Concise Communications
Self-Efficacy and Social Learning in Mental Health Care
Jan Sitvast*
Corresponding Author: Jan Sitvast, Ph.D, Lecturer, Department of Health Care, Hogeschool Utrecht, Heidelberglaan 7, Utrecht, 3584CS, Netherlands; Tel: 0031614328220; E-mail:
Received: April 23, 2018; Accepted: June 22, 2018; Published: November 19, 2018;
Citation: November 19, 2018
Copyrights: ©2018 Sitvast J. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


In the case study “Importance of Patient’s Narrative and Dialogue in Healthcare” Sitvast [1] summarized the roles a nurse can play in a narrative, person-centered approach of care: besides validating the narrative it is important to find common grounds and starting-points to base nursing interventions on. The mission of nursing in the case of patients with a chronic disease may be to help patients to live a life beyond disease and experience life as meaningful, even when physical and mental conditions do not always improve. Patients tell stories that reflect the choices, expectations, hopes and fears in real life. Sometimes they invalidate the possibility of change or they legitimatize with their stories passive roles in which they are the object of powers from outside. They are no longer then the actors (agents) of their lives, determining their own destiny, but patients (the Latin word denotes this passive submission to the fate of a disease). As a consequence patients will tend to avoid new experiences and thus cut themselves off from learning opportunities to understand their lives differently. This is what we call ‘experiential avoidance’ [2]. Sometimes patients will seek out evidence that things go the way they believe they always go (anyway since they fell ill, were diagnosed, etc.). They are trapped in a self-fulfilling prophecy, which is sometimes aggravated by the diagnosing process of health professionals and the regime of treatment that demands from patient’s therapy adherence or compliance (Box 1).

“In medicine, compliance (also adherence) describes the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication or drug compliance, but it can also apply to other situations such as medical device use, self-care, self-directed exercises, or therapy sessions.”

Adherence refers to the patient, adhering to the proper practices of medicine in an active way and on the basis of being informed and convinced about the merits of a treatment or a lifestyle recommendation. Compliance is when the patient follows the instructions of the doctor. It is much more based on acceptation that the doctor ‘knows best’.

Wikipedia,, accessed on April 10th 2018

However, where the nurse finds an entry in the patient’s narrative to ground her contact with a patient on a shared understanding of things and values that are important to the patient, she can connect with him. This is the follow-up of empathic listening and validation of narrative. It is about finding purpose in life and how this may be translated into goals. Then the nurse may suggest alternative turns to the story or stimulate the patient to take up another perspective [3]. For instance in the case where a patient imputes the role of victim to himself in the story he tells, the nurse may suggest that a more active role is also possible. The nurse may facilitate this shift in perspective by creating conditions for a social interaction in which the patient experiences how things can be different and in which he can have alternative roles. So far the conclusions of the case study “Importance of Patient’s Narrative and Dialogue in Healthcare” [1]. 


We will now discuss how the nurse can create conditions for social learning and acquiring goal readiness by the patient. Only when persons can translate purpose into goals and engage in actions to realize these goals then it becomes a living ‘animus’ that reinvigorates life and allows a person to be more resilient to obstacles, stress, and strain [4]. 

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].


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.


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].


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.

1.       Sitvast J (2017) Importance of Patient’s Narrative and Dialogue in Healthcare. Int J Emerg Ment Health Human Resilience 19: 1522-4821.

2.       Hayes SC, Luoma JB, Bond FW, et al. (2006) Acceptance and Commitment Therapy: Model, processes and outcomes. Behav Res Ther 44: 1-25.

3.       Clark M, Standard PL (1997) The caregiving story: how the narrative approach informs caregiving burden. Issues Ment Nurs 18: 87-97.

4.       Washington OGM, Moxeley DP (2013) Self-efficay as a unifying construct in nursing-social work collaboration with vulnerable populations. Nursing inquiry 20: 42-50.

5.       Bandura A (1997) Self-efficacy: The exercise of control. Freeman, NY.

6.       Sitvast J (2014) Hermeneutic Photography: An Innovative Intervention in PsychiatricRehabilitation Founded on Concepts From Ricoeur. J Psychiatr Nurs 5:17-24

7.       Cook JA, Copeland ME, Jonikas JE, Hamilton MM, Razzano LA, et al. (2012) Results of a Randomized Controlled Trial of Mental Illness Self-management Using Wellness Recovery Action Planning. Schizophrenia Bull 38: 881-891.

8.       Fukui S, Starnino VR, Susana M, Davidson LJ, Cook K, et al. (2011) Effect of Wellness Recovery Action Plan (WRAP) Participation on Psychiatric Symptoms, Sense of Hope, and Recovery. Psychiatr Rehab J 34: 214-222.

9.       Sitvast J (2011) The Photo-instrument as a Health Care Intervention. Health Care Analysis 20: 177-195.

10.    Sitvast J (2017). Photography as a Means to Overcome Health Anxiety and IncreaseVitality, A Local Group Intervention in an Ailing City District. SF Nurs Heal J 1:1