffering. The objective of strategies to elevate self efficacy are aimed at reducing suffering. My mom persists because she trusts that she isn’t harming herself, and because she believes in her skills to manage how she feels. It is important to ask what is driving persistence for the individual. In Van Damme and Kindermans’ reconsideration of avoidance and persistence they present an exploration of the constructs through a self-regulation view. They outline self-discrepancy theory as the interplay of a person’s ideal-self, ought-self, and feared-self. How a person would like to be, feel they should be, and don’t want to become. An individual may act when there are variations of the actual self and the ideal/ought/feared self. The attainment of the ideal self can lead to persistence. For my mom, pursuit of her ideal self, is related to her persistence through self-efficacy.
My mom accepted the presence of her pain. She did not accept that she couldn’t do things because of it. She remained optimistic that she would find a way to manage. She knew she could move safely. For her, pain did not result in a loss of joy or valued life roles. Was it difficult? Yes. Were there ups and downs? Yes. But her deep belief in her ability to problem solve a way through kept her doing. I want to help foster that belief and confidence in the people I serve, so they too can attain their vision of themselves doing what they love in order to return to joyful living.
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