don't wait too long

Stepping out of the glue: How to generate goals


Chronic pain has been called one of the “most powerful and insidious disruptors” of routine, habit and wellbeing (Karoly, Okun, Enders & Tennen, 2014).  When a person experiences pain, a whole range of mechanisms come into play and work together to use thinking and processing space, and especially those areas we use when we’re developing and achieving goals.  When people are first trying to make sense of their situation, they can find it hard to think about future goals and plans, and instead focus on trying to solve the problem of pain – many people call this time like being in limbo (McGowan, Luker, Creed & Chew-Graham, 2007).

It’s not surprising, then, that when clinicians begin to work with someone who has had pain for a very long time, it can be very difficult for them to think of a “goal”. After all, not everyone sets goals anyway (I heard somewhere that it’s about 3% of people – but I can’t find the research to support it). But in pain management, funders often ask clinicians to work with the client to “set goals” for therapy from the first day as a way to ensure a client-centred programme, increase motivation, and monitor outcomes. This can be a problem in a couple of ways: first of all, if the person doesn’t have goals because they’ve been in “limbo land” for a long time, and feel pretty demoralised or their goal relates to “getting rid of the pain”; secondly, if the person has vague ideas that are difficult to set into the typical “SMART” formula (incidentally, I really don’t like that acronym!); thirdly, if the person doesn’t have strong ideas about what they want from therapy, the clinician can set the goals for them, and perhaps not those the client is really all that interested in; and finally, it’s hard to set goals without having spent some time listening to and collaborating with the client.

Pain can be experienced as a major obstacle to motivation for setting goals. Negative mood associated with pain can reduce motivation to think ahead, to dream. Morning pain in particular can make it more difficult to want to do things, unless those activities are important, there are relatively structured ways to pursue them, and they don’t need much planning.  This can influence whether a person gets out of bed to go to work, or the gym, or take the kids to school. In a daily diary study, Karoly, Okun, Mooris, Enders and Tennen (2014) found that people with relatively high overall pain over a two-week period, but not necessarily just in the morning, and who have chosen to stay working, often also carry out their “lifestyle” goals in the afternoon. They suggest this could be because goals that are further out in time, and the positive feelings associated with achieving work goals keep them motivated. But they also found that even then, on the days people had more than their usual pain in the morning, they were less inclined to do as much.

The implication of this finding by Karoly and colleagues is that people who experience a “high pain” morning might need some reminders of the pleasure they get when they achieve goals – perhaps to pay attending to people and places that support their goal achievement. Helping people develop goal planning skills might also be useful – do the thinking when you’re feeling a bit more positive and can see beyond “now”, then when pain is higher, the cognitive demanding work is already done and the reminders help to generate positive emotions to encourage doing them.

OK, so we know some ways of helping people keep motivated, but what do we do to help people set them in the first place?

People are motivated by both push and pull factors. We want to move towards things we experience as good, and away from things we don’t enjoy. When pain is present, not only does it become hard to think straight, it doesn’t feel like it will ever change. So we need to help people dream a little. One way I do this is ask “What would you be doing if pain wasn’t such a problem for you?” Note that I’m not saying pain isn’t there – but that it’s less of a problem. Sometimes I’ll use a plastic magic wand and hand it to the person, asking them to dream a little. Other times I’ll add in “What gives you joy and pleasure? What makes you lose your sense of time and place? What gives you a sense of satisfaction when it’s done?”

These questions begin to identify activities in which a person might experience “flow” – Mihaly Czikszentmihalyi.

Another way is to ask the person what they need to, or want to do, perhaps using the occupational therapy broad groups of “productivity/work”, “leisure/fun”, and “self care” as prompts.

I’ve also found that by asking “what’s important in your life” can be a good way to generate personal goals. Importance indicates that the person places value on it. Values are important and lasting beliefs or ideals shared by people about what is good or bad and desirable or undesirable. Values underpin ACT (Acceptance and Commitment Therapy), because instead of setting goals, which can be achieved, values are like a compass – things we do (actions) allow us to move closer towards important values, and we never completely achieve them. They’re directional and aspirational, and allow us to do difficult things that have short-term negative consequences, just so we can move towards a better long-term consequence (van Huet, Innes & Stancliffe, 2013).

How can you use this in therapy?

Well, if a person really values family, and being a good Dad, anything that Dad does to enable him to be a better Dad will be motivational. So you can ask “What could you do today that would take you one step closer to being a great Dad?” And use whatever that might be as the foundation for a goal. Then you can go on and use all the other great goal-setting strategies like specific, measurable, achievable, relevant, and so on.

This doesn’t mean that doing that thing will be easy – far from it! But it will make achieving it more relevant, powerful and motivating. Working with the challenges is why you are a therapist.

 

Karoly, Paul, Okun, Morris A., Enders, Craig, & Tennen, Howard. (2014). Effects of Pain Intensity on Goal Schemas and Goal Pursuit: A Daily Diary Study. Health Psychology, 33(9), 968-976.

McGowan, Linda, Luker, Karen, Creed, Francis, & Chew-Graham, Carolyn A. (2007). ‘How do you explain a pain that can’t be seen?’: The narratives of women with chronic pelvic pain and their disengagement with the diagnostic cycle. British Journal of Health Psychology, 12(2), 261-274.

van Huet, Helen, Innes, Ev, & Stancliffe, Roger. (2013). Occupational therapists perspectives of factors influencing chronic pain management. Australian Occupational Therapy Journal, 60(1), 56-65.

5 comments

  1. Bronnie, as a PT, do you think graded exposure -in relation to the goals you talked in your post- is a good tool to start with a chronic pain patient? What tools (CBT, goal setting, etc) would you say are important for a physical therapist working with persistent pain patients?

    1. The ability to listen first. Use motivational interviewing to identify importance and confidence for goals, and to generate internal motivation rather than responding to external “push” motivation. Graded exposure is a useful strategy – I think it’s probably more used than we recognise! By asking the person “what do you think is the next best step?” we place trust in the person, we allow them to set the degree of difficulty, and we show them that we respect their view. Then we can nudge a tiny bit further and help people understand what’s going on in their minds when they resist/avoid/don’t engage. For this part I think it’s useful to have good CBT skills, excellent listening skills, be able to ask open-ended questions and guide discovery rather than telling people what they “should” do.

  2. I found that the two questions I asked myself were, “what was it I used to like to do?”and “what am I passionate about?” I went through a lot of soul searching, trying to find what I wanted and liked. I think for women, many of us stopped doing things we loved a long time ago to care for the home, family, career and it was sad when I realized that I stopped doing things I enjoyed many years ago. Most of us can recall what we liked to do as children or teenagers: I had to go back that far! Finding things I enjoyed and following after passion were major goals for me. Getting back to part time work was actually easier, I had a lot of experience doing that. As a result of those goals; following after my passions, my life looks a lot different now, I’m more balanced, engaged and happier, even though, I hurt. I figure, I’m going to hurt anyway, I might as well be doing something I like.

    1. I love your last sentence – it’s my attitude completely! I do like your two questions – for a person experiencing pain, I think they’re two very powerful ones to ask yourself. Because passion transforms effort into flow.

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