Stress: The final frontier (executive functions)

It’s visceral. Stress – hits you in the guts. Some of us cope well, some of us don’t – some of our stress lingers, sometimes it’s just the little things, those ‘daily hassles’ that end up tripping the switch. And I don’t think anyone would disagree that chronic pain is an enormous stressor. Regulating that stress level, or managing it effectively, has to be the main challenge in learning to live alongside chronic pain. Today’s post discusses executive functions (the parts of the brain that carry out self regulation) and stress.

Executive function is ‘… a multifaceted construct comprising a number of basic neurocognitive processes, including working memory, cognitive flexibility, response selection, inhibition, initiation, set formation, and set maintenance.’ Williams, Suchy and Rau state that ‘these processes allow us to generate goals and plans, modify our behavior in response to changes in the environment, and follow through and execute necessary actions in order to successfully achieve the intended goals.’ These functions are different from many CNS functions in that they require ‘attention’ or ‘volition’ to initiate and maintain them, whereas many other functions such as those that maintain homeostatis are pretty well automatic.

‘The areas of the brain thought to be primarily responsible for executive functions are the dorsolateral, superomedial, orbitofrontal, and ventromedial prefrontal cortices, anterior cingulate gyrus, the basal ganglia and diencephalic structures, the cerebellum, deep white matter tracks, and some aspects of the parietal lobes – and these are linked to each other and to other structures to ensure most cognitive processes including sensory perception, memory and language are linked.  As a result of these connections, EF serves as the interface between previously acquired knowledge and newly arising information in the environment.’ (Williams, Suchy and Rau, 2009) Can you see why I used a quote? I don’t trust myself to paraphrase!! These structures also link strongly to those automatic/homeostatic areas of the brain, so can influence emotional processing, autonomic control, and appetitive functions.

Even amongst people who don’t have chronic pain (or for that matter, low mood, or a brain injury), we vary in the ways in which we deal with stress. Williams, Suchy and Rau suggest that ‘even slight declines in EF can lead to a breakdown in stress regulation that affects both mental and physical health’ and that ‘aspects of EF are heritable.’ Certain executive functions such as switching attention, inhibiting a response or updating ‘working’ memory have been shown to be inherited.

I won’t go into detail about how this is studied, because it is quite complex and involves drawing conclusions from the results of both trauma or brain injury-induced deficits and the types of pathology found when people have been exposed to significant stress.  It’s also proven to be a very difficult area to study, especially in people with only slight deficits or ‘individual variations’ in the way they respond to stress.  Most neuropsychological tests are fairly blunt instruments and don’t show subtle problems, like those that occur when we’re stressed!

Some interesting findings, however, showing that traits like conscientiousness (also called ‘constraint’) have a positive association with better stress management and better health, while neuroticism (associated with the Behavioural Inhibition System – sensitising us to avoid harm, making us more tuned to negative cues) is associated with greater stress and poorer health.   Extraversion, or the tendency to want interactions with others and to become energised by them can be associated with additional risk taking, but also with positive affect which has a positive effect on health.  Openness to experience is a trait where people are basically inquisitive (that’s me to a T!) is associated with better adaptation to chronic illness, and the last one is agreeableness, or getting along with others and to cooperate, and it is associated with better health and lower stress.

What does this mean for chronic pain and executive functions or self regulation?

Perhaps some of the vulnerability to having trouble coping with longterm pain arises from genetic tendencies in the way our executive functions operate.  Remember that chronic pain is a stressor, and that chronic pain problems can arise during periods of increased exposure to stress.  This suggests that the effect of chronic pain on executive functions, or the ability to self regulate might influence how efficiently we can cope.  It also suggests that if our self regulation skills are vulnerable, then under stress we may find it much more difficult to manage.

From my last post, it also seems that we can develop self regulation, provided we have sufficient resource in terms of energy and social support (and someone to help establish appropriate goals).  Some people may find it more challenging not because they have less inclination to cope, but simply because they have certain tendencies that are inherited to make this aspect of coping much more difficult.

If as clinicians we can identify those people who need more support, and especially if we can identify some of the ‘components’ of executive functioning such as sensitivity to activating the Behavioural Inhibition System, maybe we can help prevent some of the chronic disability arising from having chronic pain, even if we can’t prevent the pain from being present. After all, it’s not the pain itself that is problematic – it’s the disability or functional limitations arising from the pain that create problems.

Williams, P., Suchy, Y., & Rau, H. (2009). Individual Differences in Executive Functioning: Implications for Stress Regulation Annals of Behavioral Medicine, 37 (2), 126-140 DOI: 10.1007/s12160-009-9100-0

Going with the flow: emotion regulation and coping
I’m in two minds about attempting to regulate emotions. From ACT, and in particular, mindfulness, I’m learning that trying to control emotions and thoughts is darned near impossible – and unhelpful. From the research on the effect of pain on emotions and subsequently on self regulation, goals and coping, it seems that pain strongly influences emotion and that negative emotions in particular, influence the range of coping strategies and goals we choose – and success or failure in turn generates further emotion, and so on.

As Hamilton, Karoly and Kitzman say ‘the primary function of pain is to disrupt other ongoing activities and to direct attention toward the cause of injury or the extent of tissue damage’ – of course, in chronic pain, there may no longer be any injury or tissue damage, and instead we are left with the experience of disruption to activities without a purpose. Pain by definition involves negative emotions, which we have seen over these posts recently, can activate ‘harm-avoidance’ strategies. Over time, pain can reduce the attention given to, and pleasure obtained from, activities that are usually enjoyable, and can reduce how well we process normally positive information.

So, pain detracts from normally enjoyable activities and reduces the benefits we usually get from achieving goals, probably makes us less likely to choose goals that are driven by curiosity or positive benefits and instead increases the chance we’ll choose ‘harm avoidant’ goals, and when things go wrong, pain makes it much more difficult for us to look creatively at ways to cope.

Self regulation is influenced therefore by emotions – but at the same time, self regulation can influence emotions. Pain management goals in one study were not only influenced by negative emotions but also by the level of social support people had. Maybe routinely including family and social networks into pain management goal setting with people with pain would be helpful. I’m noticing that over the past 20 years, the number of people who attend assessments and pain management programmes with partners or family members has dropped considerably. It’s almost as if the person with pain is the only one who ‘has’ to cope. A couple of posts ago I discussed the need to ensure that people have adequate coping resources before setting self regulation goals, because these resources become depleted (and there is no doubt self managing pain is hard work!).

Yesterday I mentioned ’emotional complexity’, or the ability to tolerate opposing moods.
Hamilton, Karoly and Kitzman think that this ability is something that is acquired rather than a trait, and suggest that CBT and ACT may, because they help people understand the relationships between thoughts and emotions, help people develop the ability to regulate emotions. Of course, ACT suggests that rather than trying to control either thoughts or emotions, we simply acknowledge them and they will pass.

By maintaining focus on values, or what is really important, ACT suggests that we’re able to tolerate the fluctuations in emotions and thoughts and remain engaged with things that we value. ACT theory suggests that by allowing the moods or thoughts to flow, the natural ebb and flow of emotions continues rather than building up to an intolerable level, or being judged negatively.

This is a different approach to self regulation from CBT where CBT suggests that by logic we can reassess our thinking patterns and replace them with more helpful ones, and in turn these will influence emotions. I think CBT has its place, but more and more I’m finding that at least part of the time I’m encouraging people to ‘sit with’ negative emotions and thoughts in order to reduce the threat value or judgements about them, and help people recognise that they will survive and can continue to do what is important even if at times they feel different feelings, including negative ones.

A good deal of pain management works on helping people cope with the stress associated with having pain. The authors suggest that it might be just as important to consider working towards approach-oriented goals, that is, doing things that have positive reward, such as social goals, because these both support self regulation, as well as generate positive emotion. ‘Therapists must emphasise to paitents that it is important to maintain focus on other goals, even during painful flare-ups…both patients and therapists [can] become focused on distress management and lose sight of goals related to an enhanced sense of wellbeing.’

The way I interpret this is that it’s just as important to help people identify social activities, leisure activities and have fun and grow as it is to persist with getting better sleep, return to work, or use relaxation to cope with a flare-up. I’ve been including scheduled pleasant events every day with patients for quite a while now – and it can be unbelievably difficult! Some people have never ‘had fun’, never had time to be sociable, never thought of relaxing or having a hobby or being creative.

I remember with one patient, we instituted a whole ‘Pyjama Day’ where she could take the phone off the hook, watch DVD’s, paint her nails, have a soak in the bath and read trashy novels! Initially it was really difficult for her to do this without feeling guilty, but later on she enjoyed it and started to look foward to it, and then started to plan self development ‘creative’ things she could do on that day. Yes, painting or photography or baking or learning a foreign language can be part of pain management!

This won’t be the last post on self regulation, coping, emotions, goals and chronic pain. It seems to neatly tie in with the focus of living a good life despite having pain, and especially of living according to values. I think self regulation is one of those ‘occupational performance components’ that might be overlooked by some occupational therapists who focus on occupational performance, or function, but might not consider the underlying skills and resources that need to be present for someone to function well. Occupational therapists have as a core philosophy that ‘doing is being’, and by doing functional activities, people become well. It looks like that assumption has some support from the literature, now it’s time to look at how to help people ‘do’.


Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76

Theories of emotion, self-regulation and pain

ResearchBlogging.orgCan chronic pain be a force that shapes how we go about responding to challenges within our environments?

Does chronic pain influence how we feel emotionally about daily activities that contribute to overall goals, and perhaps negatively bias the way we think about the process of setting and achieving goals?

I’ve already concluded that having pain doesn’t mean people can’t do what they want to do, but it certainly makes it harder and less enjoyable.  Today’s post will briefly look at two theories that link emotion, cognition and pain.  Once again, I’m drawing from a paper written by Hamilton, Karoly & Kitzman (2004).

These authors refer to two theories – the first being a two-factor model developed by Carver and colleagues in which it is proposed that people have two emotional regulation systems.

  1. A behavioural activation system (BAS) associated with positive feelings when the ‘appetitive’ systems is satisfied.  The appetitive system refers to a system that encourages us to approach and remain engaged with something for reward.
  2. A behavioural inhibition system (BIS) that associates negative emotions with goals that are involved with avoiding harm.

Carver’s model proposes that emotions develop during the course of evaluating process towards a goal – if the going is good, we feel good and carry on.  If the going is not so good, we feel less positive and may disengage from that goal.  This emotional response influences whether we persevere or simply give up depending on our tolerance to not receiving immediate gratification.  So it makes me wonder whether helping kids to learn to persist with something until they do it correctly is actually a fundamental learning experience that is needed so they can learn ‘stickability’ when the going is tough.

Hamilton, Karoly and Kitzman suggest that when we think about the effect of this model of emotion on self regulation, individual adjustments to the limitations of chronic pain might reflect how sensitive each individual is to either positive feedback or negative feedback.

This might influence how we give feedback to people who are pursuing a goal – some may need just that bit more encouragement and help to overlook the times they don’t succeed, while others might need to be encouraged to see the consequences if they don’t make progress (especially in the case of losing access to help from a compensation organisation).

The Hamilton, Karoly and Kitzman paper goes on to explore the evidence supporting Carver’s model and how this might influence individual differences that we see in people adjusting to the demands of chronic pain – perhaps some people are resilient because they can draw upon small steps towards a goal that others might overlook because they are less sensitive in the BAS.  Perhaps some are strongly sensitive to the BIS and as a result are more energised by avoiding the negative emotions associated with remaining ‘stuck’ when coping with chronic pain. They also suggest that maybe chronic pain itself influences BAS and reduces its sensitivity (ie chronic pain reduces how ‘rewarding’ achievement feels), and/or increases the BIS sensitivity (ie makes it all the more important to avoid risky situations).  As they put it ‘pain-related negative affect could have a pervasive impact on the evaluation of goal-related progress and resulting affect…whereas periodic pain flare-ups may have a state-dependent effect on BAS/BIS sensitivity.’

The second model is one I have come across in my readings – Dynamic Model of Affect (Reich, Zautra & Davis, 2003).  In this model, Zautra and colleagues suggest that how well we adjust to chronic pain depends on individual differences in the structure of our emotional response, as well as the limitations we have in information processing. This model puts forward the idea that the relationship between feeling good and feeling more negative depends less on stable personality ‘traits’ than on the relationship between general mood and what is happening in the here-and-now.  Once again, research is cited by Hamilton and colleagues to demonstrate that when stress is low, both positive and negative moods vary independently – we can feel both happy and irritable and this can fluctuate just because it does!  During times of high stress, however, how good we feel is limited by the underlying level of negative emotion we’re experiencing.

When considering both models, Hamilton, Karoly and Kitzman suggest that Carver’s model refers to responses to individual events, whereas DMA refers to mood states that might occur over a period of time and across more than one dimension.  They also suggest that the DMA gives a better description of what occurs during increased stress, when it describes that cognitive and affective processing becomes more focused on avoiding threat than on seeking reward, while during low stress, both outcomes have equivalent influence.

The final aspect of emotion and chronic pain as it related to self-regulation, and in particular, setting and achieving goals, is that some people seem to cope quite well during periods of pain flare-up, and do so positively.  Zautra and colleagues call the ability to both experience negative emotional drive AND positive emotional drive ’emotional complexity’. In terms of goals, an ’emotionally complex’ person might be able to continue to react to positive events and ‘use that energy to fuel additional goal directed efforts’.

Attitudes towards experiencing emotions might influence the ability to be ’emotionally complex’. If we’ve been taught that ‘feelings are bad’ and should be stifled, or that understanding and being clear about emotions is helpful, will influence how well we are able to identify the different emotions we experience, and how well we can tolerate having them.  Being aware that we can experience different emotions – and cope with them – has been shown to help people keep focused on goals even during periods of high stress, high pain and limited progress.

What might these two models mean for pain management?

As therapists we might need to ‘take the emotional temperature’ of the people we are working with.  If we are working with someone who is highly sensitive to being ‘driven‘ by avoiding negative emotions, we need to be aware of this during pain flare-ups – it might be even  more important to show people that they can persist during these times than to give them lots of encouragement to try new intrinsically rewarding activities.  Recording progress might help.  Encouraging recognition of even small progress during flare-ups is clearly important.

…but wait, there’s more! Tomorrow: regulating emotions and coping.



Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76

‘What do I do when I’ve had enough’: The Effect of Emotions on Self-regulation & Chronic Pain
As soon as read the first paragraph of the paper I’ve used as the basis for this post, I knew I was onto something that resonated with my original occupational therapy values. It says this:

Living with chronic pain is a balancing act. People with chronic pain are required to make daily decisions about how best to cope with illness-related demands while managing other role-related obligations. Although some people become overwhelmed by the demands of illness and daily life, many, if not most, remain focused and well-adjusted, and do not require the services of a mental health professional. … Why do some redouble their coping efforts following a health set back, whereas others become demoralised?’

I concur with the idea that ‘most remain focused and well-adjusted’ – and that it’s the daily decisions, the little things that need to be prioritised and undertaken each day that require motivation and energy to keep doing when you have chronic pain.  Karoly and colleagues have written several papers on the ‘organising’ role of goals especially in chronic pain, and this paper by Nancy Hamilton extends the model proposed by Karoly to include the ‘energising’ influence of emotion.

How does this fit with self regulation?

Well, to achieve goals within life, we require the ability to control our thoughts, feelings, actions and physiology. We particularly need to do this when goals are not met immediately or are frustrated.  It’s a skill that incorporates multiple neural pathways, builds upon traits we are probably born with, but is able to be developed (otherwise we’d all have a paddy if we couldn’t have a piece of chocolate NOW!).   It seems that the importance we place on a goal, along with our confidence that we can achieve it, strongly influences how willing we are to attempt or persist with it.

Where emotions fit within this model is, according to Karoly, in terms of the level of arousal as well as in terms of the type of goals selected. Humans are generally goal-directed rather than simply reacting to situations.  In other words, what we do and the goals we choose are related to what we think is important, and what we think is important is developed from  interaction with our social environment (family and community), and all of this is influenced strongly by the emotions we feel.  Emotions generate ‘energy’ and focus, and enable us to recruit resources to work towards goals that we’ve chosen.

We all know that people with chronic pain vary tremendously in terms of how they go about adjusting to the experience of chronic pain.  The differences are not only in terms of ‘success’ – or not –  but also in terms of the processes and strategies people employ.  Karoly’s model identifies 14 factors that influence goal-related self-regulation, and each of these introduce variation in how people adjust or self regulate.  Not all of these factors are directly influenced by emotions, but several most certainly are.

The first area to consider when looking at emotions and goals, is the role of emotion on the actual goal content – what the person wants to achieve.   Goal choice is underpinned by values, or what the person thinks is important – but deciding whether to approach or avoid certain activities is often motivated by emotions. Consider, for example, people who are fearful of experiencing pain who seek all manner of ways to avoid engaging in activities that ‘might’ increase their pain.

One client, for example, was highly fearful of bending to the floor from standing to put shoes and socks on so for three years she sat on the floor to do this.  She also avoided standing to shave her legs, wash between her toes, and to put her knickers and tights on!

In contrast, positive emotions such as joy and happiness influence us to pursue goals that increase the chance for obtaining rewards and have long-term pay-offs such as social activities or creative pursuits.

Pain is, as I’ve said before, by definition a negative experience.  The link between experiencing pain and feeling sad, guilty, frustrated, irritated, hopeless or anxious (just to name a few!) is incredibly strong – and dysregulation of affect is often a feature of chronic pain.  People do cry more often, feel irritable, get grumpy with others and become depressed.

In this paper, Hamilton and colleagues suggests that pain and negative emotion ‘tend to activate similar goal-related trajectories.’ What they mean by this is that both pain and fear, for example activate increased awareness of threat, more focus on the self, preparedness to avoid harm, and according to Affleck, quoted in this paper, ‘pain often activates the negative emotion systems, perhaps as a redundant alarm.’

Emotions also vary with the types of goal content chosen – from a study by Hamilton, Karoly & Zautra (2004), people with fibromyalgia were able to be divided into three groups on the basis of affective and disease-specific outcomes.

  1. The groups were ‘self-sufficient’ – this group endorsed goals such as ‘getting on with my life’ and gave low priority to social validation;
  2. ‘treatment seeking’ people formed a second group characterised by goals to find a treatment provider who can ‘cure’ and gave low priority to social validation;
  3. while the third group gave priority to social validation goals rather than finding effective treatment for their symptoms.

The three groups varied systematically in terms of negative affect – people in the last group also reported the highest levels of pain and negative emotions.  People who said they were ‘getting on with it’ reported lower levels of pain and negative emotion.  It’s not clear whether this is a causal relationship because of the correlational design of this study, so it will be necessary to watch and wait to see whether pain and negative affect tend to bias the goals that are selected and how they’re valued, or whether the goals chosen actually determine the emotional outcome.

Where does this leave us?

Well, it suggests that adjusting goals – both the type of goal and the difficulty of the goal – might be an incredibly important aspect of self regulation to focus on when we see people with pain.  Nothing new there.  But it might also influence and be influenced by the emotions the person is experiencing.  If we’re considering the role of failing to achieve goals, we’re likely to find that this experience of failure will have a dual effect on pain and emotion.   We may need to set goals that are very achievable, especially in the early stages of engaging in pain management.  We might need to reconsider the effect of, for example, failed attempts to return to work.

Conversely, achieving a goal, particularly a social or interpersonal goal, has an influence on mood – irrespective of pain and fatigue.  From this we could consider the role of group activities, particularly exercise or discussion groups, that engage people in positive ways and gradually increase the demands.  Success breeds success.

Recently I’ve used a ‘Plan to do’ and ‘Did do’ diary where people plan their day’s activities, then record what they actually did.  This provides immediate feedback on progress – and successfully achieving what was planned, no matter how low the level of activity, provides a sense of accomplishment and becomes reinforcing.

More on this tomorrow!

Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76

I’m so tired of coping: Self regulation, executive functions and chronic pain
Changes take energy – that’s nothing new, I know, but perhaps something as clinicians we might forget when we work with people who have chronic pain. I was thinking about this as I’ve had a week away from regular blogging so I could focus on writing and some self care.  Things are busy and as we enter the run up to Christmas, not likely to slow down any time soon – and yes, this takes energy!

Adjusting to living with a chronic health problem is demanding, it’s complex and requires people to reflect on what is important to them, how to achieve important activities all the while maintaining a sense of self.  Self regulation is a term used to refer to the ability to alter thoughts, feelings, and behaviors.  In chronic pain ‘[the] demands cross biopsychosocial boundaries and include managing the pain itself (e.g., by redirecting attention or exercising), negotiating close relationships that can be affected by the limitations associated with chronic pain, suppressing ruminative thoughts about pain, and regulating moods such as depression and anxiety that are commonly comorbid
with pain.’
(Solberg, Roach & Segerstrom, 2009).

I’m not sure that we generally acknowledge the fatiguing aspects of all this adjustment – and I reflect myself on how I respond when someone says they’re tired, I usually start to think about whether the person might be depressed, what their sleep might be like and so on, but rarely ponder the extent to which adjustment and self regulation might be a finite resource that requires replenishment from time to time.

Solberg, Roach and Segerstrom state that ‘Executive functions, largely orchestrated by the prefrontal cortex (PFC), are “a collection of interrelated abilities that enables people to modify their thoughts and actions”’. Executive functions vary both in terms of general ability and specific ability to regulate thoughts and actions. Use of a portion of the brain to self regulate (eg suppress thoughts or emotions) reduces the ability to carry out other cognitive functions such as reasoning. ‘Acts of self-regulation (e.g., attention control, emotion control) led to poorer higher order intellectual performance on tasks involving logic and reasoning, cognitive exploration, and reading comprehension.’

It’s already recognised that some chronic pain conditions such as fibromyalgia and temporomandibular disorder not only present with pain, but also affect cognition, emotions and physiological functioning.  People commonly report being fatigued, having ‘fibro fog’, and present with a range of other problems including disruption to sleep.  The authors of this paper point out that many of the same brain regions that are affected in chronic pain are also associated with executive function such as cortical blood flow to thalamus, the caudate nucleus, and the anterior cingulate cortex and gyrus.  Whether these changes are cause or effect matters less than to recognise that they are present and functionally suggest that people with chronic pain may also have trouble with self regulation.

Importantly, self regulation can be developed.  Active coping in chronic pain is almost all about self regulation – setting goals, persisting in certain tasks, halting others, managing emotions and so on.  The ability to sustain these activities varies considerably and I’m sure we’ve all encountered people who have managed well for a time, but lapsed or had a major set-back due to another significant event.  Important to remember is that ‘if patients with chronic pain are already experiencing self-regulatory fatigue, they have little strength to initiate or maintain such activities, regardless of their potential benefits.’

Maybe one part of the success of graded reactivation is not so much the habituating to pain, nor even the ‘return to fitness’ that is now being challenged (just how fit are the therapists compared with the participants who have chronic pain?!), but because it doesn’t tax the already fatigued self-regulatory resources.

The paper I’ve been quoting from provides a helpful, albeit brief, review of self regulation, executive functions and chronic pain. Recommended reading if you haven’t considered the area before, and also because it summarises a good deal of the neurophysiological information and self regulatory literature and applies it directly to the areas we are concerned with in chronic pain management.

This week I’ll be focusing on self regulation – there’s much more to learn! I think it may well be a significant part of resilience, and therefore worth developing not simply in people with chronic pain, but maybe in ourselves as clinicians. Who knows, some of us might be both!

Solberg Nes, L., Roach, A., & Segerstrom, S. (2009). Executive Functions, Self-Regulation, and Chronic Pain: A Review Annals of Behavioral Medicine, 37 (2), 173-183 DOI: 10.1007/s12160-009-9096-5

Basic biofeedback in pain management

I’m no techno-whizz in biofeedback – you have to speak to one of my colleagues (she knows who she is!) to get the technical data on things like heart rate variability – but I do use several modalities reasonably often. So today I thought I’d discuss some of the ways I use biofeedback with the people I work with.

Biofeedback basically provides visual or auditory information about normally undetectable physiological processes. It ranges from temperature sensors through to skin conduction (galvanic skin response), and includes surface EMG, respiration, blood volume pulse and sometimes these are put together to provide feedback on heart rate variability. I’m not going into HRV yet, that’s for another day!

The most common sensors I use
everyday are GSR, which is a reasonably sensitive measure of general arousal level; respiration because it provides immediate feedback on the way the person is breathing and is helpful for developing diaphragmatic breathing; BVP because it responds quickly to respiration and can demonstrate to the person the effect of slowing their breathing down; and I often use surface EMG because it can provide immediate feedback on posture changes (more…)

Goal setting: A critical skill for change

Pain management is many things to many people, but most of us would agree that if life hasn’t changed in some way after pain management, then it hasn’t really been effective.  For change to actually happen and be maintained, Prochaska and DiClemente and others (eg Miller, Rollnick and colleagues) identify that people must believe the change to be important, and that they have the ability to make it happen successfully.

I’ve posted earlier on self regulation (eg this reading, and this post), making the point that it is made up of several components, one of which is goal setting.

When I went to Google to search the words ‘goal setting’, 13,200,000 hits came up in 0.16 seconds, so goal setting seems to be rather popular – and yet it’s often the most difficult session to facilitate in the three week pain management programme I work in, and some of the ‘goals’ I’ve seen written for patients just don’t look anything like the kind of goals that can actually be measured! So perhaps goal setting is both popular but not easily carried out in ‘real life’.

So, how do we set goals?
It sounds easy if you’ve learned to set goals early in life, but for so many of the people I see it’s not a familiar activity. The research literature in psychology abounds with various models and influences on goal setting and achievement, which doesn’t really help a busy practitioner who may well be drawing on knowledge from first year professional training! And unfortunately, the information readily available online is often of variable quality.

I’m going to start with some random thoughts, mainly based on conclusions drawn from a motivational approach – tomorrow I’ll fill in with some literature!

Firstly, goals need to be relevant to the person. That means that the person believes that the goal is important. Importance is predicated upon things that the person values (see the New Zealand School Curriculum definition here)- these are usually abstract beliefs that, through action, become evident. The same action can represent many values (eg daily exercise can represent ‘time out’, ‘commitment to my wellbeing’, ‘a way to keep my partner/husband/dog happy’). And similarly, values can be fulfilled or operationalised in many different ways (eg ‘caring for my family’ can be achieved by ‘being in a high paid job’, ‘being home when they get home after school’, ‘always going to sports activities with the kids’).

Sometimes, the values appear to conflict with each other – it’s quite common for someone (perhaps yourself?) to value ‘being healthy’ while at the same time valuing ‘relaxing’ – how those values are played out in the real world may mean the person eating healthily in one part of the day, then drinking alcohol as a primary way to relax! I’ve seen this in people who say on the one hand that they’d like to return to work, but on the other, they don’t think they can – because they can’t continue working in the way that they’re used to. There is a conflict between two different values: the values that constitute ‘being a good worker’ (which is operationalised as ‘always doing a job at 120%’) and ‘being able to cope’ (which is operationalised as ‘never allowing my pain to fluctuate’).

The second is that goals need to be achievable.
That is, the person needs to feel confident enough that they can actually succeed in making the goal happen. When pain becomes chronic, confidence to achieve goals can often be eroded, especially if pain is feared or avoided. Successive failures to achieve goals only serve to confirm that taking a risk by setting a goal should be avoided. And this seems to be much more the case if the goal is particularly important – and of course, if it’s not important at all, it just won’t happen!

It almost goes without saying that goals need to be specific and measurable
– exactly what is it that the person has to do, and how will they know they’ve achieved. This is much more difficult if the area of goal development is complex, or requires sub-goals to be achieved in order to attain a longer-term goal.

Tomorrow: some readings on goal and goal-setting, and over this week – tools to use to help people set and maintain goal-directed behaviour.

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