The power of pain self-efficacy: Applying a positive psychology framework to pediatric pain
Rachel M. Tomlinson, Laura A. Cousins, C. Meghan McMurtry, and Lindsey L. Cohen
Positive psychology involves factors that promote flourishing in contrast to the more traditional focus on variables impacting pathology (Seligman & Csikszentmihalyi, 2000). The resilience-risk model for pediatric chronic pain emphasizes the importance of examining positive psychological factors and highlights potential resilience resources (e.g. optimism, self-esteem) and mechanisms (e.g. pain-related self-efficacy, pain acceptance; Cousins et al., 2015). The current commentary examines the resilience mechanism of pain self-efficacy and aims to (1) define the construct, (2) briefly review relevant literature, and (3) discuss clinical implications and future research directions.
Self-efficacy refers to the expectation of success in performing behaviors required to meet a specific goal or outcome (Bandura, 1977). In health psychology, general self-efficacy might focus on positive outcomes (e.g. adherence, motivation) in the context of chronic health conditions (e.g. diabetes, arthritis; Marks et al., 2005). Meta-analytic findings suggest that general self-efficacy predicts lower impairment, pain severity, and distress in individuals with chronic pain (Jackson et al., 2014). Specific pain self-efficacy may interrupt the fear-avoidance cycle (Vlaeyen et al., 1995; Simons & Kaczynski, 2012) by reducing the impact of pain-related fear (Woby et al., 2007; Carpino et al., 2014), thus leading to lower disability. Exposure to and mastery of feared activities might further reinforce self-efficacy attributions, possibly leading to increased self-efficacy to engage in those behaviors in the future (Bandura, 1977).
Brief review of current literature: pain self-efficacy and chronic pain
Pain self-efficacy research has been predominantly conducted with adults with chronic pain. In adult chronic and recurrent pain populations, higher pain self-efficacy is related to reduced emotional difficulties (Rahman et al., 2004; Turner et al., 2005; Nicholas & Asghari, 2006; Nicholas, 2007), fewer avoidance behaviors over time (Asghari & Nicholas, 2001), lower physical disability (Turner et al., 2005; Meredith et al., 2006; Nicholas & Asghari, 2006; Nicholas, 2007), greater pain acceptance (Fish et al., 2013), increased use of active coping techniques (Nicholas, 2007), and improved functioning (Strahl et al., 2000). Conversely, lower pain self-efficacy in adults with chronic pain is related to increases in pain (Lefebvre et al., 1999; Strahl et al., 2000; Rahman et al., 2004; Meredith et al., 2006), more frequent pain behaviors over time (Asghari & Nicholas, 2001; McCahon et al., 2005), and heightened perceived burden to caregivers (Kowal et al., 2012). Pain self-efficacy has also been identified as a mechanism of change (i.e. mediator) in the adult chronic pain literature, as it appears to explain how increases in pain intensity (Arnstein et al., 1999; Arnstein, 2000; Costa et al., 2011) or pain-related fear (Woby et al., 2007) may impact subsequent increases in disability in adult chronic pain populations (i.e. higher pain causes lower pain self-efficacy, which in turn leads to higher disability).
In pediatric populations, greater pain self-efficacy has been related to improved school functioning, fewer depressive symptoms, and lower disability in children and adolescents with chronic headache (Kalapurakkel et al., 2015), fewer depressive symptoms in children with recurrent abdominal pain (Kaminsky et al., 2006), higher self-esteem and fewer somatic symptoms in children and adolescents with various forms of chronic pain (Bursch et al., 2006), and higher acceptance and lower disability in adolescents with chronic pain (Wallace et al., 2011). Pain self-efficacy was found to mediate the relation between pain-related fear and both functional and school-related disability in youth with headache pain (Carpino et al., 2014). Given that pain self-efficacy is associated with and may explain positive outcomes in adults and children with chronic pain, it may be an important target for intervention.
Pain self-efficacy is considered a critical mechanism of change in evidence-based pain management interventions as it reflects enhanced motivation towards goals and expectations of mastery. According to a recent systematic review (Thompson et al., 2016), relative to other pain-related beliefs, pain self-efficacy has the most empirical support in enhancing treatment adherence for adults with chronic pain in multidisciplinary rehabilitation programs. Self-efficacy might have other widespread positive impacts on functioning. For instance, individuals’ confidence in functioning effectively despite pain may enable them to more easily access and utilize adaptive coping strategies, which might reinforce their ability to gain more control over the pain (i.e. augmenting internal locus of control). Finally, self-efficacy likely broadens related cognitive domains (e.g. psychological flexibility) and may foster problem-solving skills to pursue valued goals (e.g. activity pacing to increase functionality).
Patients’ readiness to change is a key variable that may interact with self-efficacy. Motivational interviewing (Miller & Rollnick, 2002) not only considers patients’ goals and values, but also identifies readiness for treatment and assesses stages of change (Turk et al., 2008). For instance, an adolescent with chronic pain who embraces the mind-body connection and acknowledges that psychological factors contribute to the pain experience will likely demonstrate greater readiness to accept the importance of learning self-management skills. In a cyclical fashion, eliciting enhanced motivation for self-control and self-management will in turn promote pain self-efficacy. The motivational model for pain self-management (Jensen et al., 2003) specifically illustrates how increasing the perceived importance of pain self-management and individual self-efficacy may directly influence readiness to change, promoting engagement in adaptive pain self-management behaviors. Thus, it is critical to continuously assess and monitor patients’ pain self-efficacy throughout treatment and utilize therapeutic techniques that foster autonomy, confidence, and mastery aligned with prescribed values and goals.
Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) are common and widely-regarded pain management interventions (Logan et al., 2014). Using a CBT approach, pain self-efficacy can be enhanced by generalizing prior successes that highlight mastery and confidence to pain-specific contexts. For example, a patient who is a former competitive athlete may benefit from reflecting on the process of becoming proficient in a specific sport when introduced to the concept of activity pacing. When first starting the sport, the patient completed basic drills and over time, gradually increased stamina and endurance as his/her body became accustomed to the activity. Additionally, other therapeutic components of cognitive behavioral interventions (e.g. mindfulness, biofeedback) provide patients with self-control tools to more effectively manage pain. ACT’s contextual behavioral framework also cultivates pain self-efficacy by fostering pain acceptance and movement toward valued goals, counteracting pain-triggered behavioral avoidance (Wicksell et al., 2015). Within CBT and ACT frameworks, utilizing graded exposure treatment to previously avoided activities and situations due to pain can also promote self-efficacy by replacing fear-based perceptions with more adaptive, goal-oriented beliefs.
Future research directions
In accordance with the resilience-risk model for pediatric chronic pain, pain self-efficacy is an individual resilience mechanism that activates in response to pain and may reduce reliance on risk mechanisms, such as catastrophizing (Cousins et al., 2015). Important future research goals include increasing understanding of pain self-efficacy across genders, cultures, and age, in addition to contextual factors that influence patient self-efficacy (e.g. familial factors including caregiver distress, pain responses, psychological flexibility, and beliefs and thoughts about pain). Relations between pain self-efficacy and other individual resilience traits (e.g. hope, acceptance, optimism) and important outcomes such as disability should be further explored. Longitudinal examinations of pain self-efficacy would provide information about the stability of pain self-efficacy over time and across development. Studies focused on the implementation of interventions targeting pain self-efficacy would provide insight into the cultivation of pain self-efficacy and intervention effectiveness over time. For instance, it remains unclear whether it is more beneficial to (a) target and augment self-efficacy prior to starting evidence-based treatments to prevent non-adherence and discontinuation of treatment or (b) integrate sessions at the beginning of treatment specifically tailored for self-efficacy enhancement.
Pain self-efficacy is an individual resilience mechanism that relates to higher emotional functioning, greater pain acceptance, and less pain and disability. Pain self-efficacy has also been shown to be a mechanism of change in pediatric and adult samples. Expanding the study of pain self-efficacy in samples of youth with chronic pain will likely lead to enhanced interventions to improve functioning in this vulnerable population.
Cite as: Tomlinson RM, Cousins LA, McMurtry CM, Cohen LL. The power of pain self-efficacy: Applying a positive psychology framework to pediatric pain. Pediatric Pain Letter 2017;19(1):9-13. www.childpain.org/ppl
R. Tomlinson and L. Cousins are trainee members of Pain in Child Health (PICH), a Strategic Training Initiative in Health Research of the Canadian Institutes of Health Research (CIHR).
Arnstein P. The mediation of disability by self efficacy in different samples of chronic pain patients. Disabil Rehabil 2000;22:794-801. PubMed Abstract
Arnstein P, Caudill M, Mandle CL, Norris A, Beasley R. Self efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients. Pain 1999;80:483-491. PubMed Abstract
Asghari A, Nicholas MK. Pain self-efficacy beliefs and pain behavior. A prospective study. Pain 2001;94:85-100. PubMed Abstract
Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977;84:191-215.
Bursch B, Tsao JC, Meldrum M, Zeltzer LK. Preliminary validation of a self-efficacy scale for child functioning despite chronic pain (child and parent versions). Pain 2006;125:35-42. PubMed Abstract
Carpino E, Segal S, Logan D, Lebel A, Simons LE. The interplay of pain-related self-efficacy and fear on functional outcomes among youth with headache. J Pain 2014;15:527-534. PubMed Abstract
Costa LdaC, Maher CG, McAuley JH, Hancock MJ, Smeets RJ. Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain. Eur J Pain 2011;15:213-219. PubMed Abstract
Cousins LA, Kalapurakkel S, Cohen LL, Simons, LE. Topical review: resilience resources and mechanisms in pediatric chronic pain. J Pediatr Psychol 2015;40:840-845. PubMed Abstract
Fish RA, Hogan MJ, Morrison TG, Stewart I, McGuire BE. Willing and able: a closer look at pain willingness and activity engagement on the Chronic Pain Acceptance Questionnaire (CPAQ-8). J Pain 2013;14:233-245. PubMed Abstract
Jackson T, Wang Y, Wang Y, Fan H. Self-efficacy and chronic pain outcomes: a meta-analytic review. J Pain 2014;15:800-814. PubMed Abstract
Jensen MP, Nielson WR, Kerns RD. Toward the development of a motivational model of pain self-management. J Pain 2003;4:477-492. PubMed Abstract
Kalapurakkel S, Carpino EA, Lebel A, Simons LE. “Pain can’t stop me”: examining pain self-efficacy and acceptance as resilience processes among youth with chronic headache. J Pediatr Psychol 2015;40:926-933. PubMed Abstract
Kaminsky L, Robertson M, Dewey D. Psychological correlates of depression in children with recurrent abdominal pain. J Pediatr Psychol 2006;31:956-966. PubMed Abstract
Kowal J, Wilson KG, McWilliams LA, Péloquin K, Duong D. Self-perceived burden in chronic pain: relevance, prevalence, and predictors. Pain 2012;153:1735-1741. PubMed Abstract
Lefebvre JC, Keefe FJ, Affleck G, Raezer LB, Starr K, Caldwell DS, et al. The relationship of arthritis self-efficacy to daily pain, daily mood, and daily pain coping in rheumatoid arthritis patients. Pain 1999;80:425-435. PubMed Abstract
Logan DE, Coakley RM, Barber Garcia BN. Cognitive-behavioral interventions. In: McGrath PJ, Stevens BJ, Walker SM, Zempsky WT, editors. Oxford textbook of paediatric pain. New York: Oxford University Press, 2014. pp. 519-530. Link
Marks R, Allegrante JP, Lorig K. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part I). Health Promot Pract 2005;6,37-43. PubMed Abstract
McCahon S, Strong J, Sharry R, Cramond T. Self-report and pain behavior among patients with chronic pain. Clin J Pain 2005;21:223-231. PubMed Abstract
Meredith P, Strong J, Feeney JA. Adult attachment, anxiety, and pain self-efficacy as predictors of pain intensity and disability. Pain 2006;123:146-154. PubMed Abstract
Miller WR, Rollnick S. Motivational interviewing: preparing people for change (2nd ed.). New York: Guilford Press, 2002. Link
Nicholas MK. The pain self-efficacy questionnaire: taking pain into account. Eur J Pain 2007;11:153-163. PubMed Abstract
Nicholas MK, Asghari A. Investigating acceptance in adjustment to chronic pain: is acceptance broader than we thought? Pain 2006;124:269-279. PubMed Abstract
Rahman A, Ambler G, Underwood MR, Shipley ME. Important determinants of self-efficacy in patients with chronic musculoskeletal pain. J Rheumatol 2004;31:1187-1192. PubMed Abstract
Seligman ME, Csikszentmihalyi M. Positive psychology. An introduction. Am Psychol 2000;55:5-14. PubMed Abstract
Simons LE, Kaczynski KJ. The fear avoidance model of chronic pain: examination for pediatric application. J Pain 2012;13:827-835. PubMed Abstract
Strahl C, Kleinknecht RA, Dinnel DL. The role of pain anxiety, coping, and pain self-efficacy in rheumatoid arthritis patient functioning. Behav Res Ther 2000;38:863-873. PubMed Abstract
Thompson EL, Broadbent J, Bertino MD, Staiger PK. Do pain-related beliefs influence adherence to multidisciplinary rehabilitation?: a systematic review. Clin J Pain 2016;32:164-178. PubMed Abstract
Turk DC, Swanson KS, Tunks ER. Psychological approaches in the treatment of chronic pain patients- when pills, scalpels, and needles are not enough. Can J Psychiatry 2008;53:213-223. PubMed Abstract
Turner JA, Ersek M, Kemp C. Self-efficacy for managing pain is associated with disability, depression, and pain coping among retirement community residents with chronic pain. J Pain 2005;6:471-479. PubMed Abstract
Vlaeyen JW, Kole-Snijders AM, Boeren RG, Van Eek H. Fear of movement/(re) injury in chronic low back pain and its relation to behavioral performance. Pain 1995;62:363-372. PubMed Abstract
Wallace DP, Harbeck-Weber C, Whiteside SP, Harrison TE. Adolescent acceptance of pain: confirmatory factor analysis and further validation of the chronic pain acceptance questionnaire, adolescent version. J Pain 2011;12:591-599. PubMed Abstract
Wicksell RK, Kanstrup M, Kemani MK, Holmström L, Olsson GL. Acceptance and Commitment Therapy for children and adolescents with physical health concerns. Curr Opin Psychol 2015;2:1-5.
Woby SR, Urmston M, Watson PJ. Self‐efficacy mediates the relation between pain‐related fear and outcome in chronic low back pain patients. Eur J Pain 2007;11:711-718. PubMed Abstract