Part of most therapy, especially in chronic pain, involves setting goals. A major part of moving from ‘patient’ to ‘person’ means refocusing life from a round of appointments ‘to get better’ to actually doing things that matter in life – being ‘better’. Some of the people we work with achieve these goals and feel more in control, start to focus on interesting things in life rather than pain, and hopefully won’t need to come back and see us again! Others find it much more difficult to achieve the goals they’ve set and need more intervention.
This paper explores the reasons people gave for not achieving goals in various domains. The goals were set in the last week of an interdisciplinary pain management programme, and follow-up was held six months later. The goal areas were coping strategies, medication, exercise, social activities, and work.
Participants were asked to rate their reasons for not achieving the goals on several questions, using a Likert-type scale. The questions were:
- Was the cause of not meeting this goal due to something about you or something about other people or circumstances?
- In working toward this goal in the future will this cause again be present?
- Was the cause something that just affected this goal or does it also influence other areas of your life?
- Was the cause of not meeting this goal controllable by you?
If you’re not familiar with the Goal Violation Effect (Abstinence Violation Effect if the goal is to completely stop something), another description is the ‘what the hell’ effect. What I mean by this is, if a goal (rule) is very rigidly defined, and it’s violated (broken somehow), one response is to say ‘oh what the hell’ and give up altogether! The term comes from the work of Marlatt and colleagues, looking at the relapse process in people giving up alcohol or drugs, but it has been extended to other forms of behaviour change such as adopting a new behaviour, or setting a specific goal.
The work of Marlatt and others suggests that ‘relapse is more likely if a person makes attributions that the cause of not meeting an abstinence goal is internal rather than external, stable rather than unstable, global rather than specific, and is perceived to be uncontrollable rather than controllable.’ So, for example, if I break a self-imposed rule and think it happened because I’m ‘lazy‘, and I believe I’m ‘always lazy’, and especially if I’m ‘always lazy everywhere and I can’t change it’, then I’m not likely to pull myself back on track and try the goal again.
So in this study, Guck, Willcockson, Schmidt & Criscuolo asked participants to indicate the beliefs they had about unmet goals, to determine whether specific domains of goals were perceived differently.
And the findings? Well, curiously enough the initial finding was that no significant differences were found among goal types for the GVE, the stable or global attributions BUT for both work and social goals, ‘lower internal attributions
compared with coping, medication, and exercise goals’ were found, and ‘work goals were found to have great uncontrollable attributions compared with coping, medication, and exercise. Coping was found to be lower than social and exercise goals.’
What this suggests is that participants in this study thought that they were less ‘to blame’ for not achieving goals related to social and work goals - ‘it’s the economy’, ‘my partner didn’t want to’, ‘my boss wouldn’t let me’ might be the type of statement used to explain why these goals weren’t met. At the same time, goals related to work were thought to be much less likely to be controllable – leading the participants to maybe think they couldn’t do anything to alter the situation. Coping was also less controllable than social and exercise goals.
One response to this finding might be to employ specific cognitive techniques such as directly discussing relapse prevention and develop different ways of viewing the situations in which goals are not met – especially those to do with working and social activities.
It might mean identifying ‘high risk’ situations where coping strategies may not be used – such as ‘good pain days’, days where deadlines need to be met, times when pain is high, times when negative emotions are likely – and helping people develop effective problem solving strategies for these situations.
In the pain management programme where I work, one month after the programme we hold our follow-up, and divide the group into three.
- One group for people who want ‘more of the same’ in terms of pain management. In other words, this group have successfully continued with their pain management plan, and are developing a sense that they are in control and can make changes to meet difficult times.
- Another group for those who are ‘waiting on someone else’ – this represents the group who believe the reason they haven’t achieved their goals is because of something external, something they can’t change. We help this group identify ways to work around the problem, or to slightly modify their goals to enable them to begin to do things to progress themselves.
- And the final group are those who have slipped up on most goals and are not yet ready to view their progress as something they can influence at all. For this group we work through a ‘stages of change’ process, to help develop the discrepancy between where they are now and where they want to be in the future, and begin to encourage them to move only one stage ahead (eg from contemplation to preparation, or from preparation to action).
For many of our participants, it seems that taking independent action and responsibility for making things change and progress is quite a foreign concept. I’m guessing that being a ‘patient’ for many years, as so many of the people I see have been (up to 20 years for some), it’s a real challenge to reconceptualise progress as something that they can make happen. Many participants have been receiving direction from case managers, doctors, physiotherapists – and instead of focusing on what they can do, have become fearful of doing anything in case it doesn’t work out.
If we can help these people review lapses, slips or times when goals haven’t been achieved as learning experiences – times when they can look at what went well, what they would do differently, and what they will focus on next – we might have slightly less ‘compliant’ patients, but we might also have participants who are viewing themselves as ‘people’ again.
Guck, Thomas., Willcockson,James., Schmidt,Rex., Criscuolo,Christopher. (2008). Attributions Regarding Unmet Treatment Goals After Interdisciplinary Chronic Pain Rehabilitation Clinical Journal of Pain, 24 (5), 415-420
Marlatt GA. Cognitive factors in the relapse process. In: Marlatt GA, Gordon JR, eds. Relapse Prevention. New York, NY: The Guilford Press; 1985:128–200.