Goals? I loathe them: What to do instead

I dislike that acronym “SMART” goals. I can never decide whether it’s meant to mean “Specific, measurable, achievable, realistic and time-bound” or “specific, manageable, active, realistic and timed” And if it’s either of those, what’s the difference between achievable and realistic? Or is it meant to be “relevant”?

In previous posts I’ve established good reasons to have a focus for therapy. Unless the focus is something valued by the client, it’s either unlikely to get done or it’s not their goal and they’re going along with it to keep you happy. Goals, targets or focus are useful, and the logic goes that unless you have them you won’t know where you’re going or when you’ve got there.

I’m not going to argue against the idea of having a focus to therapy. I just think there are risks in having goals, like some sort of checklist that says “If you achieve this, you’re all good”.

Seriously, that doesn’t work in real life. That’s the same kind of logic that says “if I just buy enough things I’ll be happy”, “if I just earn a bit more I’ll be happy”. While there’s a bottom line below which it’s hard to think beyond survival, above that line, having stuff, and even doing things as an end in themselves doesn’t fulfill for long.

What gives forward momentum, enrichment, fulfillment and can’t be ticked off like some shopping list is recognising that life is actually a whole series of actions and events that, when we think back on them, make up a good life. The richer events and experiences and actions feel good and fulfilling. The empty routine and humdrum things feel deadly dull and empty.

When I think about the purpose of therapy my focus is helping people to live the kind of life they value, doing the things they believe are important. Given I don’t want to be a long-term feature in a client’s life (for all I love them, I’d rather they were doing it themselves), my focus is on helping them work out what makes a rich, fulfilled life they can look back on and feel satisfied. My job is to help them develop skills and strategies to carry out the actions needed to live a life aligned with what they value.

Let me unpack this a little.

Many people I see place value on being a good parent, a loving partner, a reliable employee. When I see them, their pain has interfered with doing the things they believe demonstrate “being a good parent” or “being reliable”. Pain has moved in to their lives, and come and sat on their laps right in front of their face so that all they can see is pain.  If I ask someone in this state to “set goals” they laugh, rather sarcastically sometimes, and say they don’t have goals, they can’t think of anything and what’s the point anyway. Perhaps not in those words, but the meaning is clear.

Instead, I ask them “what would you be doing if your pain was less of a problem for you?” Sometimes I’ll even hand over a plastic fairy wand I have, and suggest they dream a little. It’s then that the passion takes over – they’ll say “I’d be out working, having fun with my friends, caring for my family” – and the list goes on! If I stopped there, though, I’d be holding a tantalising dream just out of reach, which is cruel, so I don’t. Instead I ask why these things are important.

That’s how I find out that “family is everything”, “I just love creating”, “I need my friends”.

Then I switch tack for a moment and ask them “How well is what you’re doing to deal with your pain right now working to help you be the kind of person for whom family is everything? How well is what you’re doing with you pain helping you create?”

The reason for this tactic is to help generate what Acceptance and Commitment therapists (ACT) call “creative hopelessness“. Because motivation to change comes from inside – that it’s important enough, and the person is confident that change can happen.

I then suggest two things: 

  1. Is keeping pain happy more important than family ?(and yes, I know I’m personalising and objectifying pain here, and yes it’s an experience not a thing, but it works OK!)
  2. What would happen if you made a little room for pain to be there while you’re doing things that contribute to you being the kind of parent you want to be?

What I mean by this last statement is that pain can interfere with doing that things that help you feel you’re being a good parent. And that can lead to either completely abandoning those activities, or doing them while clutching resentfully to “the pain that interferes”. What if you attended to the value or importance of being the kind of person who is a good parent instead of focusing on the irritation, frustration and anger of having to bring pain along for the ride?

  • For many people, the things they believe contribute to “being a good parent” far exceed what they can currently achieve. So they give up and get demoralised. They both have their pain AND they don’t manage the very things they most value.

Now it’s here that I could begin to “set goals” and suggest we work towards them using all the traditional elements of goal setting. And that probably has excellent value. But here’s the catch: often we hold very strong internal rules about how these things should be done so that unless we can do them exactly the way we think they should be done, we’re not satisfied. And for many people this fails to recognise that as time goes on, life too goes on, and we change the way we do things to accommodate new habits or capabilities. So I try to begin a process of developing flexibility – and using the values a person identifies as a compass rather than a checklist.

What would happen if we thought a little about the range of things people might do to convey “being a good parent”? Maybe it would mean going to the children’s sports games and being a spectator. Maybe it would mean making lunches, helping to do homework. Maybe it would include listening while a kid tells you about his or her day. Many of these things can be done with pain present. Many might require altering how they’re done to accommodate having pain present but provided that they express the underlying value of being a good parent, can be fulfilling.

What’s important is less about the what a person does, and a whole lot more about why and how they do it.  When “being a good parent” becomes the direction we live (because we can never tick the box that says “being a good parent” is complete), then we focus on why and how we do it. Attention goes away from “but pain stops me”, and towards discovering all the ways “being a good parent” can be lived.

Often it’s through doing this that people seek new coping strategies so they can extend what they do. People may “set goals” or future actions they want to take but instead of feeling frustrated and dissatisfied, they begin to to take actions that bring them closer and closer to living the life they want to live. And that, my friends, is what I think “goal setting” is about.

This festive season is a good time to consider what’s important in your life. What actions are you taking to live a value-filled life?

An accidental form of control: when mindfulness produces happiness ACTing Well, Living Well iv

I’ve had some success while working with a man I’ll call Peter.  He’s got chronic pain, and has been incredibly fearful of what it might mean – in fact, you’d probably call him a classic catastrophiser because each time his pain flared up he immediately thought it was something like cancer and he would rush off to his GP or the Emergency Department to have it checked out.  Luckily any scans he’s had haven’t shown anything operable because I’m sure with the amount of distress he was been experiencing, he would have been able to persuade a surgeon to operate had there been anything odd-but-common found.

We’ve been using mindful breathing as a way to get in touch with the sensations, emotions and thoughts that occur to him, and especially ‘making room for’ the thoughts his mind has been telling him of needing to check his body for symptoms, for the nauseous feeling he gets when his mind starts to worry, and for the painful sensations that he experiences throughout his body.  It’s been a real learning experience for him to find that he can be willing to experience these symptoms without judging them, and, as seems to happen for many people, he’s been finding that they disappear or reduce over the five minutes or so we do the exercise.

Now this is a trap for young players and older ones too.  While it’s nice to find that sometimes mindfulness can produce peace, relaxation and calm – that’s not the point of being mindful!  The point of being mindful is to be open to experience whatever happens.  And for those people who do experience a reduction in negative emotions, sensations or thoughts, the very reduction can begin to form a subtle type of control.  The thinking goes something like this

“I feel uncomfortable.  Quick! I’ll do some mindful breathing – and then that feeling will go!”

Sounds a lot like ‘experiential avoidance’ – although perhaps slightly more effective than running around keeping busy to avoid the negative feeling, or trying very hard to ignore the feeling, or perhaps catastrophising.

Why would we worry about this?  Does it really matter if someone does start to use ‘mindful breathing’ as a way to reduce symptoms?

Well yes.  There will be times when even though the person is using mindful breathing to ‘sit with’ something negative, the negative experience doesn’t reduce, doesn’t fade, and may even increase.  That’s not the point of mindfulness – it’s about accepting whatever happens, allowing it to be there AND CONTINUING TO COMMIT TO ACTIONS that move in valued directions.

The problem with hoping that mindfulness will reduce symptoms or thoughts is that when it doesn’t reduce these, the temptation can be to feel distressed – and stop the mindfulness.  And after stopping the mindfulness it can be very difficult to carry on doing the actions that will ultimately enact values.  That wonderful mind can kick in and accuse the person of ‘being stupid’, ‘wasting time’, ‘doing this dumb thing that doesn’t even work’ – this usually brings more negative emotion along for the ride, and ultimately doesn’t help.

So what to do?

I’m still learning this, but I think I’m going to mention that mindfulness is about allowing what will be to be.  And being ready to carry on with valued actions despite this.

I think this might be one of the hardest things to do – I’ll let you know how I go!

Act-ing Well, living well ii

The second in a series about ACT and its use in pain management from an occupational therapy point of view.
My last post (here) talked about ACT and ‘doing what matters’, or ‘valued action’ – this involves identifying what is important to a person, then helping them do it, while being careful not to encourage ‘experiential avoidance’, or avoiding coming into contact with experiences we’d rather not.

Here’s the ‘hexaflex’ or diagram that provides an overview of ACT.  What ACT tries to develop in people is ‘psychological flexibility’, or the ability to be in the here and now, open to experiences (even negative ones) and do what matters to live a life in alignment with what is important.  In people who lack psychological flexibility, it might be possible to see:

  1. The same old strategies being used over and again while not achieving the desired result (eg working incredibly hard to ‘get things done’ so that family are cared for, even though that leaves the person with pain exhausted and completely unable to emotionally care for the family).
  2. People trying all sorts of methods to avoid experiencing something they don’t want (eg stopping all enjoyable activities because it increases chronic pain, or attending multiple treatments to get rid of pain, or only doing activities in a certain way to make sure that pain doesn’t become overwhelming)
  3. Carrying on with activities despite pain, but ‘enduring’ the pain and feeling distressed or under strain when doing so.

The problem with presenting ACT to people is that if I ask a patient ‘would you be willing to accept having your pain’, they’re likely to hit me.  It goes against all of the usual therapeutic approaches in health.  Everyone ‘knows’ that pain is bad, and it’s our job as humans to prevent it, treat it or at least reduce it.  The problem is that in chronic pain, the efforts that go into struggling with pain, trying to control it or get rid of it or so often get in the way of living well – and what’s more, they rarely work.  In fact, some studies suggest that the ‘best’ results from pharmacology for chronic pain provide only a 30% reduction in pain intensity.

Acceptance is a concept that ACT embraces – but it’s not an all or nothing acceptance, far from it.  Acceptance is used when it’s almost impossible to control thoughts and feelings, and when control is possible but doing so erodes what makes life wonderful anyway.

The basic rule of thumb for an ACT practitioner to decide whether the strategies a person is using needs changing is whether the strategies are workable.  Now that’s a concept I really like.  Workability refers to whether the ways the person is living helps them achieve what is important in life in the long run. This is a concept that I think occupational therapists will find resonates with the way occupational therapy intervenes, and helps put into context some of the short-term ‘adaptive’ strategies that fail in the long term.  Here’s an example:

Belinda has been in hospital for a hip replacement.  The day she is expecting to go home she is visited by an occupational therapist who advises her of the various post-surgical precautions she must take to avoid dislocation.  Yes! A raised toilet seat and shower stool are duly provided, and she also receives a kitchen trolley because she’ll be on crutches for at least six weeks before she can put weight fully through her new hip.  These gadgets allow her to get out of hospital and back into home where she can begin to eat her normal meals, sleep in her usual bed, and be with her family.  The solutions provided to help her get out of hospital are very ‘workable’ and help her re-establish her independence.

Do they involve experiential avoidance? Oh yes indeed – they help her to feel more confident, reduce her pain (and the risk of dislocation), and ensure she doesn’t need to ask for help.  They help her avoid experiencing helplessness.   Without them she can’t use a normal toilet without worrying that she’ll dislocate, or do her cooking without leaning on the kitchen trolley.

There are risks inherent in providing gadgets, as any clinician knows.  In this case, when the danger of dislocation is over for Belinda she may continue using the gadgets to avoid the pain of moving through the range of movement. If she strongly believes this, Belinda may be limited in her ability to do some of the things she feels are important to her, like go to the shopping mall, see a movie at the theatre, or take a bath – she can’t exactly carry her toilet seat to the mall, or push her kitchen trolley around the supermarket! Now this is unhelpful, unworkable experiential avoidance.  Not such a good thing.

Clinicians may use strategies in acute healthcare settings to enable people to avoid certain experiences – this helps people return to other aspects of their lives that they do value, such as independence and living in their own home.  If these solutions remain in place, though, they’ll get in the way of the person living well in other aspects of their life.  Perhaps something all clinicians need to stop and consider, especially when considering the use of pain reduction approaches such as injections or infusions.

My focus in pain management is to help people who have chronic pain and want to think of themselves as ‘well’.  I can’t judge whether the strategies they use are ‘workable’ against my own values, but need to instead help people to look at the function of their strategies and help them examine the long and short-term workability of what they do in light of what is important to them.  I’ve used motivational interviewing skills as one way to help people look at their choices, and weigh up options.  Identifying values features strongly in MI, and it’s great to see them as part of ACT.   More about values next time I post.

Goals or actions?

Goals seem to work best when they’re important to the person, and the person has sufficient confidence that they’re going to be achieved. But…’there is many a slip betwixt cup and lip’ – while the goal might be set, actually getting there depends on many things. I wonder whether we can inadvertently slip up when we’re working to help someone set goals by focusing on outcome goals rather than process actions.

Let me clarify. Outcome goals are things like ‘sleep for 8 hours a night’. That’s what the person wants to achieve – but sleep might be disrupted by a child crying, a storm outside, or even a partner snoring! Sometimes the goal isn’t achievable not for lack of trying but because external factors intervene.

Process actions, on the other hand, are the particular actions the person does in order to work towards the desired goal. Actions are things like going to bed at a regular hour, keeping the bed for sleep and sex NOT worrying, arguing or being awake. Actions are specific behaviours the person can do, and are able to be achieved provided the person actually does them. Actions should lead toward the outcome.

I started to mull over the difference between goals and actions after reading through some of the ACT therapy manuals. In ACT, it’s important to identify the ‘why’ a particular action is being taken. The underlying reasons for an action are like a compass – they are the values that are important to the person, and guide the direction in which the person lives life. They’re never ‘completed’ or ‘achieved’, they can’t be ticked off a list and then dropped. Values can be eroded when actions that used to fulfil them stop being carried out. This can lead to a life full of actions to reduce negative experiences, but that inadvertently get in the way of actions that embody other important values.

When I look at the Stages of Change model and motivational interviewing, an important aspect of readiness to take action is to identify how important the change is, and how confident the person is to make that change.  Reviewing the importance of a change uncovers the values that the new behaviour is intended to fulfil. Without being really clear about why a new behaviour might be carried out can lead to weak engagement in the goal.  Importance is the aspect that MI identifies should be strengthened and clarified before starting to increase confidence.

Coming back to actions or goals.  If a goal is the end point and the outcome varies because of something unforeseen,  then the chances of the person becoming confident that it’s worthwhile persevering will be quite low.  After all, if my goal is to be first in a race, and I see that everyone else lining up for it has a personal best far better than mine, I’m not likely to want to even begin the race!

It’s important to distinguish between actions that the person can take, and be in control of, and goals that may not be achieved because of other things.  And the actions must tie in with underlying values or the person isn’t likely to find them important, even if they are certain they can do them.

This suggests a couple of preliminary steps before developing action plans or goals in therapy.

  1. Establishing what is important, or the values that a person has might be a necessary first step in developing a therapy plan.
  2. Values often tie in with roles that the person fulfils, but roles might be undertaken for different reasons – so we can’t make assumptions about why an activity is important to someone simply on the basis of our reasons for doing a similar activity.
  3. Sometimes people don’t know why an action is important, and we might need to spend some time working through this with the person – and in the end, may not pursue that action at all!
  4. Once the important values are identified, finding out what that value might look like in this person’s life may help to define the actions the person can take to live.
  5. These actions, and working towards being able to carry out these actions then become the basis of therapy.

Actions can be specified, measured, counted, tied to place and time and person – and they’re about what this person chooses to do (or not do).  Achieving them helps the person live what they value, even though this may look different from what we might do to live that value.

I wonder if, instead of developing ‘goals’, we started to use the words ‘action plans’.  This might help us as therapists focus on things the person can do in the process of living a life aligned with personal values.  And isn’t that what we’re really trying to do in our own lives?

I hope you’ve enjoyed this tour through some goal setting literature.  If you want to keep reading, you can subscribe using the RSS feed above left, or you can bookmark and just visit.  I write most days during the working week, love comments and respond to questions!  Don’t forget you can introduce yourself via the ‘About’ page, and if you’re an occupational therapist, there is the private section just for you.  Email me for the password via the ‘About’ page.