Rx for health: a dose of self-confidence; the mind can help the body mend when you learn to cope with what you fear
Rx for Health: A Dose of Self-Confidence
At first glance, thereseems to be little resemblance among Rachel, a young college student deathly afraid of snakes; Harold, a middle-aged stockbroker just recuperating from a heart attack; and Marian, a retired music teacher suffering from arthritis. But all three have learned how to cope with a very serious, potentially incapacitating problem through one of several special programs at Stanford University that are based, directly or indirectly, on the theories and research of Stanford psychologist Albert Bandura. A leader in his field, Bandura has encouraged fellow psychologists to recognize that learning is influenced not only by rewards and punishments but also by how people size up their capabilities and their situation –what they are thinking.
In one facet of his work, Bandurahas explored how people’s belief in their ability to cope with specific situations (which he calls their sense of “self-efficacy’) affects both their stress reactions and their subsequent behavior. He has found that a person may have a high sense of self-efficacy about one type of activity and not about another. For example, a practiced speaker may be confident that he can deliver tonight’s speech without a hitch but may doubt that he can sustain his attempt to quit smoking or even get through the rest of the evening without a cigarette.
Bandura and others have shownthat people’s judgments of their self-efficacy affect their behavior in a wide variety of situations, ranging from solving problems to choosing a career to going on a diet. They influence whether people even try to develop healthy habits, how much effort they expend, how long they persist in the face of obstacles, whether their thoughts help or hinder them and how much stress they experience.
In the late 1960s, psychologist MartinSeligman and his colleagues at the University of Pennsylvania found that dogs given random electric shocks that they could not escape developed “learned helplessness.’ Once they had learned that nothing they did made any difference, they became passive and gave up. Placed later in another situation in which they could easily escape the shock, they hardly tried.
Later experiments showed thatlearned helplessness produced diverse effects in humans. In response to repeated failure, some people gave up, others kept trying and still others intensified their efforts to succeed. Learned helplessness theory, as it applies to humans, has been refined to include the effect of attributional styles–whether people attribute their success and failure to internal or external causes. Recent animal studies suggest that physiological reactions to helplessness can make the immune system less responsive, making some stressed animals more vulnerable to illness. Similar mechanisms may be at work in humans.
Bandura’s approach to looking atthe link between mind and body has been to develop and test a mastery therapy for people with phobias. They are usually physically healthy, but when confronted with a feared situation, they are likely to have intense physiological reactions. For example, a spider-phobic person who sees a spider or even a picture of one may react with a pounding heart, convulsive shivers, shortness of breath or vomiting for hours. What makes phobics so fascinating to a researcher interested in body-mind interactions is that all these reactions are produced by people’s thoughts, not by physical causes.
In Bandura’s view, objects and situationsare not intrinsically frightening. Whatever fear and stress they evoke comes from how we interpret our ability to cope with them. For example, most people enjoy a walk in the woods, but for someone deathly afraid of snakes it can be a nightmare. On the other hand, most people would be terrified of walking on a high wire, while a professional circus performer might find it exhilarating.
People who suffer from disablingphobias doubt their self-efficacy in certain situations, their ability to cope with whatever it is they fear–an animal, closed spaces, heights, flying. They often spend their lives avoiding ordinary situations, even ones unlikely to lead to a feared encounter. One woman was so afraid of spiders that she refused to take a bath because she had once seen a spider in her bathtub.
Bandura believes that some of thesame psychological mechanisms are at work in people without phobias when they fear something. They are afraid not only of the situation but of their own inadequacy in dealing with it. It’s that added fear–of being unable to control their own behavior and immediate environment–that makes the situation stressful. Some people, especially phobics, make matters even worse by dwelling on their own deficiencies and failures, magnifying the dangers and becoming preoccupied with potential calamities. Thus, snake phobics not only refuse to go walking or camping in the woods; they are also plagued by nightmares and frightening thoughts about snakes.
Bandura’s treatment program counteractsphobics’ tendencies toward stressful thoughts by giving them a sense of control. He reasoned that increasing people’s sense of self-efficacy would decrease their anxiety when facing or even thinking about what they find threatening.
Through a process called “guidedmastery modeling,’ people such as Rachel are helped to develop a strong sense of coping efficacy in a series of graduated steps–first they watch someone “model’ how to handle the animal; then they are helped in different ways to approach the animal, pick it up and control its behavior as it roams freely in the room and, finally, crawls in their laps. As treatment progresses, outside help is withdrawn to let the phobics see that they can cope successfully on their own.
At each step, participants’ judgmentsof their efficacy are measured. Research by Bandura and others shows that these judgments predict accurately how far someone will go in dealing with a feared animal. Presumably, when people see themselves as highly efficacious, they do so because they believe they can control the things they fear.
Bandura and two colleagues, psychologistsLinda Reese and Nancy Adams, tested this hypothesis in a series of experiments. They found that bolstering self-efficacy decreased physiological fear symptoms such as increased heart rate and blood pressure in people with phobias, no matter how the bolstering had been achieved.
Working with psychologist LloydWilliams and psychiatrists Jack Barchas and C. Barr Taylor of the Stanford Medical Center, Bandura looked more closely at how beliefs about self-efficacy affect physiological stress responses. In one experiment, the researchers drew blood samples from 12 spider-phobic women as they went through the treatment program. Whenever the women faced situations in which they felt unable to cope, their levels of two catecholamine brain chemicals–epinephrine and norepinephrine –shot up. But when the women confronted situations they believed they could handle, levels of both catecholamines declined. By the end of the treatment program, the women were able to do calmly acts that had recently terrified them, and their catecholamine levels decreased accordingly. Furthermore, many became less plagued by frightening thoughts and dreams in their everyday lives.
We all have experienced somethingakin to this kind of terror. Everyone who has been called on unexpectedly in class when unprepared or who has lacked a critical piece of information when the boss asked for it has felt that sinking, heart-pounding “Oh no!’ sensation. Perceived control is the key. If we believe we have all the answers, we’ll probably feel nothing worse than normal nervousness. Similarly, when spider-phobic women gained assurance that they could control the spiders’ movements, they could then let the spiders walk on their bodies without fear or physiological stress.
In an analogous situation, Yale Universitypsychologist Judith Rodin found that elderly residents of a nursing home who were taught how to increase control over their own lives had lower levels of the stress hormone cortisol, better health and more positive outlook than others who lacked a sense of control.
Bandura’s emphasis on controllingefficacy differs considerably from other explanations of how behavior-modification programs work. While recognizing the importance of environmental influence, Bandura focuses on the interaction between coping capabilities and environmental demands. In his view, all successful therapies work by increasing people’s sense of self-efficacy; this psychological change, in turn, allows participants to exercise greater control over their own behavior, motivation and environment.
If strategies such as Bandura’s canreduce the physiological stress caused by emotional disorders such as phobias, can they also reduce physical pain? For some types of pain, such as headaches, and even the aching joints caused by arthritis, the answer seems to be yes.
When psychologist KennethHolroyd and colleagues at Ohio University compared how well biofeedback training and self-efficacy training alleviated headache pain, the researchers told study participants, in line with common medical wisdom, that headaches are caused by muscle tension, and that biofeedback would help them learn to relax their scalp muscles and decrease headaches. Half of the participants were given this kind of biofeedback. The others received false feedback: The signals were reversed so that the more they tensed their muscles, the more the feedback signals indicated that they were relaxing. Within each group, half were tole they had been very successful at biofeedback, while the others were told they had been only moderately successful.
Those led to believe they had beenvery successful, whether they had really learned to relax or unknowingly had learned to tense their muscles, reported a 53 percent reduction in headache pain. The others (some of whom had actually learned to relax) reported only a 26 percent reduction. This suggests that people’s belief, valid or not, in their ability to control headache pain may directly reduce the stress that causes it.
Findings such as these help to explainwhy one of the most promising applications of self-efficacy theory has been to chronic conditions such as arthritis. This disease, which affects 36 million people in the United States, is difficult to live with because its course and its treatment are often uncertain, pain may flare up unexpectedly and physicians have little to offer besides pain medication and exercise.
As the greatest single cause of disabilityin the elderly, arthritis costs the nation $14 billion annually. (The average arthritis patient over 50 spends more than $1,000 yearly on medical visits and on drugs, which often have negative side effects.) Given the enormous costs of this disease, it is important to encourage arthritis patients to function as fully as their disease will permit and to use as little medication as they can.
Just as some people are afraid ofsnakes, arthritis patients are often afraid of the pain and disability that can go along with the disease. And like phobics who forgo a potentially snake-free walk in the woods, arthritis patients may begin to avoid activities they fear will bring on pain and thus end up constricting their lives unnecessarily. The story of arthritis patient Marian Green shows how the approach pioneered by Bandura with phobics has helped to make life with arthritis more active, more bearable and less expensive.
Green didn’t know she had arthritisuntil she fell and broke two fingers. Her physician looked at the X-rays, told her she had a degenerative disease, prescribed drugs and advised her to “live with it.’ If that didn’t work, he could fuse the joints in her fingers.
Green, an accomplished pianist, wasindignant: “I didn’t feel diseased, and I hate the word “degenerative.” She disliked taking medicine, even though her arthritis worsened. So she looked around for something better.
What she and more than 15,000 otherarthritis sufferers found was a 12-hour patient-education course first offered at the Stanford Arthritis Center. It was designed by Kate Lorig, a public-health educator. The course, “Arthritis Self-Help,’ is offered nationwide by the Arthritis Foundation (see “Further Information’ box).
Lorig started the course in 1979 tohelp change patients’ behavior and reduce their pain by providing information about their disease and ways to deal with it. She was also interested in trimming the costs of arthritis treatment. The course provides both education and a support group for arthritis patients and uses trained nonprofessional leaders, most of whom have arthritis themselves. One of these is Green. “The course helped me so much,’ she says, “that I just had to tell others about it.’
When the first course was evaluatedby comparing people who had taken it with others on a waiting list, it was clear that the participants ended up with less pain and more knowledge about arthritis. Further, on the average, participants also made fewer visits to their physician and were more active than those on the waiting list.
But even as Lorig and her collaboratorswere congratulating themselves, they were puzzled by the lack of any relationship between how participants felt and how much they had learned about arthritis. In other words, the course worked, but they didn’t know why. What had happened, later studies confirmed, was that the researchers had “rediscovered’ self-efficacy theory in practice. These later studies showed that those whose level of self-efficacy had increased during the course felt less pain. As Lorig observed, the program seems to work more by increasing patients’ sense of self-efficacy than by teaching them helpful ways to handle the disease.
There is a difference between havingskills and being able to use them effectively. As Bandura said in his keynote address at a recent conference of the Society of Behavioral Medicine in San Francisco, “If people are not fully convinced of their personal efficacy, they rapidly abandon the skills they have been taught when they fail to get quick results or experience some reverses.’
Continuing evaluations of Lorig’sprogram, which has been revised several times to make its benefits last, attest to its success. As now given, the program incorporates many elements of Bandura’s phobia-treatment program to give patients an enduring sense that they can gain control over their condition. Course leaders such as Green teach patients relaxation techniques to reduce their anxiety about the disease and to relieve their pain. Leaders also encourage people to devise their own exercises based on general principles provided in the course, rather than giving them ready-made ones. All of this makes patients feel more in charge of their own health care and more confident that they can deal with their disease.
Participants also learn to monitortheir own condition by filling out daily pain and mood charts. Some people find that painful joints make them feel low; others discover that the bad mood comes first and seems to cause more physical discomfort. Still others find, to their surprise, that they can feel cheerful even when in pain and grumpy even when pain-free. As one patient said, “I may not have any less pain than I did before, but I feel like I can cope with it better now.’
This feeling of control makes somepatients less dependent on increasing dosages of medication. Even though some people with arthritis need to continue taking medication, Green now takes no drugs at all. “I’ve had such bad experiences with family members taking drugs that I refuse to be dependent on anything,’ she says.
The same self-efficacy approachesthat work for arthritics have proven invaluable for other kinds of patients, including those recovering from heart attacks. Once patients recover from the acute phase, physicians usually give them a clean bill of health and encourage them to exercise and resume their former activities and sexual relationships. Instead, many such patients become depressed, helpless and fearful. Like phobics and arthritis patients, their fear leads to avoidance. In this case, fear that they may overtax their heart leads to inactivity, which then causes real disability.
As Bandura describes the situation,”The recovery problem stems more from patients’ beliefs that their cardiac system has been impaired than from physical debility.’ And even if a heart-attack victim overcomes personal fears, a spouse or children may treat the patient as an invalid, afraid that too much activity will precipitate another heart attack.
Bandura and psychiatrist Craig Taylor,working with cardiologist Robert DeBusk, psychologist Craig Ewart and nurse educator Nancy Miller, conducted a research project in which women helped their husbands recuperate from an uncomplicated heart attack. It focused on the initial treadmill test that these men took to assess how well their hearts were functioning. The special twist in this project was that wives took the treadmill test along with their husbands.
These researchers found that if awife merely watches her husband on the treadmill, she is likely to misinterpret what she sees. If he becomes fatigued and breathless during strenuous activity, she may view this as a sign of disability and conclude that his heart is weak despite what the physician says. But if she takes the test herself, she learns firsthand how much stamina it requires and can then judge his capability more realistically. And if she sees her husband match or surpass her own treadmill performance, she is likely to be convinced that his heart is truly sturdy.
If both husband and wife are confidentthat he has a robust heart, he is likely to return to his normal life-style. He becomes encouraged to remain active, which in turn strengthens his heart so that the activities he tries will not tax it.
The researchers found that howwell the husbands’ cardiovascular systems functioned six months after the initial treadmill test was predicted more accurately by the husbands’ and wives’ beliefs in the patients’ cardiac capabilities than by how well the men did on the treadmill test. The more they believed in these capabilities, the more the men improved. Significantly, when couples were confident of the men’s cardiac capabilities, they were more likely to follow the prescribed exercise routines.
Cardiologist John Farquhar andpsychologists Nathan Maccoby and Joel Killen of the Stanford Heart Disease Prevention Program are applying self-efficacy principles in devising smoking-cessation and other programs to promote good health. One program includes a self-directed exercise kit, which provides information about the role of exercise in preventing heart disease, as well as a series of graduated walking or jogging regimens. The program seems deceptively easy at first, but it is designed to enhance self-efficacy by guiding participants through small, manageable steps that gradually lead them to do more than they ever thought they could.
What people do, how they interprettheir actions and how they translate their successes and failures into a sense of self-efficacy all influence their future behavior and health. In applying psychological concepts such as self-efficacy to a wide range of health problems, researchers and clinicians are beginning to understand not only how individuals’ beliefs cause or prevent illness but also how they shape its course and the chances of recovery.
Photo: Undaunted by arthritis,Marian Green, a retired music teacher, learned how to cope with her disorder through the “Arthritis Self-Help’ course developed by Kate Lorig of Stanford. Now teaching the same course, Green helps other patients at the Stanford Arthritis Center overcome their fears of pain and disability.
Photo: Albert Bandura, pioneer of the “self-efficacy’ approach.
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