There is no such thing as a new idea continued

(continued from last post)…Socio-cognitive models have been used by health psychologist to increase our understanding of a variety of health behaviours.  What about disability associated with low back pain?  If we can think of disability as made up of specific behaviours then and if these behaviours are intentional it follows that people with low back pain can decide whether to perform them (or attempt to perform them).  Behaviours are regarded as intentional when the proximal determinant of the behaviour is the formation of intent.  This is the essential part of the model; it is the key that gives psychology access to pain related disability, as intention to perform any given behaviour is the best predictor of actually performing it.

If the behaviours that make up disability are intentional – a person decides whether to get up from a chair using an armrest, or decides to stay at home, or take time off work, or walk more slowly than usual – what is intention, how is an intention formed?

There have been a number of socio-cognitive models proposed to explain intention but probably the most commonly used and applied model is the Theory of Planned Behaviour, proposed by Azjen (1988).  It isn’t perfect, doesn’t work in every context and has evolved to include some other predictors over the years, such as habit and context.  The general principles have quite a bit of research support and I think that it is a helpful model to think about low back disability.  The theory proposes that intention is formed by a combination of an attitude towards the behaviour, the social pressure to engage in it and whether a person believes that he or she has the necessary internal and external resources to achieve it.  Respectively these constructs are called attitude, subjective norm and perceived behavioural control.

This model has helped me think about some of the things we observe in patients with low back pain who are disabled.  Social influences on disability, for example, are often referred to in the literature but their mechanism, or the way in which they affect disability is rarely explained.  The Theory of Planned Behaviour proposes that social influences; influences from a partner, family, doctor, physiotherapist and the wider culture, act on disability through social pressure to perform (or not perform) particular behaviours. If you perceive that your family are telling you to rest when you have low back pain, you are more likely to form an intention to rest, and then to actually rest.  Some cultures may value these types social influence more highly than others and for some patients with low back pain trying to get them to change their behaviour is probably made easier if the rest of the family are involved too.  Perceived behavioural control can be thought of as simply whether a person believes that he or she has both the internal (skills or self efficacy) and/or external resources (time, money, opportunity etc) to perform the behaviour.  Finally an attitude towards behaviour describes the subjective evaluation (positive or negative) of the behaviour, or more specifically the outcome of what we think the behaviour will lead to.  If a person has low back pain, pain intensity, expectation of pain, and fear of pain will very likely to play an important role in the formation of the attitude towards any particular behaviour.

That is a pretty sketchy outline of the Theory of Planned Behaviour, and that is only one example of a socio-cognitive model.   Few of these models have research support for them in the literature on low back pain as to my knowledge they haven’t been tested (a exception is Bandura’s Social Cognitive Theory from where we get the construct of self efficacy).  It may not be the best model and things in psychology tend to move on pretty quickly, health psychologists in particular seem enamoured with developing models.  The most important point for me though was that it made me consider that low back disability is primarily governed by psychological principles, and might be regarded, at least to some extent, as a motivational problem.  It also made me think more broadly about what other influences there might be on low back disability, other than just pain, and how changing these influences might lead to changes in disability.

James McAuley

James McAuley BiMJames is Manager of the BiM research group at NeuRA. He is a veritable expert at this sort of thing – having been Manager of the Back Pain Research Group at Sydney University and the George Institute. James is possibly the most interesting manager in the world – former club promoter, bar/restaurant and night club operator, underground house music connoisseur, psuedo-vegetarian (for the most interesting of reasons), moped rider and psychologist (yes – that does make him interesting). James has a PhD from Brunel Uni, UK on cultural influences in back pain.

James’ personal research is in identifying and treating risk factors for chronic back pain and developing approaches to improve management of chronic low back pain. Recently he has become interested in novel strategies for managing clinical pain in the real world. More about James here. Link to his published research here.


Johnston, M. (1996). ‘Models of Disability’. The Psychologist, 9, pp. 205-210

Johnston, M (1996). Models of Disability Physiotherapy Theory and Practice, 12 (3), 131-141

Ajzen, I. (1988). Attitudes, personality, and behavior. Milton-Keynes, England: Open University Press & Chicago, IL: Dorsey Press.


  1. Mike, I think that you have highlighted something that is very often overlooked in healthcare – that changing thoughts, beliefs, attitudes and behaviour is incredibly difficult. Even psychologist, despite what they might think, aren’t as good as they think they are at doing this (Henshcke et al., 2010 – Behavioural treatment for chronic low-back pain (Review).

    I think that too often it is assumed that telling a patient something should be enough to make them change their beliefs/attitudes and therefore their behaviour. Sometimes these attempts at belief/attitude change can be as simple as giving someone a booklet, or just telling someone how things *really* are. Exactly as you have highlighted, I think that the most important thing that a patient brings to an encounter with a health professional is all of their previous experiences and then the task is probably how these can be used to allow them to see different ways of thinking. Some clinicians, from all sorts of professions, are natural expert at this.

  2. Hi Adam – thanks for the compliment, a very nice thing to say 😉

    Mike, I think the reason that I was attracted to the Theory of Planned Behaviour, and some of the other socio-cognitive models are that in essence they are offer pretty simple explanations for behaviour. At least they try to simplify things, and give us somewhere to start when we think about testing theories etc. I find the messy stuff interesting but I often really don’t know that to do with it in terms of moving things forward. Don’t get me wrong, I like qualitative research (well some of it, i think that it can disappear up it’s own bum when it gets too ‘academic’), but I’m a bit too simple and not clever enough to see where some of it leads.

    I liked Brene Brown’s talk, she’d doubtless hate me for saying it but she tells a good story – but my brain can’t help simplifying it into “don’t be judgmental, tolerate ambivalence, accept yourself how you are”. Probably good advice, and relevant to people with pain in relation to Acceptance and Commitment therapy (ACT) which seems to have some moderately strong evidence in a range of fields.

    Mike Reply:

    James, thanks for the dialog.
    …moving from theory to practice…. I spend every day with 3 or more patents (some days 10) who are in chronic pain. This way of thinking about pain and connection all helps me remember that, what they ‘do and say’ is far more important than what I do. I am often engaged with guiding patients in improving movement and posture, but now keep in mind that what they do with that guidance is essential. What I look and listen for is ‘are they willing to shift from seeking care to using their internal resources?’ The conversation often shifts to what’s going on at home because they need to be making changes there.


  3. Thanks James. This argument colors in the healthcare scene nicely.
    This is messy stuff.
    It does seem to me that the view in healthcare needs to be expanded to 360 degrees.
    You make the point well that people do not travel to chronic pain an their own.
    From Nortin Hadler using epidemiological evidence…Yes back pain and most musculoskeletal pain (with not clear damage to bone of joint) has no structural basis. These are problems with movement posture and patient expectations. It is normal to have pain from time to time. What is not normal is to seek care (Hadler 2005).
    So how are care seekers different and how to we meet them? What is the care giver’s intensions?
    What are we looking for for when we seek care? Are we looking for relief from pain and is that intention connected to something profoundly deeper? Who is the care givers and what message to we unconsciously send due to our beliefs, attitudes and our own self-efficacy.
    For a terrific talk on the messy stuff see:

    Physical Therapist, USA

  4. Adam Bjerre says:

    What a well-crafted and open-minded argument for how psychology, behaviour and pain might interact together without pointing the finger at the patient, but including the person instead of the still present dogma of describing the disability in terms of “meat and bones”. Thank you so much, James! Impressive debut in this type of media for an extremely experienced person… 🙂 I still love this site to bits!

    Adam Bjerre
    Physiotherapist, Denmark