A few posts ago I discussed a motivational strategy that had been shown to help people be specific about the benefits of exercise and plan to overcome obstacles that may prevent them from engaging in it (Christiansen, Oettingen, Dahme and Klinger,2010). Today’s post relates to this as I read an editorial written by Schrooten & Vlaeyen about that same study in which it is pointed out that goals are a very complex concept, and that to simply identify the pro’s and con’s of a single activity that has been ‘imposed’ on the person might fail to address one of the most important aspects of goal setting – the relevance or context of the goal itself.
I’ve written quite often about goals and goal-setting, mainly reflecting that setting goals is a pretty difficult thing, it takes a lot of time, and it’s often not something health providers are taught to do in a collaborative way. In fact I’d go so far as to say we’re probably taught how to tell someone what to do rather than help them set their own goals!
Some of the research about goal setting shows that goals set in collaboration with people, and then achieved, contribute a great deal to how satisfied people are with their pain management, that people who fail to achieve their goals can come up with some interesting self and other attributions as to why their goals weren’t met, and that goal setting is strongly influenced by some of the brain changes that occur as part of having chronic pain, especially executive functions.
It’s relatively easy to carry out the basic ‘steps’ to set a goal – that SMART goal formula actually works, and there is a large body of research from psychology showing that specific goals, those that have a time frame, can be measured, are just out of reach but not too much, and those that people believe are important are much more likely to be achieved than vague, poorly defined and irrelevant goals.
What is a whole lot more complex is to help someone who doesn’t have a lot of self efficacy for achieving goals because of their pain, maybe hasn’t had a lot of practice at setting and achieving goals anyway, and perhaps doesn’t have a clear view of what they can currently do and what the future might look like.
Goals reflect motivation – that is, if something isn’t important, then it’s unlikely the person will pursue it. And because we’re rather perverse people, goals can be conflicting. We can have a goal to remain comfortable and feel safe, but at the same time want excitement! We can strongly want to avoid failing and increasing pain, but at the same time want to return to work to earn money and support the family.
Let’s take the idea of exercise. Now I openly admit to loathing the thought of jogging, going to a gym, slogging up hill with a pack on my back, or doing a set of calisthenic exercises every night. At the same time I know the health benefits of exercising, I enjoy the feeling of being fit, I know it helps reduce my pain, and I even know it can be fun! How can I resolve this?
One way is to choose an exercise form that doesn’t violate my views that jogging, gym etc is boring, sweaty and hurts too much. For me it took a while, but dancing and walking are my two favourites.
Another way is to work with me to uncover my automatic thoughts about jogging, gym etc and help me challenge those beliefs and maybe reframe them.
Schooten and Vlaeyen suggest that clinicians might benefit from considering some other ways to evaluate the relevance and importance of the goal: We believe that the intervention may benefit from a more detailed estimation of important life goals and inter-goal relations, as well as from a stronger focus on strengthening facilitative relations between goals. In other words, what sort of conflicts might there be between goals, and how does exercising, for example, fit with other ‘life’ goals; and how can we kill two birds with one stone – and maybe achieve two goals together?
Another point Schooten and Vlaeyen make is that ‘efficient goal pursuit and behavior change require cognitive and behavioral flexibility.’ It’s worth remembering that one of the effects of chronic pain is to weaken executive functioning, so sometimes goal setting and particularly persevering with a goal in the face of obstacles can be limited. It might be useful to establish whether people do better with some external support for using cognitive strategies, or whether they managed to come up with other ways to achieve the exercise that could cope with the obstacles that life can throw us.
We also know that many people with chronic pain find it difficult to ‘change tack’, and may persevere inappropriately with one strategy when maybe recognising that the way a certain goal was ‘meant to be’ might not be a helpful way to achieve that in the future. Psychological flexibility is being increasingly seen as an important component of adaptation to adversity.
The final point Schooten and Vlaeyen make is Christiansen et al. expected that their intervention would enhance physical exercise. However, they did not directly track this goal-directed behavior. It so happened that physical capacity did improve, but there isn’t any exploration of how this happened. Did patients pursue the activities consistently, what was the pattern of their engagement, did it change the number of times the participants exercised each day, and exactly what did the intervention change – getting to understand how this intervention influenced perhaps goal intentions, perhaps lower conflict between various goals, perhaps increasing the relevance of the goal to the person’s own life. We don’t know.
Today I meet with a group six months after their pain management programme. We’ll be reviewing goals, and I’m going to be looking carefully at some of the thoughts and behaviours of those who achieved their goals, and those who did not. The more I listen, the more I understand, the better I can work with other people so they too can get where they want to go in life, despite pain.
Schrooten, M., & Vlaeyen, J. (2010). Becoming active again? Further thoughts on goal pursuit in chronic pain Pain DOI: 10.1016/j.pain.2010.02.038