Locus of control and self-efficacy: the implications of both a stable and a situational psychological variable for people with chronic pain
Hilary Flavell
Clinical Psychologist affiliated with Geelong Pain Unit, Geelong
Introduction
It is well recognised that severity of a health condition is insufficient to explain why some people appear to adjust well and others become extremely distressed. Environmental factors, personality traits, and cognitive appraisals have all been investigated, and amongst the theories developed is the stress and coping model of Lazarus and Folkman (1984). These researchers suggested that a balance between problem focussed and emotion focussed coping was dependent on the appraisal of an event as either a challenge or a threat. As the research is equivocal a study was designed investigating a possible pathway from stable environmental and personality factors via self-efficacy, sense of uncertainty, and style of coping, to adjustment for ninety six people with Multiple Sclerosis (MS). While path analyses did not support the model, interesting results were obtained when a multiple regression analysis was conducted. When entered together the stable factors of family support, self-esteem, internal locus of control, along with the situational personal variable of self-efficacy were all significant contributors of emotional distress, accounting for 47% of the variance. This PH.D study (Flavell, 2000) was useful to the pain arena from two points of view: in terms of research, major theoretical problems with the stress and coping model were identified; and in terms of treatment of people dealing with chronic health conditions, both stable and situational psychological variables need to be considered.
The locus of control (LOC) and self-efficacy combination
In the pain literature stable trait and situaiotnal state variables are usually investigated separately. One study that included both was that of Hadjistavropoulos and Shymkiw (2007) who found that LOC together with pain self-efficacy were particularly salient in the motivation to self-manage pain. Those with a low internal LOC score and low self-efficacy relied more heavily on medical interventions, experts and medication, those with high scores on both were more interested in self-management strategies. While these two variables are generally highly correlated they are not the same thing. Locus of control develops across time and as such it becomes a more stable way of interpreting the world. On the other hand self-efficacy, that is perceived ability to do things despite pain, varies according to the particular situation. The main tenet of the LOC theory is that people who tend to believe powerful others or chance are more influential in bringing about an outcome than themselves, have an external LOC. Those with an internal LOC believe more strongly in their own influence.
Numerous studies have found that an increase in self-efficacy through cognitive behavioural programs leads to an improved outcome, for example, Turner et al.(2007). However, this is not the same for internal LOC (Smeets et al., 2006). This should not be surprising as most programs are brief. Thus, the situational rather than stable variables will change. However, to dismiss LOC as irrelevant may be to overlook its importance. It is likely that this combination of stable and situational variables can explain the data of the participants of the cognitive behavioural program at the Geelong Pain Unit. While self-efficacy improved significantly from the commencement to the end of the program, data collected at the six-month follow-up revealed that those who had entered the program with a low self-efficacy score had not maintained their gains, whereas those with a moderate or high score had. LOC was not measured and so conclusions must be drawn tentatively. However, conceptually it makes sense that those entering the program with a low self-efficacy score also had an external LOC. Across time, and without the support of the group, the improved situational variable of self-efficacy lost its impact and the stable LOC became more influential. The implication for treatment is that this subgroup of program participants are likely to return to the experts stating they have tried pain management and it doesn’t work, and they are likely to request more medical interventions or medication. On the other hand, for those who have an internal LOC the acquisition of management skills fits well, and so they continue to use them and gain the benefits.
Research indicates that while LOC is stable, it is not fixed. Bates and Rankin-Hill (1994) found that for injured workers with chronic pain internal LOC decreased in the initial stage but with time two subgroups emerged: those who regained a sense of control and used adaptive strategies; and those who continued to struggle to manage their pain. As health professionals it is necessary to consider the ways to change a person’s self-efficacy so that they can begin to approach the idea of acquiring the skills necessary to management their pain. However, for many this will not be enough. A sizeable group will require assistance and support in the long-term to maintain their skills.
Implications for treatment of a locus of control and self-efficacy combination
First, a consistent long-term view needs to be taken. Treatment needs to be planned with the involvement of the patient because an ad hoc approach is too often a response to a person’s suffering rather than to medical indicators, and can readily lead to frustration and a loss of personal control. Multidisciplinary teams are an important way of increasing consistency and planning.
Second, Motivational Interviewing is a very useful way of decreasing patient resistance to the principles of self-management. This is a process of questioning that encourages the patient to see the benefits for themselves, rather than hearing themselves argue the reasons why the experts should take responsibility for their management.
Finally, it is essential to ensure that imposed obstacles do not cause a reduction in perceived control. Unfortunately being involved in “the system” can do this. Lack of support from the workplace, wages not being paid on time and surveillance, not to mention the minefield of the legal process, can all serve to reduce an injured workers sense of control and self-efficacy to manage their pain.
References
1. Bates & Rankin-Hill (1994) Control, culture and chronic pain. Social Science and Medicine, 39, 629-645
2. Flavell H (2000) Psychological adjustment to Multiple Sclerosis: The applicability of stress and coping and social comparison models.Unpublished PH.D Dissertation
3. Hadjistavropoulos H & Shymkiw J. (2007). Predicting readiness to self-manage pain. Clinical Journal of Pain, 23, 259-266.
4. Lazarus and Folkman (1984) Stress, Appraisal and Coping. New York:Springer.
5. Smeets R., Vlaeyen J., Kester A., Knottnerus J. (2006). Reduction of pain catastrophising mediates the outcome of both physical and cognitive - behavioural treatment in chronic low back pain. Journal of Pain, 7, 261-271
6. Turner J., Holtzman S., Mancl L. (2007). Mediators, moderators and predictors of therapeutic change in cognitive-behavioural therapy for chronic pain. Pain, 127, 276-286.
Time of Presentation
1330
