Fake it ‘Til You Make it: Educating Patients on Self-Efficacy

You and your patient have been over this many times. She complains of feeling isolated but still sits at home instead of going out with friends who call. When you point this out, she says she doesn’t feel like going out; she will go out when she feels “better.” 

Or, he says he feels depressed about the breakup with his girlfriend but continues to talk about her and ruminate about what he could have done differently in their relationship. Although he has been involved with a group like Habitat for Humanity in the past, he resists suggestions that he get involved again. He says he will when he feels “better.” 

That’s when I do some educating to counter a common misunderstanding about therapy. I tell my patients that people sometimes believe one comes to therapy, talks about problems and, after awhile and like magic, everything is different in your life. 

But that is not how therapy works. With newer evidence-based therapies like cognitive-behavioral therapy, identifying the erroneous ideas behind one’s behavior is a major key to understanding how we sabotage ourselves on a daily basis, but the real therapy goes on OUT THERE in the real world, in the changed behavior based on corrected ideas. 

So, it is important to get out there and practice changing behaviors that are based on maladaptive ideas before “feeling better.” For many people who have been steeped in the psychoanalytic notion of gaining insight that leads to behavior change, this is standing the whole process on its head. 

My practice is informed by the concept of ‘self-efficacy,’ a concept put forth by psychologist Albert Bandura of Stanford University (Bandura, A. (1977). Self-efficacy: Toward a Unifying Theory of Behavioral Change. Psychological Review, 84, 191-215).  Self-efficacy is the belief in one’s own ability to complete a task and reach a goal. Bandura hypothesized that expectations of personal efficacy determine whether a behavior will be initiated, how much effort will be expended, and how long it will be continued in the face of obstacles and aversive experiences. 

Expectations of self-efficacy come from four sources.  The first source is performance accomplishments.  I point to previous levels of accomplishments as a template for starting to engage in new behaviors. Generally, there are some accomplishments to point out in adult patients, so this is an easy start. 

A second source of efficacy expectations is vicarious experience.  With a rather shy young male patient who complained that he could never meet and talk to women in social settings, I asked if he knew anyone who embodied his idea of success. He said ‘yes’ and went on to describe how this other fellow would act. He already knew how to do it! He thought the idea of acting like this guy was a bit strange, but he did it and surprised himself. 

The third source of efficacy expectations is verbal persuasion, and I am not ashamed to ‘cheerlead’ efforts to adopt new behaviors, even as I acknowledge that anything I can say is much weaker than what patients tell themselves. I also make sure they understand that I realize how difficult it is for them to make changes. 

The fourth source of expectations of efficacy has to do with keeping emotional arousal within limits of tolerance. So, we rehearse situations, and, if necessary, I teach relaxation techniques with the proviso that the techniques are merely tools for them to use – that the tools are within their control, a win-win. 

Sometimes engaging the patient in starting to change behaviors in small ways gets parlayed into bigger changes that keep on snowballing. However, when all the tools lead nowhere and resistance continues unabated, it’s time to look at what else is going on. Next time, I’ll talk about when what to do when the therapist realizes he’s working harder than the patient. 

In the meantime, let me know your own experiences about self-efficacy. How do you incorporate this concept into your practice?

Leslie Durr, PhD, RN, PMHCNS-BC is an advanced practice psychiatric-mental health nurse with a private psychotherapy practice in Charlottesville, Virginia.

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors.