WORK A Journal of Prevention,

Assessment & Rehabilitation

ELSEVIER

Work 8 (1997) 189-196

Chronic illness and return to work: a social cognitive perspective 1 Richard T. Roessler* , H. Michael Kirk, Patricia L. Brown Department of Rehabilitation. University of Arkansas. Fayetteville. USA

Received 19 May 1996; accepted 19 June 1996

Abstract High unemployment rates for people with multiple sclerosis are frequently attributed to decreases in self-efficacy and outcome expectations with respect to job seeking and retaining tasks. Hence, return-to-work interventions must enable people with MS to develop positive expectations. They must believe (a) that they possess the abilities needed to respond effectively in the job interview and request reasonable job accommodations (self-efficacy) and (b) that they will secure employment as a result of their efforts (outcome expectations). Based on social cognitive strategies, the Accommodations Planning Team (APT) Seminar offers the skill training required for increasing employment-related efficacy and outcome expectations. © 1997 Elsevier Science Ireland Ltd. All rights reserved

Keywords: Employment; Multiple sclerosis; Accommodation planning

1. Introduction This article provides a theoretical explanation for the unacceptably high rate of unemployment among people with chronic illnesses such as multiple sclerosis (MS) and relates that theoretical explanation to a needed return-to-work intervention based on social cognitive theory (Lent et aI., 1994). Past research indicates that people with multiple sclerosis are not only unemployed at a higher rate than people with disabilities in general but that their unemployment rate is higher

I This

research was supported. in part. by a Health Services Research Project Award from the National Multiple Sclerosis Society (New York, New York).

than would be expected given the nature and severity of their symptoms (LaRocca et aI., 1985). Obviously many people with MS require additional support if they are to initiate efforts to resume employment. In this article we use a social cognitive perspective to describe the Accommodation Planning Team (APT) Seminar, a 4-hour program developed to help people with MS improve their job and workplace accommodation seeking skills. 2. Multiple sclerosis and unemployment One powerful explanation for the devastating effect of MS on retention of employment has to do with the psychological intrusiveness of the

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condition (Devins and Seland, 1987). Given the episodic and unpredictable nature of MS, people lose a sense of certainty and control with regard to their personal futures (LaRocca et aI., 1985). In other words, they increasingly doubt their own capabilities to exert control over the environment and to achieve desirable outcomes such as resumption or retention of employment (Roessler and Rumrill, 1994). Believing that one is no longer effective in achieving desirable outcomes is consistent with the two types of expectations that Bandura (1986) described in his theory of social learning, i.e. efficacy expectations and outcome expectations. Hence, these two types of expectations help to explain the lower than expected employment rates for people with MS shortly after their diagnosis. People with MS do not hold the self-efficacy belief, i.e. can I do it? (Lent et aI., 1994), that they can perform the behaviors required to (a) seek and secure employment (i.e. complete the job interview, application, and resume), (b) seek and secure needed on-the-job accommodations (i.e. identify, plan for, and request accommodations), and (c) organize and monitor the job search process (i.e. locate potential employers, organize the job search, and record outcomes of employer contacts). Moreover, given anticipated job discrimination and the reality of their unpredictable symptom patterns, they no longer hold positive expectations regarding the outcomes of these behaviors, i.e. will I get a job if I make the effort? (Lent et aI., 1994). Specifically, even if they feel efficacious about their job and accommodation seeking abilities, they do not expect that they can achieve the desired ends of securing and maintaining employment. To improve the return-to-work outcomes of people with MS and other chronic illnesses, return-to-work interventions should address two critical needs. They should not only help people strengthen their self-efficacy beliefs about job and accommodation seeking, but also encourage them to hold more positive outcome beliefs with respect to those behaviors. In other words, the career outcome of returning to work is a function, in part, of two constructs, self-efficacy and outcome expectations. Fortunately, a recent theory applied to career development, social cognitive

theory, describes not only how these two types of expectations influence choice making and performance, but also how to help individuals develop more positive efficacy and outcome expectations. In presenting the social cognitive theory of career development, Lent et ai. (1994) described how self-efficacy levels and outcome expectations influence 'interest' which is a precursor to goal setting, action, and performance outcomes. 3. Social cognitive theory and return-to-work outcomes One may explain a variety of outcomes such as choice of a college major, selection of a career goal, or resumption of employment, from the social cognitive perspective. First one must specify the outcome in question (i.e. resumption of employment) and then determine how the person's status on predictor variables in social cognitive theory will affect pursuit of the outcome. According to social cognitive theory, attainment or lack of attainment of a specific goal depends upon how personal dispositions (i.e. internal cognitive and affective states) and environmental opportunities interact to produce learning experiences for the person (Lent et aI., 1996). These learning experiences are the wellspring for the two expectation variables: self-efficacy and outcome expectations. Believing that one is or is not capable of effectively implementing certain skills (level of self-efficacy) and that implementing those skills will or will not enable one to achieve desired ends (type of outcome expectation) creates a motivational state of approach or avoidance, i.e. a press toward or away from a goal such as returning to work. Lent et ai. (1994) labeled this motivational state as an 'interest.' Interests that compel individuals to select goals and to act commensurately rest on a foundation of positive levels of self-efficacy and outcome expectations. Goals are important, of course, because they enable people to self-regulate their behavior, i.e. to modify activities so that they contribute to goal attainment, and thus satisfy the interest. Goal attainment results in a positive learning experience that contributes to increased levels of self-efficacy and positive outcome expectations

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that, in tum, encourage future approach behavior. Of course, one should keep in mind that factors other than psychological ones affect goal attainment. Goal attainment is affected by contingencies in the environment that either encourage or discourage continued action. Limited employment opportunities in the community, discrimination on the part of hiring personnel, difficulties in arranging reliable transportation and childcare, and/or lack of support from family members have a direct impact on the person's SUCCess in resuming employment. Nevertheless, by looking through the lens of !ioclal cognitive theory, one can better understand why people with MS have such high unemployment rates. Deciding that returning to work is in one's interest and acting on that interest requires beliefs that one can successfully complete the job interview, request needed on-the-job accommodations, and organize the job search process. Additionally, the person must believe that completing those tasks will result in employment. In the process of adjusting to the physician'S diagnosis of MS, coping with the unpredictable and episodic nature of MS symptoms, and dealing with the debilitating effects of such symptoms on their sense of control and mastery, people with MS encounter a series of frustrating and unproductive learning experiences. Without intervention from rehabilitation professionals, they can become discouraged by those experiences which gradually results in lower levels of self-efficacy and negative outcome expectations with respect to resuming work. Consequently, they may lose interest, i.e. motivation, to set return-to-work goals and act accordingly. After studying the dynamics of social cognitive theory, the rehabilitation professional quickly realizes that any employment intervention must address 'interest' in returning to work and its precursors, self-efficacy and outcome expectations. More than that, the theory postulates that learning experiences are the key formative events with regard to those two types of expectancies. Describing how self-efficacy expectations are formed by learning experiences, Betz (1992) suggested interventions that, according to social cognitive theory, should have equally desirable effects on

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the type of outcome expectations held by the individual. Stating that the choice (approach versus avoidance) to perform persistently is a function of self-efficacy expectations, Betz (1992) drew on Bandura's (1986) work to describe four positive learning experiences that influence expectancies: performance accomplishment, vicarious learning by observing the performance of others, verbal persuasion and encouragement, and control of negative physiological states (i.e. anxiety) that cause people to doubt their capabilities. 4. Shaping expectations through positive learning experiences Lent et al. (1994) linked the four sources of learning that affect one's level of self-efficacy to outcome expectations. First, they noted that selfefficacy expectations will maintain a person's efforts even in the face of uncertainty about the nature of outcomes. At the same time, they described how outcome expectations are a function of self-efficacy. 'In the course of interest formation, it is likely that outcome expectations will partly be determined by self-efficacy, since people presumably expect to achieve desirable outcomes in activities in which they view themselves to be efficacious' (Lent et aI., 1994). One should not, however, underestimate the influence of outcome expectations on performance. For example, Lent et al. described how young women who may feel efficacious in math and science choose not to pursue study or careers in that area because they do not expect to be successful in those pursuits. They have learned these negative outcome beliefs as a result of lack of support (null environment) and/or even negative reactions from parents, teachers, and counselors (Betz, 1989). People with MS may encounter similar discouragement in their job seeking. Thus, although they may believe that they can learn to be more efficacious in the job and accommodation seeking process, they may become pessimistic about the outcomes of such efforts. Hence, in designing a return-to-work intervention for people with chronic illnesses such as MS, one must consciously strive to include learning experiences that draw on the four sources

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of self-efficacy and outcome expectation information. In two recent articles, Betz (1992) and Strauser (1995) demonstrated how to apply the four sources of efficacy information in counseling and rehabilitation interventions. Betz noted that classes and workshops are good sources of performance attainment information because they provide people with opportunities to master the behaviors necessary for goal attainment, i.e. mastery-oriented or task-focused learning. Both authors stressed the importance of presenting examples of people who successfully achieved the desired outcome (i.e. returning to work) with particular emphasis on the cognitive and behavioral factors related to their success. These stories about successful role models are powerful sources of vicarious learning. Reading material and video and film portrayals are other ways to introduce helpful vicarious learning experiences. Betz noted that counselors and group facilitators are constant sources of verbal persuasion and encouragement. By prompting individuals to act and reinforcing them when they do, counselors begin the process of efficacy and outcome expectation enhancement. Group leaders in a returnto-work intervention for people with MS have many opportunities for such encouragement and reinforcement. Betz offered suggestions for dealing with the anxiety (physiological arousal) associated with learning new expectations and behaviors. First, she recommended a task, rather than self focus. Learning experiences that clearly specify the target behaviors required to be efficacious (mastery-oriented) not only provide performance attainment information but a task focus that helps to control negative physiological states that cause people to conclude that they are not capable. During skill training programs, facilitators should also identify and suggest alternatives to negative self-talk that increases anxiety and thus impairs learning and performance. 5. APT seminar

The Accommodation Planning Team (APT) Seminar (Reed et aI., 1994) incorporates the four

types of information designed to influence selfefficacy and outcome expectations. Designed for people with chronic illnesses such as MS, the four-hour APT Seminar involves six to eight unemployed people with MS, each of whom is a member of a team including a rehabilitation professional and an employer. Following directions in the APT Trainer's Manual, two rehabilitation professionals facilitate the work of the participants and their support teams as they complete the structured activities in the APT Participant's Manual. The rehabilitation professional on each team, preferably the person's rehabilitation counselor, provides vocational counseling input and directs the person's accommodation and placement planning. In addition to conducting a mock job interview with the participant, the employer on the team helps to identify barriers to accessing the job site and to performing essential functions of jobs suggested by the client. At least one or more of the employers in the seminar should be a person with a disability who can serve as a role model of the return-to-work outcome sought in the APT Seminar. The goal of the APT Seminar is to help the participant develop positive self-efficacy beliefs and outcome expectations about resuming employment. Three important clusters of skills are taught in the APT Seminar: (a) completing the job interview, (b) managing the accommodation process, and (c) organizing the job search. Each of the instructional segments incorporates the four sources of efficacy information. Specifically, the behavioral or mastery learning approach (i.e. teaching target behaviors) addresses the need for performance attainment information. It also helps the person maintain a task, rather than person, focus which helps to control negative emotional arousal (i.e. anxiety). Vicarious learning occurs as participants are exposed to information about people who have returned to work or remained employed while coping with a severe disability or chronic illness (e.g. the employers with disabilities who are team members). Finally, in conducting the APT Seminar, the two facilitators are sources of verbal persuasion and encouragement. The three skill training components of the APT Seminar are described in the material to follow.

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5.1. Completing the job interview

Having the qualifications for a job is necessary, but not sufficient, for acquiring employment. If this were not so, resumes and references would be the only factors to consider in the job seeking process. Although important, resumes and references are unlikely to outweigh the effects of poor performance in the job interview. The employment interview is the opportunity to 'market' one's personality, skills, and abilities to the interviewer. The quality of this marketing depends on the individual's competence in responding to the specific tasks of the job interview, e.g. describing past work and educational experience and asking pertinent questions about the position. Therefore, the first component of an APT Seminar presents skills for successful performance in the employment interview. Increasing interviewing self-efficacy is accomplished using strategies consistent with the four sources of efficacy information: (a) performance accomplishment, (b) vicarious learning, (c) control of negative physiological states such as anxiety, and (b) verbal persuasion. Vicarious learning and verbal persuasion are involved in the first step of interview training, i.e. presenting information didactically that educates the participant about interviewing skills. Topics covered during the educational phase of the training include types of interviews (e.g. informational versus employment interviews), dressing for success, typical employer questions and recommended answers, interviewing etiquette, anxiety reduction techniques (i.e. positive self-talk), and approaches to disability disclosure. Vicarious learning is enhanced via modeling a job interview 'in vivo' by the seminar leaders or by showing a videotaped job interview. Seminar leaders identify effective behaviors in the modeling sequence and communicate that participants will learn to perform those skills (verbal persuasion). The next phase of interview training draws on performance accomplishment as a source of selfefficacy information. In their APT teams, participants practice answering typical job interview questions asked by the employer on the team (a mock interview). Questions asked by the em-

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ployer are those presented and discussed during the didactic part of the interview training. Both the employer and the rehabilitation professional on the team provide feedback to the participant regarding the effectiveness of the role play. The employer and the rehabilitation professional first provide information about what the participant did well, then address observed skill deficiencies and strategies for remediating those deficiencies, and finally close with a confidence boosting statement to the participant (i.e. ' ... and with a little more practice, you will do very well in the job interview'). The purpose of the mock interview is to reinforce and improve interview performance, thus, increasing participants' job interview selfefficacy and outcome expectations. During the educational introduction and the performance accomplishment stages, participants learn anxiety reducing techniques such as visualizing themselves as confident job interviewees, breathing slowly and deeply, identifying negative self-talk, and using positive self-talk (Betz, 1992). After learning to visualize success in the interview, to control their breathing, and to replace negative self-talk with positive self-talk, participants practice implementing each of the strategies during the mock interview. Team members and leaders of the seminar identify both positive and negative examples of anxiety control on the part of participants and provide encouragement and correction as needed. After completing the first part of the APT Seminar, participants have acquired the fundamental skills required to complete a successful job interview. Therefore, the probability that they will receive a job offer is increased which places an even higher priority on teaching participants how to clarify their needs for on-the-job accommodations after the employer has offered them employment. 5.2. Managing the accommodation process

During the accommodation training phase, participants (a) identify their on-the-job accommodation needs, (b) develop an accommodation plan, and (c) request a review of their accommodation needs with their supervisor or employer. In teach-

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ing these three steps, APT facilitators use each of the sources of self-efficacy information. For example, control of anxiety is achieved by providing a cognitive structure of how to identify accommodation needs and develop accommodation plans and by presenting a task-focus approach (defining specific accommodation request behaviors) to learning to request an accommodation review with one's employer. Facilitators offer verbal persuasion and encouragement throughout the training as clients identify their accommodation needs, write an accommodation plan, and present their accommodation requests to their employers. To increase participants' self-efficacy through vicarious learning, APT leaders demonstrate how clients can use the forms provided in the APT Participant's Manual to identify their accommodation needs. With the help of their teams, particularly the employer members, participants indicate what they perceive to be barriers to their accessing the workplace or performing essential on-the-job functions. After completing an access and essential function checklist, they share the results of their work with the team and the total group. During this sharing process, participants not only learn from each other (vicarious learning) but practice communicating their own accommodation needs (performance attainment). With input from their team members, participants set priorities for their accommodation plans by deciding on their top three barriers. They also specify (a) reasonable accommodation solutions to these barriers, (b) who can help them implement the accommodations, and (c) how those individuals can help in the accommodation process. Team members provide technical consultation regarding feasible accommodations and encourage participants in their efforts to develop and present their plans. By the end of this phase of the accommodation training process, participants clearly understand what their barriers, accommodations, and resources are. Their level of self-efficacy with respect to requesting an accommodation review is increased through the encouragement, vicarious learning, and control of anxiety that occurs during the training. To help participants learn how to request an accommodation following the job offer, utilizes all

four sources of self-efficacy learning. First, APT leaders describe the legislative protections for the accommodation request process provided under Title I of the Americans with Disabilities Act. Second, they present didactically the steps required to request an accommodation in the interview process, followed by modeling of those same steps. This didactic phase of the program employs vicarious learning (showing how to request an accommodation), anxiety reduction techniques (a task focus and a cognitive overview), and verbal persuasion and encouragement from the team members and APT facilitators. In role plays with employers on the teams, participants learn through performance attainment the following recommended steps for requesting accommodations in an appropriate manner (Roessler and Rumrill, 1995). (1)

(2) (3)

(4)

(5) (6) (7)

(8)

Following the job offer, explain that you require accommodations on the job to maximize your productivity. Describe your functional limitations and how they affect your performance on the job. Present the types of accommodations that have helped you in the past, giving careful consideration to the cost effectiveness of the accommodations (reasonable accommodations) and the employer's point of view. State how each of the different accommodations helps you to be more productive on the job, an outcome in which you and the employer have a vital interest. Summarize what you would consider a range of reasonable accommodations that would enable you to be even more productive. Listen carefully to the employer's ideas; do not react angrily to resistance. Return the discussion to the rationale for accommodations, i.e. enhanced productivity, and keep the employer focused on the mutual benefits of implementing reasonable accommodations. At the end of the discussion, restate any agreements that have occurred and review the next steps that you and the employer will take. Once again, the employer and the rehabilitation professional provide genuine re-

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inforcement (verbal persuasion and encouragement) and necessary corrections. Upon completion of this phase of the APT Seminar, participants have improved their accommodation management skills in order to move on to the next training segment, organizing and conducting the job search process.

5.3. Organizing and conducting the job search process

Believing that they can successfully complete an employment interview, advocate for needed accommodations, and develop an accommodation plan develops enhanced self-efficacy that positively affects the return-to-work process. Participants are much more likely to say to themselves, 'These are tasks I can do.' However, when a new task such as organizing and conducting the job search is confronted, participants may return to lower levels of perceived self-efficacy. Doubt and anxiety arise when participants ask themselves such questions as 'What if I can't get an interview?', 'What if there are not any openings?', 'What if no one will talk to me?', or 'What if I fail to find a job?' Again, the APT Seminar approach uses the four factors of self-efficacy information, i.e. performance accomplishment, vicarious learning, control of anxiety, and verbal persuasion to influence efficacy ('I can organize and conduct a job search') and outcome expectations ('If I take these steps, I will get an interview') for the job seeking process. In the first part of job search training, APT facilitators employ verbal persuasion and emotional control techniques. They inform participants of the rationale and behavioral approaches for a successful job search and communicate their expectations that participants can master these skills. The facilitators then describe how to develop job leads, how to network, how to conduct informational interviews, and how to utilize available resources (i.e. sources of occupational information and local employment agencies). Employers and rehabilitation professionals on the teams contribute verbal persuasion and encouragement

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during the discussion phases of the presentation. To help participants control their anxiety, facilitators identify examples of negative self-talk and present positively phrased alternatives. Vicarious learning, i.e. learning based on observing others, occurs as participants view demonstrations of the techniques involved in organizing and conducting job search activities. Facilitators present lists of resources, guides for monitoring networking and interviewing contacts, schedules for activities, and a format for developing a formalized job development plan to illustrate how the process works and to demonstrate the reinforcing effects of job seeking efforts. Employers and rehabilitation professionals contribute 'real world' perspectives to the job search and plan development phase, thereby modeling realistic expectations and productive activities. With the help of their teams, participants complete their own placement program. At the end of the APT Seminar, they present the steps of their proposed job seeking plans to the total group. Identifying and communicating behavioral steps in their job seeking plan is a useful first step in performance attainment learning. 6. APT seminar outcomes

Unemployed people with MS, rehabilitation professionals, and employers participated as team members in three APT Seminars during 1995 (Milwaukee, WI; Cleveland, OH; and Louisville, KY). Although some team members did not submit ratings, 48 individuals responded very favorably to the three APT seminars. On a 5-point scale (5 = excellent), they gave the overall program a mean rating of 4.8 (S.D. = 0.46). They also evaluated each phase of the training positively (Job interview training, 4.7; Accommodation identification, 4.4; ADA orientation, 4.6; Accommodations review with employer, 4.6; Placement planning, 4.5; and APT Seminar materials, 4.7). Each of the constituent groups provided positive ratings of the program as well. Using the 1 to 5 scale, unemployed people with MS (n = 17) gave the overall program a mean evaluation of 4.6 (program ratings were not available for four par-

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ticipants). Employers (n = 14) and rehabilitation professionals (n = 17) rated the overall program positively (M = 4.7 and M = 4.9 respectively). Evidence from 12-week follow-up surveys with participants of the three APT Seminars documented positive employment outcomes. Of the 21 unemployed individuals with MS who completed the three APT Seminars, seven participants (33%) resumed involvement in competitive employment. Unemployed before the program, they held the following job titles 12 weeks following the seminar: part-time medical receptionist, full-time shoe salesperson, part-time clerical worker and parttime student, part-time hairdresser, full-time medical technician, part-time telemarketer, and part-time substitute teacher. 7. Conclusion The APT Seminar is a structured employment intervention that is designed specifically for the needs of people who are coping with the effects of chronic illnesses such as multiple sclerosis. Recognizing that the impact of such chronic conditions results in lowered self-efficacy and outcome expectations regarding employment, seminar developers utilize the four sources of self-efficacy learning in APT activities. Specifically, verbal encouragement and persuasion, vicarious learning, control of anxiety, and performance accomplishment are used to teach three clusters of skills: (a) responding appropriately in the job interview, (b) requesting accommodations needed on the job, and (c) organizing and conducting the job search. Instruction occurs in a supportive environment which results from the positive efforts of the two group facilitators and each participant's team members, i.e. the rehabilitation professional and the employer. APT leaders and team members

contribute both to formal learning via programmed activities and informal learning via opportunities to share personal experiences. Participating in learning strategies that enhance their self-efficacy and outcome expectations regarding their abilities to secure and maintain employment, unemployed people with MS enjoy the APT Seminar and use it as a springboard to increased involvement in productive roles. References Bandura, A. (I986) Social foundations of thought and action: a social cognitive theory. Englewood Cliffs, NJ: PrenticeHall. Betz, N. (I989) Implications of the null environment hypothesis for women's career development and for counseling psychology. Counsel. Psychol. 17, 136-144. Betz, N. (1992) Counseling uses of career self-efficacy theory. Career Development Quarterly 41, 22-26. Devins, G.M. and Seland, T.P. (I987) Emotional impact of multiple sclerosis: recent findings and suggestions for future research. Psychol. Bull. 101, 363-375. LaRocca, N., Kalb, R., Scheinberg, L. and Kendall, P. (1985) Factors associated with unemployment of patients with multiple sclerosis. J. Chronic Dis. 38, 203-210. Lent, R., Brown, S. and Hackett, G. (1994) Toward a unifying social cognitive theory of career and academic interest, choice, and performance. J. Vocational Behav. 45, 79-122. Lent, R., Brown, S. and Hackett, G. (1996) Career development from a social cognitive perspective. In: Brown, D., Brooks, L. (Eds), Career choice and development. San Francisco: Jossey-Bass, pp. 373-422. Reed, C, Rumrill, P., Roessler, R., Brown, P. and Boen, L. (1994) Accommodations planning team seminar: an implementation manual. Fayetteville: Arkansas Research and Training Center in Vocational Rehabilitation. Roessler, R. and Rumrill, P. (1994) Strategies for enhancing career maintenance self-efficacy of people with multiple sclerosis. J. Rehabil. 60, 54-59. Roessler, R. and Rumrill, P. (I995) Enhancing productivity on your job: The win-win approach to reasonable accommodation. New York: National Multiple Sclerosis Society. Strauser, D. (J 995) Applications of self-efficacy theory In rehabilitation counseling. J. Rehabil. 61, (1), 7-11.

Chronic illness and return to work: a social cognitive perspective.

High unemployment rates for people with multiple sclerosis are frequently attributed to decreases in self-efficacy and outcome expectations with respe...
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