goalsetting

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.

Attributions regarding unmet goals after treatment


ResearchBlogging.org

After searching for a while, and finding not that much about goals in the peer-reviewed pain management literature, it’s nice to have an article that specifically discussed goals and the effect of not meeting goals on participants. This article by Guck and colleagues from the University of Nebraska, examines how a group of participants in a pain management programme view their achievement of goals – do they blame themselves, or external factors for their ‘lapse’ or ‘relapse’.
It’s interesting that this piece of research is based around the concepts of relapse prevention, because one of the main reasons for considering the place of goal-setting is to ensure participants make changes in their lives that matter to them – and retain those changes over time. So relapse prevention theory will have much to add for therapists wanting to help their clients stick with the ‘programme’. I’m not sure that many therapists would have really considered this body of knowledge in relation to physical exercise or using coping skills, because much of the theory is directly related to smoking cessation, dietary change or alcohol abstinence.

Anyway, onto the research.
In this study 100 particpants from 263 people who entered an interdisciplinary programme over a five-year period were asked to participate. Of the original 263, 30 failed to complete the programme, and of the remaining people, 100 provided complete information.

From the description, the programme sounds very similar generic and consisted of a four-week programme of exercise, medication review, active coping strategies and other issues such as work, family and social issues were also addressed in both individual and group sessions.

In the final week of the programme, relapse prevention sessions were held, covering high risk situations, and how to reduce the likelihood of the rule violation effect.

Interestingly, the group developed their goals for after the programme at the time of this discussion – in full awareness of the role of ‘slips’ and ‘lapses’. Participants develop between 4 – 6 goals, and staff assisted them to ensure goals met the ‘SMART’ goal schema. The goals were to be achieved in the next six months.

Six months after discharge from the programme, participants were contacted with a copy of their goals list, and were asked to identify whether they had met the goal, and for each unmet goal, to record on four attributional rating scales, the reason for not doing so. The attributional scales were 1 – 7 likert-type scales, with ‘internal’ to ‘external’, ‘stable’ to ‘unstable’, ‘gobal’ to ‘specific’ and ‘uncontrollable’ to ‘controllable’ factors as the anchors.

Results – Overall, the 100 participants identified 487 goals they intended to meet – 322 of these goals were recorded as met, while 165 goals were not. 46 of the 100 participants met most of their goals, while 16 failed to meet more than 2/3 of their goals. Chi-squared analysis indicated that more goals than not were met in most of the goals categories – except for work.

The causes for not meeting work and social activity goals were attributed to external rather than internal factors more often than were causes for not meeting coping skills, medication change, or exercise goals. Work goals were more often to be thought to be uncontrollable.

So, it seems that goals that were set during this programme by and large were met – except in the two areas that depend a lot on other people (social and work). And the attributions that people made as to why these goals were met or not met differed depending on the type of goal. This suggests that it’s not helpful to use the same relapse prevention model for some of the goals – that is, people do tend to believe that when they can’t manage work or social goals, it’s about external factors, uncontrollable factors, and global factors that are stable.

This makes it very difficult for people to reconsider how to cope with these demands, and from other research in relapse prevention, makes it more likely for them to feel there is nothing they can do to change the situation, and reduce the likelihood they will attempt again.

The researchers in this study suggest that people who need to set goals in social and work areas need to be taught how to cope with factors that affect work and social goals that are external and uncontrollable – unfortunately, as many pain management programmes don’t even consider return to work as a goal, and certainly don’t seem to break that goal into manageable ‘chunks’, this may remain a concern within New Zealand at least.

Once again I’m left with the impression that developing pain management skills and goals to help people return to work despite chronic pain is different from and more complex than simply helping people develop generic pain management skills. The workplace is different from the home – and goals made for using pain coping strategies, exercise and medication at home seem to be much more easily achieved than those about using them at work. Food for thought: perhaps pain management at work is a specialised area for pain management, and not simply the same as ‘any old pain management’?

Gluck, T.P., Willcockson, J.C., Schmidt, R.L., Criscuolo, C.M. (2008). Attributions regarding unmet treatment goals after interdisciplinary chronic pain rehabilitation. Clinical Journal of Pain, 24(5), 415-420.

A Wish List for goal directions


I’ve been posting about goal-setting, and mentioned the Wish List approach – today I can do the Big Reveal!

Thanks to my colleagues at PMC (who shall remain nameless!) I have attached a copy of the ways-i-want-my-life-to-change-wish-list that people can use at the very beginning of a programme to help identify the areas they want to influence by developing pain management coping skills.  It can be used instead of the menu I showed yesterday, or it can be used alongside it.

There are quite a lot of areas that people would like to change or learn about with regard to chronic pain, and this list isn’t designed to be exhaustive. It’s also not especially specific in terms of making measureable goals based on research into goal-setting that we’ve discussed a few days ago.

What it does do is give you, as the clinician, a really good idea of the sorts of needs the person has already identified. In terms of motivation or readiness for change, it can indicate areas that the person is already ‘contemplating’, or is even perhaps in ‘preparation’ for change. Prochaska and DiClemente’s model (oh yes, I’ve talked about this a LOT!) and work around this model clearly supports the finding that people need to be in the right space to even start to consider making changes.

If the person is never asked to consider an area that could change, though, it’s fairly difficult for them to actually decide that they would like it to be different, so part of our role is to help open up the possibility for change – and you can see this in the ‘Wish List’.

I use this Wish List at the very beginning of the programme, asking people to tick all the areas they would like to see changes in. Then after a week or so, I ask them to indicate their three most important ‘wishes’. Then we can start working on importance and confidence: why these areas are important (providing the person with the opportunity to reflect on how important it is to them, and uncovering personally-relevant values to support their change process), and how confident they are to achieve them. Once we’ve identified their level of confidence, it’s part of my work to help the person build the confidence to start taking steps towards achieving the changes they want to see in their lives.

To me, pain management is not simply about developing a set of new coping strategies that can be employed while the person continues on in their life. It’s much more about reconceptualising who they are: to move from a person who has become quite experienced at being a patient, and following other people’s requests or directions, into someone who has their own life to live, their own direction to follow and is becoming a person again.

This is why I feel quite frustrated with many self-help books, even for chronic pain, that are chock-full of new ways to cope, but leave the integration of these coping skills to the person.  Integrating new skills is critical for the skills to actually be used. If you’ve ever been to a workshop and come away with a whole set of new ideas – only two weeks later find yourself doing just what you’ve always done, you’ll know exactly what I mean!

In industrial and organisational psychology, a lot of research has been undertaken into ‘transfer of training’ – and things like ongoing support in different contexts, refresher courses, memory prompts, support from ‘important people’ (eg line managers in a factory) are all known to be both effective and almost essential before training can be implemented in a workplace. (For some good information on transfer of training, this site provides some good resources).

Now, start to think of how we as health providers, support transfer of skills developed in a clinic: how many of us get the support of the ‘important people’ in the person’s life to help them use the new skills? How often do we consider the network of relationships that are a part of an individual’s context? How could we help that person make the links between what we show them and what they can readily use in their own environment?

This is really important as far as developing pain management skills in the workplace goes. Without specific support to help someone use their skills, in the context of work where all the cues for old behaviour exist, it’s going to be very difficult for them to recall and do something different. Especially when they are perhaps not entirely convinced that this new way of working is helpful.

So while pain management itself is not about ‘personality makeover’, it is all about reconceptualising the person-as-patient into the-person-as-person. Without that essential ‘new belief’ the person will likely return to old habits.

Your challenge for today? What about taking some time to think about one method you could use to support someone to recall a skill that you are helping them develop? How could you transfer what they are starting to learn with you into their home or work situation – hey, even into their car!