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Self-efficacy and paradoxical dependence in chronic back pain



The 2024 Global Year will examine what is known about sex and gender differences in pain perception and modulation and address sex-and gender-related disparities in both the research and treatment of pain.

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Chronic back pain is one of the most common medical problems patients experience, and it may also be psychologically and socially disabling. People with chronic back pain are significantly more likely to experience depression, anxiety, and other mental health conditions than the general population. I wanted to get a deeper appreciation of how chronic back pain impacts people’s sense of self-efficacy–that is, how being in pain all the time affects their own general sense that they can set and accomplish goals in their lives.

There is already a Pain Self-Efficacy Questionnaire for quantitatively measuring people’s sense of control over their lives despite pain, and there are known interventions for chronic pain that aim to increase self-efficacy, empowering people to take control of their own experience of pain. But I wanted to get beyond the numbers, and learn from people with chronic back pain exactly what aspects of self-efficacy they report are important to them. So, to obtain people’s stories, instead of using a questionnaire or other quantitative or measurable method, I opted to use a qualitative technique called phenomenological interviewing.

With some help from my mentor, Larry Davidson, PhD, I learned to use this technique to get people to think about important aspects of their life experiences and then to recount those experiences to me exactly as they had experienced them. In each interview, my goal was to elicit a rich narrative that consisted entirely of what that person found important, without infusing any of my own assumptions. I conducted these interviews with twenty patients in a spine pain clinic, then analyzed the narratives and found common themes.

In my study, I was most struck by how often people talked about their social relationships. They craved human connection, and resented it when their pain kept them from connecting with others:

“I want to be a good father. I really want to be able to do things with my son. You know, run around, and play catch, and do these things that I always wanted to do. And with this pain it’s like, oh my God, how am I going to get through this?”  -Participant 6, 29-year-old man

“I have a high school reunion coming up, and I’m just not up for it. I know it means a lot of being on my feet, a lot of up and down, so I’m like, I’ll pass on that. Relationship-wise, it’s a lot of stress.”  -Participant 13, 38-year-old woman

Importantly, some of the participants connected their social difficulties with their own lack of self-worth. Some felt they had less to contribute to their social relationships.

“When you live with chronic pain, you don’t have a lot of self-worth. You can’t do anything. It was hard on my marriage. That was part of the problem with me, was I felt insignificant. I was looking for a reason why I was here. And I don’t have a reason. I can’t do much. I did attempt suicide once. My husband and I were arguing. I knew I was going to do it.” -Participant 19, 57-year-old woman

I found that for the people I interviewed, loss of independence was very much tied into their social difficulties.

“I can’t do the gardening, because if I bend over too long, the pain comes back. I can’t walk my daughter’s dog. And my daughter who lives across the street from me took away my driving. She drives me, and I hate it.” -Participant 3, 75-year-old woman

Here’s the picture I ultimately ended up with: people with chronic back pain can feel less able to connect socially, due to a combination of diminished physical functionality (i.e. being able to do less) and diminished self-worth (i.e. feeling like they have less to contribute to others). But on the other hand, having chronic pain means they have to accept more help from others in order to get through their daily lives. The key connection here is that when people with chronic back pain have to accept help from others, this may worsen their already degraded sense of self-efficacy and self-worth. Relying on others can further decrease their sense of independence and worsen their outlook on life.

The major takeaway from my study is that when treating chronic back pain, any efforts to promote self-efficacy will need to acknowledge patients’ diminished sense of functional capability, and to recognize that pressure to be more self-efficacious could exacerbate underlying concerns about needing to rely on others. There is need for a balanced treatment approach in which individuals are not only empowered to support themselves, but also especially encouraged to accept support when needed while still cultivating a sense of self-worth in social relationships.

About Elizabeth Cummings

Libby CummingsElizabeth (Libby) Cummings is graduating this spring from the Yale School of Medicine in New Haven, Connecticut, USA. She will be starting Primary Care Internal Medicine residency this summer at the University of California, San Francisco. During her time in medical school, she helped design and lead an interdisciplinary course called US Health Justice, which focuses on the social determinants of health and health disparities. She also facilitated reflective writing sessions and reflective art gallery sessions about implicit bias for other medical students. She graduated from Stanford University in 2012 with a B.A. in Human Biology, concentrating in health disparities and community health. Her interests include the social determinants of health, health systems, narrative medicine, and the psychosocial experience of chronic pain. Outside the clinical setting, Libby enjoys backpacking, skiing, and cooking (as her latest hobby, she is trying to get into cheesemaking).


Cummings EC, van Schalkwyk GI, Grunschel BD, Snyder MK, Davidson L. (2017). Self-efficacy and paradoxical dependence in chronic back pain: A qualitative analysis. Chronic Illn. 13(4):251-261.



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