A profound statement in the paper by Hamilton, Karoly & Kitzman is this: ‘If emotional well-being influences the selection and the valuation of a particular goal, then it is likely that the relationship between goal content and affective outcomes is mediated in the social context within which a person pursues his or her goals.…Health goals that depend on cooperation from other people … may set the stage for the experience of personal distress.‘ Emphasis is mine.
And don’t we see this so often. Not only in people with chronic pain – those who set goals while seeking social validation (warm fuzzies!) and then don’t get that support or validation, are likely to feel more distressed, give up their goals and consequently feel even less efficacious. Karoly suggests in an earlier paper (1999) that there must be consideration of the ‘fit’ between goals and social resources.
A practical example might help illustrate this. A farmer hoping to return to work is learning how to set limits on how much he does at any one time. His pesonal view is that ‘a real man’ always does what is necessary, no matter the cost. He has struggled for months to feel ‘OK’ about doing less, and is highly sensitive to implied criticism – anything suggesting that he is ‘not pulling his weight’. He’s felt unaccepted by others since he stopped work, and his main goal is to get back to work and ‘be normal’. His risk is ‘overdoing’ things in order to fit in with the others at work, and as a result he has a great deal of trouble asserting himself.
A key point in terms of looking at self regulation and emotion – and relating back to the post I wrote a couple of days ago about the effect of depletion of resources to carry out self regulation – is that how a person is feeling (emotionally and in terms of energy) influences how that person chooses to spend his or her energy in pursuit of goals.
Hamilton, Karoly and Kitzman identify that managing chronic pain reduces the range of goals in terms of energy available to pursue goals, and in terms of choosing to pursue harm-avoidant goals (things that reduce pain, or the effect of pain) rather than forward-looking and intrinsically rewarding goals. At the same time, when choosing self management goals in pain management, the social context is vital because of the internal desire for us to want to be accepted, when many of our pain management goals require doing things that will have an impact on others.
For these reasons, developing appropriate goals at the beginning of pain management is fraught with tension. I’ve always reflected that at the beginning of a programme of therapy, people have little idea of the possible goals they can achieve. This is where I find the COPM (Canadian Occupational Performance Measure) both somewhat helpful and somewhat unhelpful. In this assessment, participants are asked to identify activities they ‘need to do’ or ‘want to do’, and rate them in terms of importance and satisfaction with performance. While this starts to uncover some of the practical and personal goals of therapy, it is often confounded by several factors.
- At the commencement of therapy, people are often not confident about achieving their goals from the past, and can constrain their range of goals, or reduce the difficulty of those goals to reflect this
- It’s often difficult for participants to conceptualise the need to develop skills in order to begin working towards some of these goals. There is a parallel process in pain management of developing skills to manage pain, then applying these skills in order to achieve personally-relevant goals.
- COPM goals at the beginning of therapy may continue to constrain goal selection even when the person can now see that there are more possibilities. The original activities identified in the assessment act as a cognitive anchor that may need to be raised before new goals are introduced.
- The level of importance of various activities can change along the process of therapy – initially return to work may be a high priority, with developing something like activity regulation or assertiveness much lower down but as therapy progresses and the person becomes aware of other important goals, the original value placed on returning to work may reduce until these other goals are achieved.
Karoly suggests that we can liken the goal achievement process as a journey, and that how people appraise this journey (as a challenge or a demand, or both!) influences progress. The ‘map’ or mental model of the goal achievement journey includes appraisal of self efficacy, plans, praise and criticism around progress and emotional arousal relevant to the goal (is this a goal that is exciting, or is it a goal that feels scarey).
A study by Affleck and colleagues looking at goals and progress with goals in women with fibromyalgia found that on days when pain and fatigue were at their greatest, progress toward goals was reduced by perceived barriers to goal attainment. At the same time, days when women were feeling more pain and fatigue, they also felt less positive – and vice versa. So it looks like the way we feel influences our perception of obstacles in the way of achieving goals, and pain intensity can influence mood, adding to the perception that goals may be unattainable and making it less likely for people to recognise that progress has been made. Women who were generally more positive in their explanatory style (ie the way they talked about their day) experienced less influence from pain and fatigue. It pays to develop the ‘positivity muscle’!
The conclusion drawn from studies like Affleck and colleagues, and those of Karoly and colleagues, is that chronic pain may act as a constraint on engaging emotionally with the activities carried out on a daily basis in order to achieve goals – and to bias the way people view their progress negatively. Hamilton, Karoly and Kitzman put it this way ‘people…were able to do what they needed to do, but pain made it harder and less enjoyable.’
Plenty to reflect on there, I believe, as clinicians we start to work with patients to set personally relevant goals. There probably needs to be a real balance between allowing the person to set their own goals (bearing in mind they may set goals that are too low, but are perceived as too hard when progress is slow), and encouraging them to lift their sights a little higher (remembering that their energy to maintain engagement with goals is probably lower, and their cognitive efficiency in how they go about achieving these goals may be also low.)
I’ve said before, and will probably say again, goal setting is much harder than we often give credence to. Is it really possible to set a goal in an hour session on the first day of seeing a patient? Especially when we are unlikely to have a good case formulation to understand what is going on, and when the person we’re working with may not have past experience with effective self regulation, and currenlty views goals negatively. Can this be something to discuss with funders and purchasers when they draw up contracts for services? Maybe spending a little longer developing a goal could help the whole process move more smoothly, and even increase the achievement level?
Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76