A theme in almost any reading about health is that treatment should be patient-focused, typically goal-directed and have some sort of measureable impact. Over the past few weeks I’ve been reading about the process of goal setting and motivation, finding that there can be quite some differences between what a therapist sees as a suitable goal for therapy, and what the patient/participant sees as ‘the goal’.
Today I thought to ponder the types of goals we might see during pain management treatment.
On the one hand, each therapist will identify several areas to target on the basis of clinical reasoning (in my case, using a case formulation). Usually these targets for therapy are derived from the application of theory to the specifics of the person in front of the therapist.
So, we see some physiotherapists identifying that the lack of adequate core stability may be contributing to low back pain, so improved core stability will be the treatment. We might also see an occupational therapist determine that loss of daily routine is contributing to poor sleep patterns, so a daily timetable might be instituted.
Another approach is to ask the patient about areas he or she would like to target. Once past the ‘if I had a magic wand I’d love to get rid of the pain’, we often hear about poor sleep, wanting to work, being able to play with the kids, be a less irritable person around the house.
The challenge then is to turn these personal goals into something that therapy can actually influence.
I guess that underlying the drive to ask patients what they really want as the focus for treatment is a belief that people will be more ‘motivated’ if the things they are doing count for something they really want. There is also a strong belief that people have rights to self-determination, so that there is almost a moral obligation to ensure ‘what the patient wants’ is incorporated into treatment.
Several problems arise for me during goal setting.
- First of all, lots of people don’t routinely set goals for themselves, and even fewer know a structured process for setting goals. I’d bet that some people even view goals as ‘good intentions’ that might even represent failure – a bit like the New Year’s Resolutions, or the diet and exercise efforts that often start, but just as quickly stop.
- Secondly, a lot of goals the patient wants are very very vague – like ‘sleep better’, or ‘be less irritable’. It takes a lot of time and effective listening to help people develop these sort of general goals into something that can be the focus of therapy, be measured and reviewed.
- Goals may differ significantly between therapist and client – and some of the goals may even be at cross purposes. Clients/patients may focus on short term goals such as ‘reduce my pain’, while therapy goals may be focused on increasing activity level which will increase pain for a short while.
- The language may differ between therapist and patient – after all, we’re often used to thinking in terms of SMART goals, while this can be a foreign concept to patients. While we might think about ‘acceptable activity levels’ they may be viewing any limitation as ‘unacceptable’.
- Many patients are not used to thinking ahead, in fact they often say ‘but I’m only living day by day’. Asking someone what they would like to achieve might not even register, especially at the beginning of therapy, or at the end of a long assessment. Yet goals set at this point might direct the focus of treatment for weeks or months to come.
I have a particular concern that setting goals is a technically demanding practice that requires much more listening, reflecting, negotiating and high-level clinical reasoning than is typically recognised. The difficulty with setting goals probably varies depending on the clinician’s listening skills, the client/patient’s familiarity with goal setting and own self reflection skills, and on the context in which goal setting is carried out.
I’d like to see goal setting continue to be seen as of huge importance – in fact I’d like to see it so important that goals are not set until the therapist and participant/patient have spent some time getting to know each other, and to have put together a formulation about how and why the person is presenting for treatment. The process of setting goals could even be seen as a skill to be developed – because if we take self-regulation view of goal setting (see Siegert, McPherson and Taylor, 2004), it’s something that people would benefit from developing for life rather than just rehabilitation.
Siegert, R., McPherson, K., & Taylor, W. (2004). Toward a cognitive-affective model of goal-setting in rehabilitation: is self-regulation theory a key step? Disability & Rehabilitation, 26 (20), 1175-1183 DOI: 10.1080/09638280410001724834