This is where self-efficacy enters the scene. Self-efficacy stands for beliefs in being able to perform successfully actions needed to realize a desired outcome [5]. Self-efficacy is very much a matter of social learning, as we will see. On the one hand there is the confidence that one will attain a certain goal and on the other hand there is the belief that one can perform the skills and strengths needed for realizing the goal. Self-efficacy concerns the individual’s agency (actorship).

Self-efficacy presupposes a good understanding of one’s potentials and also what action options there are to choose from that will lead to successful goal attainment. We call this goal readiness and it is learned from the feedback of the social environment. However, harassed by setbacks in life and beset by illness, persons with severe mental illness (SMI) may have developed a low self-image that prevents them to profit from the learning opportunities offered by thinteraction with others. How then live a ‘valued life’ with value-based goals to strife for? They may need the help of professionals to overcome shame and connect again with their deeper and whole core. And develop a greater goal readiness. How can professionals assist service users in these difficult tasks?

There are four sources of self-efficacy that belong to the realm of social learning and which professionals can make use of to support service users [4]. We quote Washington et al. as they list the four sources of self-efficacy (abbreviated as SOSE):

i.            Vicarious experiences through exposure to powerful role models and their constructive use of emotion, cognition, behaviors and skills, particularly as ways of either coping with a situation or in transcending it;

ii.            Emotional arousal involving self-awareness of both self-defeating and productive emotions;

iii.            Verbal persuasion in which influential people encourage and support change;

iv.            Performance in which recipients practice new behavioral forms, enact new behaviors in relevant settings and accumulate evidence for the efficacy they need to face life challenges or to achieve goals.

Examples of each of them are easy to find. For instance (first SOSE): a service user participating in a phototherapy session [6] during which he pictured himself to take his exams for a driving license. He used a photograph of Len Armstrong, the racing cyclist as an image of perseverance in a difficult situation when one is beset by a severe illness (cancer in the case of Armstrong; a psychosis in his own life). The photograph became a reminder of what his stake was. How Len Armstrong had persevered was also taken account of in order to derive lessons from him.

The second SOSE is best illustrated by situations in which professionals have developed a working alliance with service users and then share emotions on the basis of commitment and reciprocity or where professionals can show their emotions in order to make the service user become aware of success or of what goes wrong. This happens when we celebrate milestones on the path to realizing a goal or when we show our disappointment over failed actions.

The verbal persuasion, in which influential people encourage and support change, was the third SOSE. It reminds us of the importance of systems in which people are embedded and of the opportunities to actively involve relevant others in the treatment and support.

The last SOSE is: performance (engagement) in which recipients practice new behavioral forms, enact new behaviors in relevant settings and accumulate evidence for the efficacy they need to face life challenges or to achieve goals. Performance presupposes goals that can be attained. Goal finding and goal formulation are important here and of course facilities or niches in which service users safely can exercise and practice their new behavior and newly learnt skills. This explicitly involves consumers taking personal control of their recovery and drawing from their own expertise and experience in order to develop an individualized self-management plan. Self-management of psychiatric illnesses is an important principle of consumer-directed mental health treatment and the most well known and most widely disseminated manualized self-help program is the Wellness Recovery Action Plan, known as WRAP [7]. WRAP is a peer-based program. Service users coming together in peer-groups identify internal and external resources for facilitating recovery [7,8]. WRAP aims at improving their ability to effectively take responsibility for their own wellness and stability, manage and reduce symptoms and effectively learn skills to reach out and use support [7].

Assisting service users to help themselves and achieve outcomes they value will contribute to increasing hope that their lives will be purposeful and that their self-efficacy will become stronger. Where they face distressful circumstances as in a period of transition they will be better armed “to identify issues they want to resolve to improve their functional health and wellbeing.” [4].

AWARENESS, REFLECTION AND EXPRESSION

We assume that the anticipation of issues still ahead and the transference of what one has learned in one area into another presuppose a certain awareness of one’s strength. This awareness does not come natural but must be brooded on and made explicit. It is not enough to formulate it semantically, as words are only words. It must be felt and experienced, confirmed in the contact with relevant others (among them professionals) and highlighted. The next step is expressing it in a visual or palpable form as a kind of externalization of what otherwise remains only a mental image. What is needed is a certain degree of iconization: images laden with meaning engrained in the emotional life of the service user. Then awareness becomes a vehicle for exchange between people, a message that invites feedback and hails someone else’s empathy. Reflection as essential element of social learning is embedded in true engagement and social interaction. We will give one example here Boris [9]. Boris (pseudonym) lived in a sheltered home because of his vulnerability for psychotic decompensation and depression. He struggled with overweight. He discussed with his mentor nurse how to deal with this problem and Boris decided to make cycling one of his regular activities. He showed his intention in a number of photographs which served as his visual agenda and reminded him of his plans. After 6 months he had lost enough weight to celebrate his success together with his mentor nurse (who also had accompanied him on some of his cycling outings). The photograph (Figure 1) served not only the celebration, but also to underline the shared effort and commitment.

IMPLICATIONS FOR NARRATIVE AND DIALOGUE

What does this mean for narrative and dialogue? The service user’s narrative becomes much more grounded in lived experiences and the communication with others. Images do not only have a metaphoric power to tell a story, but also re-activate narrative creativity where the service user used to be quite set in patterns of ‘closed’ narratives. New meanings which may arise are often grounded in a sensed vitality that comes from realizing one’s goals [10]. Having achieved something invites people to explore the values, wishes and aspirations they may associate with them. Those values, wishes and aspirations can be used as a motor for further goal oriented actions.

“It will infuse vitality and resilience into a person’s coping with issues of health and illness because it will mean living to the full of one’s potentiality and will cause a bodily felt thrill. Vitality is the physical sensation that you feel good, energetic and that you are glad or happy. Resilience comes from being aware that there are things that you are good at and you like to do or, in other words: the things that make you happy, get energy from and that make you feel good. When resilience joins self-efficacy, then we have the ingredients for a greater psychological flexibility” [10].

CONCLUSION

Narrative does not come into being from out of the blue. It transposes the real life experiences in a coherent message about the person and his identity. It may become the vehicle for awareness about deeper values, strengths, hopes and expectations when there is a shared understanding and dialogue with relevant others. When the real life experiences are based on social learning facilitated by the nurse and its positive results are explicitly incorporated in the narrative through reflection and dialogue, then the ‘closed’ narrative may open up and give rise to a new psychological flexibility and more well-being. When the service user then follows the advice of his nurse and adheres to lifestyle recommendations it will be much more grounded in his own awareness and not in complying with what the professional seems best. Visualization of the narrative may be of great help in this process as it strengthens the mental image through iconization and communicative potentials.