Goal setting — again!


This post is most definitely an opinion piece, because once again I’m struggling with the practicalities of goal setting with people experiencing chronic pain. There is no doubt at all that goal setting is an integral part of pain management – it’s designed to focus the input, make sure the underlying reasons for using pain management are relevant to the person, and it helps the person monitor their own progress (not to mention help the therapists measure outcomes!).

The problems are that goal setting is a really complex activity, and to make goals patient-centred rather than therapist-driven involves time, and great communication skills.

Here are some of my observations about what makes goal setting difficult, at least in my experience in pain management:

  1. many patients have lost sight of the future – they are living from day to day, and can’t conceive that things might be different
  2. many patients don’t seem to have ever set goals before, or at least have never used goal setting as a formal strategy in life
  3. some patients view goals as ‘obligations’ and the whole concept of goal setting is clouded by past failures (think of how many times people set New Year’s Resolutions – and fail to keep them)
  4. some patients really don’t know the processes they need to follow to achieve a goal – how do they work out what job to return to? how can they repair their relationship?
  5. it’s so tempting to help the person set their goals but in actual fact, end up setting them for the patient, especially when the patient might have a vague idea about where they might like to progress, but doesn’t have a feel for what success in that goal area might look like.
  6. it’s tempting to include ‘outcome’ goals rather than ‘actions’ the person can take

An example might help.

Say Alex has a vague idea she wants to get back to a better family life.  My next step would be to ask her ‘What does a better family life look like? What would you be doing if your family life was good?’

Hopefully Alex will have an idea of the sort of activities she might be doing with her family and that makes it quite easy to set goals – for example, if she and her family like to go on a picnic, and currently she can’t sit long enough to get to the picnic spot, and when she gets there she finds sitting on the ground really uncomfortable, then we can set goals around sitting tolerance, driving tolerance, and we can probably even think of locations or modifications to the picnic that might make it more achievable in the short term.

Where it becomes problematic is when Alex can’t think of activities she would be doing with her family and instead comes up with more complex ‘problems’ that are contributing to her sense of dissatisfaction with her family life. Maybe she says ‘I feel so irritable all the time’, or ‘they need to be nicer to me’, or ‘if I was more positive it might happen, but my pain gets in the way’. Or even more likely, it’s difficult for Alex to even think of what a good family life might look like and the answer ‘I don’t know’ comes up!

Now before you rush in and tell me how to work from there – yes, there is definitely a process to go through to help clarify behavioural outcomes for each of these goals, and yes it’s possible to help someone finally identify these behavioural outcomes – but can you see how complex the process actually is?

It involves really listening to the person, being aware of the factors contributing to their current presentation, being committed to helping the person develop personal responsibility to make changes (probably changes that involve difficult behaviours like increasing assertiveness or becoming aware of his or her own contribution to that situation), and being so very careful not to put words in their mouth.   It really does involve formulating ‘on the fly’ unless shortcuts are taken – and this is when goal setting moves from being truly patient-centred to therapist-driven.

Goal setting is so much more than simply coming up with a ‘SMART’ formula. In order for a goal to be ‘SMART’, participants need to know why it’s important to them to achieve that particular goal, what’s really achievable (when they’re pessimistic that they can make any sustainable changes), and how to persist when the payback may be quite delayed.

I don’t have the recipe yet.  I wonder whether we need to recognise that goal setting is not as simple as ‘Deciding what to work on and then doing it.’ While that might look like what is happening on the surface, and in truth that is what goal setting looks like – underneath that deceptively simple process lies a complex mass of listening, clarifying, formulating and reflecting that is no simple task.

Yes, we can set simple, concrete goals ‘for’ our patients, and it might even be an effective way to begin the process of learning how to set goals (the mechanics of setting goals) – But is it truly patient-centred? How long will a person persist with a goal that they’re doing simply to please a therapist?  And at what point will we help that person understand the contributing factors that lead to them being dissatisfied with their current situation?

Do we set goals at the beginning of therapy when the person has little idea of what is possible and even less optimism that thing can change? Do we create goals to work on that mean less but have rapid success to demonstrate that change is possible – then challenge the person to set their own, personally relevant goals?  Do we make sure the goals are actions rather than outcomes that depend on other variables?

The pondering continues – looking forward to comments from all and sundry on this really important topic!  And you can bet I’ll be scouring the information highways and byways to locate resources that might shed light on how to do effective goal setting in a practical way.

4 comments

  1. Hi

    Tough questions in there. I guess I would want to know just how important it is for the patient’s goals to be completely patient centred. Does that automatically lead to greater compliance or success? How do children manage their pain? What about people in lower socio-economic groups who may also live day-to-day? (That’s not intended to be offensive, just if you don’t have much money it’s harder to look past the next day).
    If it is a core element, then is that reflected in the time spent on it in either individual or group sessions? I suspect not – the clinician led ‘goals for next weeks session’ are much quicker to tag on the end of the days session.
    What about outcomes – what is a good outcome from a pain management intervention (group or 1:1)? Is goal setting key to the idea of self-management or just another one of the practical coping strategies that we offer to patients (pacing, exercise, self-regulation, communication, goal setting?). ie can someone coping well with persistent pain be a poor goal setter?

    There seems to be a conclusion being drawn at the moment around people who do well from pain management intervention having a ‘shift’ in attitude / outlook rather than embracing one (or more) particular strategy. Whilst I can see goal setting as providing a greater sense of control, and hugely helpful, perhaps its not as important as we think.

    OR do we (clinicians) need the goals more than the patients in order to determine our impact / success with the individual? Hence our desire to ‘SMARTen’ them up into nice clean objective measures.

    I don’t know the answers, I just think if you are going to pour a lot of effort into something (and tear your hair out in the process) the first step is to make sure that it will be worth it!

    P

    1. The question of whether patient goals need to be patient-centred is critical I think. It’s both a philosophical/ethical issue as well as a practical one. Disability rights (and those of personal autonomy etc) suggest that the individual has a right to determine his or her own treatment priorities (with some arguable exceptions: end of life decisions especially) – and I suppose I fundamentally agree with this because it avoids the potential for imposing external values and beliefs on the individual, especially with regard to priorities (e.g. is improving my exercise tolerance more important than improving my sleep? should we ‘expect’ a woman to prioritise looking after the home, and a man to consider return to work first priority). I think these are philosophical and ethical reasons for being patient-centred, and I think it would be hard to argue against this because to do so is to presume someone other than the patient has the right to determine another’s priorities.

      On the other hand, there are also practical considerations. I need to re-read the goal setting literature, but I think the findings were that personally-relevant goals are more likely to be achieved than those imposed on an individual, unless in achieving those goals, underlying values are being met (eg need for recognition, avoiding punishment).

      While I agree that the latest conclusions about ‘what works’ in pain management seems to show attitude change rather than adoption of specific skills, I think that is still arguable, depending on how the use of skills is being measured. Some skills become relatively automatic and hard to recall, while others remain very identifiable – eg it’s a whole lot easier to recall using relaxation or exercise, while cognitive reframing and using positive coping statements are maybe much less readily remembered. What does seem to be a solid finding is that those who learn to persist despite setbacks, end up achieving positive changes while those who fail to persist don’t. I can’t recall the exact citation for that, but I do remember it being around job seeking. If an individual doesn’t have something to aim for, I’m not sure how they’d learn to persist despite setbacks.

      I do agree that we as clinicians are obliged for many reasons to identify specific goals – this is because some of us have to answer to funders or purchasers. I’m sure this doesn’t happen for all clinicians, because I can’t recall any contracts with ACC that require doctors who carry out injections or surgery to measure their outcomes in functional terms. But maybe this reflects the relative lack of ‘power’ that nonmedical clinicians have, or maybe that nonmedical clinicians actually want to know whether we’re doing a good job.

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