Coping with Chronic Pain: What Can We Learn from Pain Self-Efficacy Beliefs?

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Coping with Chronic Pain: What Can We Learn from Pain Self-Efficacy

Beliefs?

Journal of Rheumatolgy

June 2004

Editorial

DOUG SAUNDERS, PhD, CPsych,

Department of Public Health Services,

Faculty of Medicine,

University of Toronto,

Toronto, Ontario, Canada.

E-mail: saunders@...

Address reprint requests to D. Saunders, , Saunders, and

Associates, 700 Bay Street, Suite 2307, PO Box 156, Toronto, Ontario M5G

1Z6, Canada.

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The perplexing question of what determines effective adjustment to

chronic musculoskeletal (MSK) pain has been an important area of

research for the past 3 decades. Despite a relatively large and growing

body of scientific studies, however, there are few definitive answers.

This is due partly to the complex nature of chronic pain, with its

interlocking physical, psychological, and social factors, and partly to

the heterogeneous nature of the chronic pain population.

Nevertheless, the continuing importance of this area of research is

underlined by estimates that at any point in time, one in 5 members of

the general population suffers chronic pain1,2. Chronic MSK pain, in the

form of self-reported chronic back pain, chronic joint pain, and chronic

widespread pain is far and away the largest contributor3,4.

In addition, the direct and indirect healthcare costs of chronic pain

conditions are very high. Studies indicate that individuals with chronic

pain are frequent and repeated users of physician services and are

commonly referred to specialists. The evidence shows that the vast

majority use medications to treat their pain problems. Moreover, once a

chronic pain condition develops, it is likely to persist for many

years5,6.

Clinically, these patients are challenging because the complex etiology

of chronic pain frequently defies straightforward answers based on

physical findings. Conservative therapy is commonly of little or no

benefit. Treatment with other approaches is prolonged and complicated,

with outcomes that are often less than satisfactory for both patients

and clinicians7. Medications frequently provide, at best, only limited

and short term symptom management, and at worst, exacerbation of

symptoms. Many patients are, understandably, highly ambivalent about

their use of the prescribed medications, and report feeling " trapped "

between the pain relief they desire and the side effects they

experience6. This leads to adherence and dependency issues that can

further exacerbate their pain condition.

The study by Rahman and colleagues8 of factors associated with pain

self-efficacy in patients with chronic MSK pain adds to a small but

growing body of research evaluating the psychological concept of pain

self-efficacy as a means of clarifying relationships between the

physical, psychological, and social components of chronic pain. Pain

self-efficacy beliefs as measured by the Pain Self-efficacy

Questionnaire refer to an individual's reported level of confidence to

cope with pain, accomplish life goals, live a normal lifestyle, and

maintain normal activities such as socializing, household chores, forms

of paid and unpaid work, and pursuit of hobbies and leisure activities

despite pain.

Previous investigations9,10 have found that pain self-efficacy beliefs

as well as pain intensity may be important predictors of disability and

depression in different samples of chronic pain patients. The results of

these studies clearly demonstrate the strong impact of high pain

intensity as well as pain self-efficacy beliefs as important

determinants in the development of disability and depressed mood. Thus

pain intensity and pain self-efficacy beliefs may capture 2 important

dimensions in better understanding what factors contribute to effective

adjustment to chronic MSK pain.

In the current study, Rahman and colleagues approached the issue from a

different direction, attempting to ascertain the determinants of pain

self-efficacy beliefs. Their subjects are patients with chronic MSK pain

recruited from a tertiary rheumatology clinic. Unfortunately, the

cross-sectional nature of this study precludes any causal inferences.

Nevertheless, the authors have argued that their results show that

occupational status, reporting of depressive symptoms, and possibly

distribution of pain sites, i.e., extensive or widespread pain versus

limited or regional pain, are associated with significant differences in

pain self-efficacy beliefs8.

However, a more detailed review of their results suggests a more

cautious set of conclusions is warranted. First, as the authors

themselves acknowledge, differences in pain self-efficacy scores between

those with extensive or widespread pain versus those with limited or

regional pain are not statistically significant. This finding is further

strengthened when the necessary corrections are made for conducting

multiple comparisons to maintain an appropriate experiment-wise

statistical significance level.

Second, a detailed review of their results indicates that across

occupational status categories, both pain self-efficacy scores and pain

intensity scores are significantly different. Unfortunately, this

indication of a relationship between pain self-efficacy scores and pain

intensity scores was not explicitly accounted for in subsequent

multivariate analysis. This leaves open the likely possibility that the

significant association of occupational status with pain self-efficacy

scores identified by the authors may really be the result of differences

in pain intensity scores across the categories of occupational status.

Thus a more cautious conclusion from the study's findings would be a

reiteration of the previously identified significant association between

pain self-efficacy beliefs and depressive symptoms. This conclusion is

further support for the findings from earlier studies of pain

self-efficacy as a significant predictor of depressive symptoms.

However, although this result is a useful piece of corroborating

evidence to earlier findings, it does not contribute any better insights

to the authors' original goal of what factors may be determinants of

pain self-efficacy beliefs.

In the absence of any further research findings at the present time, it

may still be possible to offer useful insights and directions for future

investigations in this area. In this regard it is important first of all

to reiterate the conclusions of earlier studies that both pain intensity

and pain self-efficacy beliefs appear to be important predictors of

disability and depression. As the evidence shows, pain self-efficacy

beliefs can mediate the impact of pain intensity on disability and

depression, but they do not eliminate it. As has been noted high pain

intensity itself has the strong impact on disability and depression9.

This in fact is common sense for anyone who has suffered persistent

pain. Moreover pain intensity itself has been shown to be strongly

associated with self-efficacy beliefs related to coping with pain and

managing work demands11,12. Thus pain intensity on its own may be an

important determinant of pain self-efficacy beliefs. Unfortunately, very

little research has been published that examines this issue.

However, pain intensity alone is not the only determinant of mental

appraisals such as pain self-efficacy beliefs. In the original

formulation of self-efficacy theory, Bandura13 outlined 4 basic

processes by which individuals establish or change their beliefs about

self-efficacy. The most vital are direct mastery experiences, where

people can retain information about how they previously performed

successfully in similar situations. Next to direct experience are

learning processes such as modeling, where people may benefit from

seeing the responses of others who they perceive as similar to

themselves in the same situation. A third process influencing

self-efficacy beliefs is persuasion, particularly when it involves the

opinions of others who the individual perceives as experts or

authorities in this area. The fourth process proposed by Bandura

involves educating and training people to reinterpret somatic

information in less aversive ways.

However, the success of efforts to promote increased pain self-efficacy

beliefs through mastery experiences, modeling by others, persuasion, or

reinterpretation of somatic symptoms can be quite mixed. To achieve

mastery experiences usually requires sustained changes in behavior.

Rothman14 has noted that studies show that appraisals such as

self-efficacy are important to initiate behavior change but have little

value in sustaining behavior change. He argues that sustaining behavior

change depends on other appraisals related to the actual outcomes

achieved by the behaviors and the person's satisfaction with those

outcomes. Thus a person's self-efficacy beliefs, that is, their

confidence to successfully engage in particular behaviors, likely

depends on other appraisals of their satisfaction with the outcomes of

these behaviors, such as how the behaviors make them feel, whether the

behaviors help them do what they want, to what extent the behaviors help

them maintain their self-identity, and how the behaviors help them

maintain quality relationships14,15.

Rothman's conclusion that appraisals such as self-efficacy beliefs are

important factors in initiation of behavior change but not the

sustaining of behavior change appears to be contradicted by the findings

from an earlier study, in which higher Pain Self-Efficacy Questionnaire

scores were predictive of total pain behavior and avoidance behavior

over the 9 month study period, controlling for factors such as pain

intensity, disability, and depression10. This apparent inconsistency can

be addressed by closer examination of the items included in the Pain

Self-Efficacy Questionnaire.

In his original formulation of self-efficacy, Bandura had described it

as the confidence to engage in specific discrete behaviors. Further

elaborations have incorporated the importance of the outcomes produced

by the behaviors as a modifying element. However, examination of the

items in the Pain Self-Efficacy Questionnaire suggests that it is no

longer simply the confidence to engage in discrete, specific behaviors

but also a mental approach, an attitude or orientation that goes well

beyond confidence to complete discrete behaviors.

Items such as, " I can enjoy things, despite the pain " ; " I can live a

normal lifestyle, despite the pain " ; " I can accomplish most of my life

goals, despite the pain " are clear examples of this attitude, approach,

or orientation. This is further reinforced by the instructions that

remind respondents, " Remember, this questionnaire is not asking whether

or not you have been doing these things but rather how confident you are

that you could do them at present, despite the pain. "

This suggests that many of the Pain Self-Efficacy Questionnaire items

are not about self-efficacy, i.e., the confidence to engage in specific,

discrete behaviors, but rather about a type of commitment to a mental

approach or an orientation. Unlike self-efficacy beliefs that are driven

by the reinforcement that comes from engaging successfully in discrete

behavior, this type of commitment is fostered by the intrinsic

meaningfulness of pursuing a line of action in recognition of adverse

consequences (i.e., despite the pain). Patients who espouse these

statements are not endorsing a self-confidence to engage in specific

behaviors so much as they are endorsing an overall attitude about their

lives. Clinically, these are the patients we love to see walk into our

offices; the ones who inspire us with their upbeat determination, full

lives, and cheerful manner, despite the pain.

This clarification helps explain the apparent contradiction between

Rothman's conclusions and the findings from the Pain Self-Efficacy

Questionnaire. Rothman's review involved a broad array of behavior

change studies that used more typical self-efficacy measures that are

more consistent with Bandura's self-efficacy formulation. These measures

tap psychological processes that depend on reinforcement to sustain

behavior change. On the other hand, scores from the Pain Self-Efficacy

Questionnaire capture a very different dimension: the meaningfulness or

intrinsic motivation respondents associate with their behaviors.

Evidence from the psychological literature shows that under aversive

conditions, it is this intrinsic dimension that is far more likely to

sustain behavior change. This is borne out by the findings from the

earlier study10.

Thus to return to the initial question posed by this editorial of what

determines effective adjustment to chronic MSK pain, it is pain

self-efficacy beliefs but not the self-efficacy beliefs postulated by

Bandura. Those beliefs are important for initiating behavior change, but

are unlikely to sustain the behavior. To sustain behavior change,

especially when it likely involves aggravation of persistent pain, it

must be associated with an intrinsic meaningfulness. This meaningfulness

in turn fosters a sense of commitment or intrinsic motivation that

sustains the behaviors, despite the pain. This is at least an answer to

the initial question and perhaps offers a useful insight and impetus to

further research in this area.

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