Goals, goals, goals


Today I had the challenge of working with a new group of participants in the Pain Management Programme. They’re with us for three weeks, and at the beginning of this time I say to them that if their lives are no different six months from then, it’s not worthwhile attending. Usually they’ll all nod happily in agreement, and I think to myself ‘good, now let’s get on and work out what they want to be different’. After we’ve worked our way through ‘get rid of my pain’ (and I make the quip about the magic wand in my office that’s a self management wand made of plastic), we start to work on goals.

My first step is to ask people to go through a list of possible areas that people with pain often want to focus on – things like learning to relax more, have a more consistent level of activity, communicate better with my family, accept my pain. Most people want to tick all the boxes on the list and end up with this enormous number of potential goals, so we have to whittle the list down a bit. I do this by asking them to choose maybe three goals that catch their eye – and emphasise that these goals are not the final ones they may choose to carry out at the end of the programme.

The main problem with these type of goals is that they’re not goals. Well, they are vague areas for learning about, but they can’t really be used as goals that can be achieved. They don’t have the characteristics that have been identified as most effective. The problem I find is that so few participants in the programme have ever learned how to set good goals. AND most people are both used to having someone else ‘set the goal’ and turn a dream into a series of actions, and fail to achieve these goals – I wonder sometimes if people are a bit fearful of the whole process.

A few months ago I started to look at goalsetting and whether it has been researched in pain management (there is a tiny bit of research, but not a lot) or researched in rehabilitation more generally (a little bit more, but again not a whole lot). I also looked at how well health professionals go about developing goals – whether participants generate goals, how long therapists spend establishing goals, and whether there was any consensus amongst team members about how to establish goals. Sad to say, there is a little research out there but it’s not a very popular topic, and what is known shows that goal setting is actually a high-level skill that many of us as health professionals either pay lip service to, or we focus on what we think should be achieved rather than what the person really wants.

The problems I’ve observed working with people to help them set goals are these:

  • many haven’t set goals before and find the whole process challenging
  • many haven’t looked forward for a long time, living day by day with pain as the dictator, so maybe feel fearful of committing to goals
  • some have learned through past experience (like New Year’s Resolutions) that ‘goals don’t work’
  • some have lived lives that drift and are relatively undirected, calling it ‘being flexible’
  • some have no idea of what they CAN aim for
  • some are grappling with accepting limitations to what they can achieve (this goal is too EASY they cry!)
  • many don’t know how to break a goal down into steps they can do
  • many have outcome goals that depend on other people’s actions, rather than looking at the things they can do (process goals)

Setting a goal up to be a series of actions that can be done takes a lot of time, knowledge about what each step needs to be, and for some people it’s the whole ‘pen and paper’ component that makes it challenging.

I’ve pondered whether it’s a good idea to establish a ‘real life’ goal at the beginning of a programme or nearer the end – I still don’t have a clear idea of which is best.  I do find, though, that participants resist setting ‘real life’ goals at the beginning of the programme – perhaps fearing being tied to something they may not achieve, perhaps because they don’t know how to go about them.  My current strategy is to work through the process I described above, then pick an arbitrary goal for the whole group (there is usually a common theme) and use it as an example as I work through the ‘SMART’ goal format.  Actually I have another acronym, ‘SPART’ – Specific, Positive, Actions, Recorded and Timetabled’.  This week I’m using ‘to identify one pain management strategy that can be used over the weekend at home’ as the goal.  Then that strategy can be used as ‘the goal’ for the weekend – giving another opportunity to write and achieve a goal.

I’d love to hear others talk about their experiences establishing goals, especially goals that are not about exercise, because I think those goals are reasonably straightforward.  It’s the ones about communication, developing good relationships, re-establishing a social life, developing an effective relaxation strategy and so on that I find more difficult to develop.  Let me know what you do!

8 comments

  1. Hi Bronnie

    I’ve got more questions, not answers I’m afraid.

    If setting exercise related goals are so easy – and I’m assuming you think this because there are so many more objective measures (weight loss, distance, speed, time etc) – then are your patients more successful in achieving their exercise goals in comparison to those around, say, socialising or relaxation?

    If they are (and if so you must have a REALLY good physio working with them!) then perhaps the difficulty lies more with the process. if you want to improve your relationship, and you are quite clear on what that would ‘look like’ (more sex, more talking, shared chores, shared holidays etc) you have set a SMART goal. But how do they get to it? Scheduled meals? Topics to discuss and cover? it needs breaking down. the exercise goals start being achieved immediately. “i’m going to walk for 20minutes every day”. The weight loss / bikini body / happy holiday that the goal is about just happens at the end.

    If the group aren’t even achieving the ‘easy’ exercise goals then I think the problem is more fundamental. They aren’t ‘getting it’ at all even with simple things. which would make me want to have a look at how it is being explained and delivered in the programme. If it is THAT important (and I believe it is) then is that reflected in your programme timetable.

    If it IS working for exercise, perhaps you need to look at what the PT/OT is doing in their sessions to generate those changes. My (vast and extensive!) experience with physio’s is that they are goal setters extraordinaire. the only problem is that their first reaction is to set the goal for the patient, rather than let the patient take control.

    Did your readings around goal setting in rehab identify issues around patient-centredness?

    Good luck, it sounds like you have quite a challenge on your hands!

    Penelope

    1. Yes, a challenge.
      To answer your questions: no I don’t think they’re ‘getting’ exercise goals (or at least, they’re not achieving them!) but identifying the steps to achieve a physical goal does seem a lot clearer than a more complex goal like improving a relationship or setting limits on others! It’s partly because they’re more easily measured (time, number of steps, weights and so on), but also they are more prescribed by the ‘authority figures’ in the clinical setting – ie the physio or occupational therapist.

      I think it’s so easy to set goals for the person – and yes, occupational therapists and physiotherapists are terrific at identifying the goals AND the actions to achieve the goals FOR the person, even though the person may have initially
      identified the areas they want to focus on. But this leaves the person struggling to then generate ongoing ‘real life’ goals when they leave therapy.

      The reading I did around patient-centred goals suggested that therapists struggle to actually develop patient-centred goals. The patient often isn’t included in team goal-setting sessions, and although they may have identified the areas they want to achieve in, the links between in-therapy actions, home-based actions and the ultimate purpose for the goal is often vague or assumed. The therapist may tell the patient why the short-term goals are in place, but there can be assumptions that the goals will be relevant in the real world.

      Yes, the physio is fantastic, but that aside, I agree that if goal-setting is important it needs to be an integral part of the programme and be accorded that priority in terms of timetabling. And there does need to be some consistency around both the language and the process of goal-setting.

      Of course, I could be over-complicating the whole process too!

  2. I don’t think you are over-complicating it. You’ve identified a problem within your programme and are trying to address it.

    Do others in your team feel the same way? Do they have any suggestions?

    What about with your 1:1 patients? Are you finding the same problems or is it unique to the group intervention?

    I wonder if they (the group) are able to identify what they could change, and by how much. It must be pretty hard to set a realisitic but challenging goal if you are starting from a position of perceived helplessness.

    Why not try a different approach for one group, and then moniter the quality of their goals and their overall success in achieving them, compared with the existing approach?

    Penelope

    1. It would be an interesting question to ask the team! No, individual patients have much less difficulty, but then again they may be less challenging too!
      I do think participants with chronic pain often see their situation as hopeless and feel helpless – I indicated this in my post – and there is no doubt that this has a huge influence.
      I’ve already altered and trialled several ways of goal-setting – similar outcome each time. Sometimes externally-set goals ‘work’ better in the short term, but the participants seem unable/unwilling to pursue them over the longer term. Perhaps I shall just remain with this approach – alternatively, grab another team member to do them with me!

  3. As a person with chronic pain, I thought that you touched on many good reasons that real goal making and acheiving is hard.
    Although I have set goals before, and acheived them, now I have seen situations that I can’t just will my way through and I am a bit flammoxed as what to do now. Not only that, but I have sensed this feeling in my Dr. (I’m not responding to the med. given)
    In order to manage, I have very much changed from living for the future to living for the moment. I often don’t have concrete plans for tomorrow. Things I will do if possible, yes, but there is always the thought that it might not happen.
    Sometimes I accept limitations, sometimes I accept more limitations than I have to, sometimes I rale against any limitations and completely overdo. Very occasionally, I get by with that.

    I think that it is a first step just to identify what sorts of things might be thwarting the goal process.
    Then those things have to be addressed in small bits.

    Probably takes too long if the practioner is the one doing all the work.

    1. Hi Karol
      Thanks for taking the time to comment on your experience of goals as a person who has chronic pain. I have a suspicion that the art of setting goals that are flexible and fulfil the underlying values you want to have in your life are what works for people like me and you who have chronic pain. What I mean by this is that if what we want in our lives is to have balance and serenity, there are all sorts of ways we can achieve these – and so the specific actions we do might be different for each of us. What gets me into trouble is where I confuse the actions with the underlying values and I end up focusing on what I want to do rather than why I’m doing it in the first place! For example, if what I want to have is a tidy house, because I like it to be clean and peaceful – I can do it myself, I can ask my children to do some of it, or I can have someone do it for me, or I can arrange my house so that it takes less time and energy to keep tidy (or I can go out and enjoy somewhere else where things are clean and peaceful!). I’ll write more about this, but I think that sometimes we get so tied up in ‘doing it’ (and not achieving it!) that we’re a bit fearful of aiming for anything in case we let ourselves down. Thanks for stopping by, and I hope you come again!

  4. The thought of getting caught up in the actions supposed to lead toward a goal instead of the goal struck a chord with me. I think sometimes of theraputic goals mainly being focused on the actions because there is supposed to be underlying theraputic benefit and that is the REAL goal instead of the spoken goal.
    So that is more like game-playing.

    1. I think you might be right about therapeutic goals being actions that are supposed to lead to the ultimate goal – if that’s happening to you I’d start asking ‘why am I doing this? where is this leading to? what is the end result?’

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