- strengthen the therapeutic relationship through collaboration;
- focus therapy on areas that the patient wants;
- help the patient maintain motivation and adhere to treatment; and
- ensure specific outcomes are identified and measured – amongst other things.
The problem is that in pain management there is very little specific research on either the benefits of various types of goal setting, or on the processes that make goal setting effective. This research paper by Veronika Schoeb from the University of Applied Sciences, Western Switzerland, is one of the few I’ve read that explores in detail how a group of therapists develop goals.
The setting is an outpatient physiotherapy department in a Swiss University Hospital. Three physiotherapists provided audio-tapes from a single initial treatment session, which were then analysed in detail using ‘conversation analysis’.
This is a method developed as ‘an interpretive enterprise seeking to capture the understandings and orientations displayed by the participants themselves’ with the underlying theory being ‘that previous actions are a primary aspect of the context of action, that meaning of an action is heavily shaped by the sequence of the previous action, and that social context itself is a dynamically created thing that is expressed in and through the sequential organisational interaction’. Hmmmm. Let’s unpack that from the jargon and work out what it actually means before I go on?!
What I think this means is that dialogues are analysed to identify patterns of interaction, by reviewing what has happened before (the context), and by looking at the conversation in terms of who has said what and when – by looking at specific aspects of dialogue such as who starts and finishes the conversation, how it is structured, the type of language used and the conventions such as who directs the conversation. By doing this it’s possible to develop an understanding of how decisions that are verbalised actually happen, giving insight into some of the ‘invisible’ processes that occur. (I did briefly cheat by looking up wikipedia, but it didn’t help much!)
OK, back to the findings of this paper.
Schoeb identifies four phases in the process of goal setting in this setting:
- Eliciting patients expectations of treatment
- Introducing goal setting activity
- Formulating goals
- Closing of goal setting activity
This looks so simple when its written down in point form! But as the analysis in Schoeb’s paper shows, for example, formulating the questions to elicit exactly what the patient expects from treatment requires considerable effort on the part (especially) of the therapist.
When introducing goal setting as an activity, two main variants were identified – therapist-driven or collaborative. This is indicated in terms of the language used eg ‘your goals’, ‘we’ve developed’, and in terms of how readily therapists summarise what patients indicate are their problems as part of reformulating them into goals that can be agreed to.
This particular process, especially collaborative goal setting, takes a long time and a lot of skill. Not only does the patient need to be able to articulate what is important to him or her, but the therapist needs to hear this accurately and translate this into areas that can be addressed in therapy. The therapist must then re-translate these ‘things’ back into language that the patient recognises, and acknowledges will help reach the original goal. Now if you’re getting confused reading this, it’s not surprising!
Schoeb states that her data suggests alignment on goals either takes a long time, or is not reached, because of the various descriptions of symptoms (in language that is not shared) and that these are not negotiated. It seems that agreeing on common language and ensuring that both parties in the process of setting goals is an important aspect – but one that requires time and effective listening skills from the therapist.
The final part of goal setting is the ‘closing’. Schoeb found therapists and patients taking turns to confirm what has been discussed and to establish ‘the next appointment’ or ‘the next step’. She notes that in other medical research, referring to arrangements for the future can signal this phase of the conversation. Therapists in this study were actively looking for agreement from the patient.
In the conclusion of this paper, Schoeb points out that one reason for infrequent goal setting in some clinical settings is the time required to do it effectively. The process involves high level active listening skills on the part of the therapist – and at the same time, it requires the therapist to direct the discussion. The more collaborative the process, the longer it takes because assumptions held by the therapist are checked out with the patient, eliciting greater ‘buy-in’ and more frequent utterances from the patient.
The arguments for including goal setting include directives from the World Health Organisation, reflecting the increasing desire for ‘active rather than passive decision making’ by people with health needs. Most health professions require ‘patient-centredness’ as an ethical standard. There are various factors that influence how effectively therapists actually conduct this shared process – these include the amount of time available, the privacy, the skill level of both participants (therapist and patient), and shared beliefs about the roles of each participant. This study demonstrates how complex the task is – and details how the ‘dance’ can develop.
The limitations of a very small study (only three physiotherapy interactions were recorded and analysed), and one in which the participants were aware their dialogue was going to be used for training purposes later are clear. On the other hand, it is within this type of detail-rich study that we can observe the specific elements that go to make up what at face value looks like a relatively simple four-step process. Oh if it were only that easy!
Here’s a thought: what if you sought permission and recorded a goal-setting session with a patient of yours, then analysed it in terms of turn-taking, organisation of the content, how turns are taken, who speaks more, who speaks less, and how the process is drawn to a close. It might be revealing!
Schoeb, V. (2009). “The goal is to be more flexible” – Detailed analysis of goal setting in physiotherapy using a conversation analytic approach Manual Therapy DOI: 10.1016/j.math.2009.02.004