Why Are We Ignoring Self-Efficacy in Vocational Rehabilitation?

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Self-Efficacy: what a boring yet weird word for such an important concept! Put simply, self-efficacy is our self-confidence, but in a very specific way: it relates to whether or not we feel we can successfully achieve a certain goal, task, or outcome.

In voc rehab, it is all to easy to fall in the trap of thinking that because someone can functionally perform a task, that they will actually succeed, or keep at it when times get tough. Actually, self-efficacy has been shown to be a stronger predictor of disability and pain rating after injury than the injury itself. Seriously! So why do we keep ignoring it?

Just because a person seems functionally OK to get back to work, it doesn't mean that (1) they will take the steps required to do so or (2) they will maintain positive work behaviours when things inevitably go a bit pear-shaped or their injury flares up.

So where did self-efficacy come from?

To begin, let's go back in time to the early 1970s. This era brought us some important changes in the way we view human behaviour - namely Social Learning Theory - and it still informs our practice today.

Before this time, the dominant theory of human behaviour was Behaviourism. Perhaps the most infamous Behaviourist was B.F. Skinner. If you don't believe me, you better learn about the Skinner Box. Yeah... that was a real thing.

Through his experiments, Skinner was able to demonstrate that you can encourage, manipulate and even eliminate a given behaviour by changing the events that precede the behaviour (called antecedents), as well as the consequences of the behaviour itself. A classic example of this is the Skinner Box, in which lab rats quickly learned that pressing a lever would reward them with food on-demand. Pigeons weren't too far behind on the learning curve, either.

Turns out you can train pigeons to play a mean game of ping-pong if you feed them after each shot. Image courtesy of Richard Grandmorin.

Behaviourist models have taught us an incredible amount about why us humans behave the way we do. Our behaviour really is a response to our environment - and we don't keep doing things that don't reward us in some way or another.

But... if only it was that simple.

"Radical Behaviourism" does not give us the whole picture. In the late 1960s, Albert Bandura built on Skinner's work by developing Social Learning Theory.

According to Bandura, we humans have complex, weird and beautiful brains, and we get stuck in there a lot. We apply our own unique beliefs, values and meaning to our experiences, which deeply affects our sense of competency and ultimately our likelihood of setting and achieving goals.

In the next decade, Self-Efficacy would emerge as a central concept of Bandura's Behaviour and Learning theories. Again, Self-Efficacy is all about our personal sense of capability to achieve something, and to perform the behaviours required to get there. Good or bad, Self-Efficacy is the result of our past experiences, what we have learned from the actions of others, the feedback people provide to us, and even our bodily functions (more on that in part 2).

vicarious learning in action - i'd rather not try that after seeing things go pear shaped for you...

Self-Efficacy is a strong determinant of whether someone will initiate and maintain a behaviour in the face of adversity. In terms of working, it means that people who doubt their skills, talent and knowledge to engage in work-positive behaviours are, you guessed it, unlikely to enagage in work-positive behaviours. And this means they are less likely to set realistic goals, and find and maintain employment.

Now, the above point may sound obvious, but Self-Efficacy is often an afterthought in many job rehabilitation schemes for people with an injury, disability or other social disadvantage. Notions of "fit to work" still tend to be based on more objective measures - most of the time, symptoms of the diagnosis itself - leaving little room to address how a person's subjective beliefs about their coping skills, job skills and self-management might affect their success.

For some people, it has been observed that beliefs about pain, injury and self-management are more predictive of disability and unemployment than their level of physical function - that is, our subjective beliefs can come to manifest as objective disabilities, beyond what can be explained biologically. For example, in 2004, Denison et al. found that Self-Efficacy is a stronger predictor of disability than pain intensity and pain duration for people with musculoskeletal pain. Talk about the mind eclipsing the body.

If we keep ignoring self-efficacy, we are leaving out a huge part of the equation. While the injury is important - we can't forget about the person. We mustn't.

Check out part 2 for practical advice for improving self-efficacy, managing goals and helping people get back into work.

Sources and Further Reading:

Denison, E., Asenlof, P., & Lindberg, P. (2004). Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care. Pain, 111, 245- 252.

Image Credits: The above images by Ludovic Bertron and Richard Grandmorin are licensed under CC BY 2.0.