Goals, outcomes, direction & values

Someone asked recently, how do you decide the difficulty level of a goal?  Or words to that effect.  It’s a good question – and like most good questions, there doesn’t seem to be a nice clear-cut answer.  So here’s a ramble on where I’ve got to with goals.

The first thing I remember about goals is that there is a big difference between a goal that I am aiming for and the actions that I can do to achieve the goal.  What I mean by this is it’s pretty easy to set a goal like ‘I want to get a job by March 2011’ – but this goal could well be setting you up for failure.

Why? Not because it’s about working, no, but because it doesn’t depend entirely on your actions – in fact, it depends on an employer deciding that you are worth the money to employ.  So you could be the most motivated person in the world, do all the right things to look for a job, but you may not actually get one in that timeframe.  The outcome of that goal is not up to you – it’s up to the employer. Similarly, someone might want to achieve top in class – but getting top depends on whether there is anyone else in the class who might be able to achieve a higher score.  You can’t be responsible for that other person’s ability, you’re only responsible for your own actions.

So rule number one for me is to make sure goals are about actions, or things that you can do rather than outcomes that might depend on others.

The next thing I’ve been pondering comes from ACT – and it is that goals or actions need to be important, they need to enact a value in some way. The ‘why are you doing this’ part of deciding the direction you want to take.

What I mean by this is that we know there are multiple ways to live out what is important in life. For example, being a good provider for my family is a value.  It’s not something that can be ticked off a list and then, with a sigh, say ‘I’ve done that’!  It’s something that is lived every day in a series of actions that embody the value I hold of being a good provider.  I could do this by having a wonderful garden and supplying veges to my family, or by preparing great meals, or obtaining a good job, or budgeting carefully, or supporting my partner to go out to work – you can see how many different ways this value can be played out!

For clinicians to help someone decide ‘what to do’ or what kind of goals to set, we need to help people clarify what is important to them and then set actions accordingly, so the goals are contributing to the person being able to live out their values.  If we as clinicians forget this, we could end up dictating a set of activities that are meaningless to the person – and as a result, don’t get carried on when we stop seeing the person.

The actions we establish may not look very much like the values that the person wants to live out, especially in the initial stages.  For example, if the person wants to be more open and honest in relationships, perhaps initially identified a goal of ‘no longer being tied up in my worries when I’m around people’, the first steps towards this might be to simply sit in the same room as other people and be prepared to remain there for 10 minutes, being mindful.  On its own, this action doesn’t look like being open in a relationship – but it’s a step towards being able to allow the worrying thoughts to be present without being acted on, while remaining open to being present in a group of people.

Another example might be for the person who is fearful of walking in busy environments such as a shopping mall or supermarket – maybe because he or she could be bumped and that painful limb or back might get more uncomfortable, or because he or she might be asked ‘and what are you doing for a living right now?’  The first step could be to go to a mall early in the morning when it’s all quiet and have a cup of coffee with a friend.  It’s a first step towards the living the value of being free to walk wherever and whenever.

So while the SMART goalsetting mnemonic certainly has value – after all, it’s been around for a while! It also fails us as clinicians at times.  I think it’s a great way to begin to develop an action plan – or committed actions the person is prepared to do (Specific, measurable, achievable, recorded, timeframed – or whatever variation you’ve learned!). but it’s not enough on its own.  As clinicians we must recognise that SMART actions must be things the person can do, not outcomes.  And SMART actions need to be important to the person in some way – there has to be a reason for doing them beyond pleasing the clinician!

So – is it OK for a person with pain to have very high goals?  Of course!  If someone wants to return to paid employment, it’s a fabulous goal to have, even if I, as a clinician, have no idea what that might look like.  I would ask what is so important about being in paid employment as one of the first steps to fleshing out what the next best step might be.  It might be about finances, it might be about self esteem, contributing to the community, being busy through the day, feeling useful – all of these could be underlying values for returning to paid employment.  I’m likely then to ask about how confident the person is to achieve this goal – and what contributes to this confidence.  Then I’m likely to ask what the person thinks the ‘next best step’ might be.  This could be something like learning more about transferable skills, developing confidence in physical abilities, becoming good at interviewing and presenting skills well, or developing effective pain management strategies that mean activities can be sustained reliably day in and day out.

All of these possibilities can become actions – but the reason the person is doing them is to return to paid employment because of some underlying value.  My job? To help the person identify what the obstacles are and how to work through them, while recognising that the person can only be responsible for his or her own actions.

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