Flexible goals and distress: a research study

As I mentioned yesterday, finding research articles on goal-setting in chronic pain is not easy – there are not many out there! So this article is reasonably old, but an interesting one because it deals with something I’ve wondered about for a while: flexibility. To be flexible doesn’t just mean being able to touch your toes! it does mean being able to change tactics, direction and even focus in order to achieve fulfilment in life.

This study looks at the difference between assimilative coping: ‘active attempts to alter unsatisfactory life circumstances and situational constraints in accordance with personal preferences’ and accommodative coping: ‘revising self-evaluative and personal goal standards in accordance with perceived deficits and losses’.

We have a good body of research that suggests ‘active coping’ is better for people seeking treatment for chronic pain (e.g. Jensen et al., 1991), but coping isn’t well defined, and there doesn’t seem to be a good theoretical model that most people can agree on.  Coping strategies haven’t been derived from people who don’t seek treatment (and therefore cope well) use for their pain, and most coping assessment measures don’t recognise that what may be helpful in one situation may not be in another.

So this study was based instead on Brandtstadter’s (from the University of Trier) work on developmental problems and role transitions in adult life, where he studied assimilative and accommodative modes of coping.
As I described yesterday, goals are developed from a discrepancy between what is and what the individual would like to see happen. These discrepancies are often instigated by the individual, but can also be triggered by a change in the context, environment or demands from another person. Coping refers to efforts an individual takes to achieve – neutralise a threat or avoid loss, or perhaps achieve a success.

Brandtstadter identified that assimilative coping strategies involve altering the situation – for example, asking another person to help, using gadgets, or developing new skills based on feedback, changing the way an activity is done. Accommodative coping strategies involve altering expectations – changing desires or preferences, perhaps changing the expected outcome, giving up ideals (working to 100% for example), or even comparing how the person is going with other people who are more disabled.

The researchers in this paper identified that a ‘healthy pain patient’ is someone who is managing their pain in a way that ensures he or she has good quality of life, and feels well, and this probably requires the person to make ‘accommodative adjustments’ to existing goals and standards.

The recruits in this study were 120 people receiving inpatient treatment at a facility in Germany. More women than men were recruited, and most were married. The average pain duration was 11 years, and half of the participants had been away from work, and of that group, 40% had been so for at least 6 months. Most of the patients had headache (40%) while the remainder had low back pain, whole body pain, or pain in other sites as well as headahce.

The participants were assessed using the Pain Disablity Index (Tait et al, 1990), and the mean score in this study was 31.67 (SD=15.71). Psychological distress was measured using the CES-D, with a mean of 19.65 (SD=10.60), meaning that 53% of this group scored at or above the cut-off score usually used in the German version of this questionnaire. 24% of the respondents were diagnosed with an affective disorder using the Structured Clinical Interview for Diagnosis (SCID).

In terms of pain coping, three cognitive and three behavioural aspects of coping were assessed using likert-type scales from 1 (not at all true) to 6 (absolutely true). Finally, ‘dispositional coping tendencies’ following the Brandtstadter model were assessed using a questionnaire developed by Brandtstadter & Renner (1990). Two scales are formed by the questionnaire: ‘flexible goal adjustment’ such as ‘I adapt quite easily to changes in plans’ and ‘I find it easy to see something positive even in a serious event’; and ‘tenacious goal pursuit’, such as ‘when faced with obstacles, I usually double my efforts’, and ‘even when things seem hopeless, I keep on fighting to reach my goals’.

What did they find out?
Coping and pain intensity weren’t correlated, but a negative relationship was found between disability and distraction. Cognitive restructuring and self-efficacy were strongly associated with less depression. Both ‘flexible goal adjustment’ and ‘tenacious goal pursuit’ were negatively correlated with depression, although flexible goal adjustment had a stronger relationship than tenacious goal pursuit.

With further multiple regression analyses, it was found that flexible goals adjustment played a protective role when pain intensity and disability were high – that is, the ability to adjust goals flexibly seems to be a resource which ‘buffers the negative effect of chronic pain on psychological well-being’. This same positive relationship wasn’t found for people who continued to pursue their original goals by working harder.

The authors finally conclude that pain-related coping is only adaptive (that is, reduces pain severity or perceived disability) when the person has both ‘an accepting attitude’ towards chronic pain and uses positive coping strategies. In saying this, Schmitz, Saile & Nilges make a point that today has been empirically studied by researchers such as Lance McCracken and Kevin Vowles at Bath University: accepting chronic pain makes a difference to how well a person copes with ongoing disability.

A final point to make about this study – of the cognitive coping strategies, cognitive restructuring was the only strategy that moderated the relationship between depression and disability. Cognitive restructuring involves things like positively reinterpreting pain, reducing pain’s significance, or directly accepting pain.

Some cautions to consider when interpreting this study: it is a correlational study, so can’t demonstrate cause and effect. It’s also in a small group of people presenting to a specialised pain management centre. To date, it seems to be only study on this type of coping in people with chronic pain.

Food for thought from this study, however. Goals are all about achieving things. For some people, as I mentioned yesterday, having high goals and feeling dissatisfied with the ‘way things are’ can be a way of life that has helped them succeed. When chronic pain is present, this style of coping can become unhelpful – and it will be important to identify other ways for the person to retain their sense of self efficacy and achievement.

I think that identifying ‘different’ ways to act according to values that are important is one way to help someone live well despite their disability. This suggests that Acceptance and Commitment Therapy (ACT) may be an appropriate approach especially for people who have previously been high achievers. On the other hand, helping people who have lowered their expectations to re-set their ‘satisfaction’ set-point might involve helping them recruit new and different strategies to improve their ability to commit to ‘tenacious goal pursuit’.

Next post: another study on goals in chronic pain, and (with any luck) a worksheet!
Have a great day – and leave a comment if you’ve enjoyed this series, or have any questions.

Jensen, M., Turner, J., Romano, J., & Karoly, P. (1991). Coping with chronic pain: a critical review of the literature. Pain, 47, 249-283.

Schmitz, U., Saile, H., Nilges, P. (1996). Coping with chronic pain: flexible goal adjustment as an interactio buffer against pain-related distress. Pain, 67, 41-51.

Feedback, difficulty and satisfaction: goals!

To summarise yesterday’s post, this quote from Latham & Locke (2007):
The theory of goal setting states that there is a positive
linear relationship between a specific high goal and task
performance. Thus, the theory makes explicit that a specific
high goal leads to even higher performance than urging
people to do their best. A goal also affects satisfaction
in that it serves as the standard for evaluating one’s own
performance. A higher goal requires higher performance
for a person to experience positive affect than does commitment
to a lower goal. Two factors affect the goals that
a person chooses: the importance of the goal to the individual
and self-efficacy, namely, self-confidence that the
goal for a specific task is, indeed, attainable. The mediators
of goal setting are choice, effort, persistence, and
strategy. Goals are moderated by ability, goal commitment,
feedback in relation to goal pursuit, the complexity
of the task for an individual or group, and situational factors
(e.g., presence of needed resources).

Today we’ll look at feedback, goal complexity, the relationship between personal goals and incentives, and satisfaction with performance.

Feedback: Without some sort of indication of the difference between where the person is performing currently and where they need to be, it seems that people have trouble working out exactly how much effort they need to put in to achieve. Usually, people who find out they’re performing below the level expected will increase their effort – or seek an alternative strategy to use. The combination of goals plus providing feedback is more effective than just setting goals.

What this means for pain management is that

  • if the individual is just given tasks such as ‘do this set of exercises’, but no target is ever specified, they probably won’t persist with the exercises.
  • if they are given an exercise target, eg walk for 20 minutes once a day, but it is never reviewed with them, they’ll find it more difficult to persist.
  • if, however, they work together to set an exercise programme, establish how often they need to do it, and it’s reviewed periodically, then the chances of the person persisting increase.

Difficulty: It seems paradoxical that people who have achieved a difficult goal will, next time they set a goal, set a more difficult one. From the research that Locke & Latham reviewed, it seems that Bandura’s observation that ‘goal setting is first and foremost a discrepancy-creating process’ holds true. We’re not machines, simply responding to situations in our environment (discrepancies), we actively search out and create situations that demand persistence and the development of skills.

This suggests that, with encouragement, people who start to develop new skills will find ways to extend themselves by setting themselves new goals – depending upon, however, their level of self efficacy and the times they find themselves able to succeed. As the saying goes, ‘success breeds success’.

  • People with pain often find themselves in an ongoing cycle of failure, as their efforts to cope using skills they’ve found helpful in the past fail to support them in their goals, and their self efficacy drops.

As I mentioned yesterday, people begin facing challenges (goals) by using skills they already have, if they don’t have those skills, they try to find skills they’ve used elsewhere to help them manage. When they find themselves without the necessary skills, they seek help from others – but if those others (especially important people, such as health care providers) cannot provide them with appropriate skills and encouragement, their self efficacy drops and they begin to withdraw from what they perceive as unsatisfying and unachievable goals.

Complexity: Most of the goals that we encourage people to develop in pain management are quite complex. They involve multiple changes across a range of thoughts and behaviours. Locke & Latham (2002) found that ‘as the complexity of the task increases and higher level skills and strategies have yet to become automatized, goal effects are dependent on the ability to discover appropriate task strategies’.

It seems that the availability of different strategies to choose from can influence how readily a complex goal can be achieved. This effect is influenced by the type of goal being demanded: performance-outcome goals can interfere with learning and integrating new strategies.

For example, a goal like ‘move all these boxes within 20 minutes’ demands speed and as a result newly acquired skills such as pacing may be forgotten. If instead, a specific difficult learning goal is required, for example ‘use your pacing skills to help you move these boxes within 20 minutes’ is given, high goals lead to better performance as compared with a general request to ‘do your best to move these boxes’.

Proximate goals: To make these complex goals more easily achieved, research suggests that it’s better to develop smaller ‘proximate’ goals. Locke & Latham found that poor performance (or errors) may be due to poorly constructed proximate goals – that is, these smaller goals may not actually directly contribute to the longer-term goals. The benefit of smaller sub-goals is probably due to the feedback from errors in the performance of these goals giving an individual a picture of how realistic their longer-term goal may be.

Goals have an influence on the level of satisfaction an individual feels. To set a goal says that the person is not satisfied with their current level of performance, and their ‘satisfaction level’ drops. As a goal is achieved, people feel more satisfied. But paradoxically, people who achieve the highest goals are the least satisfied with the present situation. They do more because they’re dissatisfied with less. Their ‘satisfaction set-point’ is set very high – and so they work very hard to achieve.

In pain management this may work against some of our patients. For example, the person who typically strives to do well may find developing ‘working to quota’ or activity regulation very hard to do, because their satisfaction comes from having achieved a very high standard. For these people specific and difficult learning goals may be more helpful than performance goals.

The above model shows what Latham & Locke (2007) describe as the ‘high performance cycle’. Although, as for all of the information I’ve review so far, it’s about organizational performance, there are many similarities between this cycle and what we observe in the performance of pain management goals.

What I’ve discovered as I’ve worked my way through the literature on goal-setting, is that while we talk about goal-setting within pain management settings, there is very little empirical research on it with patient groups. Tomorrow I’ll review one of the few papers I’ve seen – so y’all come back now!

Latham, G.P., Locke, E.A. (2007). New Developments in and Directions for Goal-Setting Research. European Psychologist, 12(4), 290-300. DOI: 10.1027/1016-9040.12.4.290

Practical and useful goal-setting theory?

Some people doubt the existance of a theory that happens to be either practical or useful, but perhaps this review (which is now relatively old, but still good!) will prove the rule. While this review covers goal-setting within an industrial/organisational context, it still offers some helpful advice and findings from both experimental and ‘field’ research. I’ll comment, of course, in terms of how this may fit within a clinical pain management context!

So, what is a goal? Locke and Latham (2002) define goals as ‘the object or aim of an action, for example, to attain a specific standard of proficiency, usually within a specified time limit.’ Their definition refers to performance of work-related tasks rather than ‘discrete intentions to take specific actions’ (and they give the example of applying to graduate school, to get a medical examination). Their definition relates quite well to those in chronic pain management, where the goals referred to are often ‘to increase sitting tolerance to 20 minutes’, or ‘to be able to take a shower safely’.

How difficult should a goal be? Although during the 1950’s it had been found there was a curvilinear inverse relationship between difficulty and performance, (that is, a goal shouldn’t be too low, nor too high, or performance was affected), Locke and Latham proposed there was a positive, linear relationship between difficulty and level of performance. They found that performance levelled off only once the limits of ability were reached, or when commitment to that goal lapsed.

Additionally, Locke and Latham found that specific, difficult goals consistently lead to better performance than just telling people to ‘do their best’. Having a target seems to work better because people have something to aim for, and are clear on what needs to be done.

What this implies for pain management, is that without a specific target to achieve, people have trouble knowing whether they’re ‘doing enough’. It seems to be important to have goals that the person feels are ‘just out of reach’ but are actually within their ability, and to be very specific about how often, how much, or exactly what they have to do, in order for them to be committed to making it happen. This suggests that a vague goal to ‘try using relaxation during the next week’ probably will work less effectively than identifying exactly how often, what time of day, and what type of relaxation should be attempted.

Social cognitive theory (I’ve posted on this before! Remember Bandura?) suggests that self-efficacy, or confidence that the individual can successfully achieve his or her goals plays an important part in goal-setting. Latham and Locke state that ‘when goals are self-set, people with high self-efficacy set higher goals than do people with lower self-efficacy’.

We know that self-efficacy for many activities can be affected by pain – the Pain Self Efficacy Questionnaire (Nicholas, 1989) measures self-efficacy to participate in a range of daily activities such as work, future goals, social activities and leisure despite pain using a 1 – 10 Likert-type scale, and although the maximum score is 60, most of the people we see at Pain Management Centre will achieve less than 20.

Goals appear to affect performance through four mechanisms, according to Locke and Latham (2002).
They are directive – that is, they ‘direct attention and effort toward goal-relevant activities and away from irrelevant activities’.
They energise – high goals lead to greater effort than low goals. This has been demonstrated with goals that require physical effort, repeated performance of cognitive tasks, subjective effort as well as physiological indicators of effort.
They affect persistence – when people can control how long they spend on tasks, hard goals elicit more time being spent on them. But what often happens is that people increase their work pace in order to achieve a goal rather than work more slowly but less intensely over a longer period of time.
They affect action indirectly by leading people to discover relevant information and strategies that they can use to achieve the goal. So it seems that people actively seek and use the information they have around them to solve problems in order to achieve goals – without them, the information they have may never be integrated.

There seems to be a hierarchy of ways that people search for, and use information relevant to the task:
1. People automatically use knowledge and skills they already have to achieve a goal.
2. If already existing knowledge and skills don’t quite cut it, people draw from related skills they may have used elsewhere.
3. If the task is actually new, they will deliberately plan to develop the skills necessary to achieve the goal.
4. People with high self-efficacy are more likely than those with low self-efficacy to develop effective task strategies. People may take some time to look for ways to achieve goals they are set.
5. When people are asked to address a complex task, sometimes encouraging them to do their best can work more effectively than the usual specific performance goal because anxiety to succeed can make them look for strategies to deliver in an unsystematic way and fail to learn what actually works.
6. When people are, instead, trained to use systematic strategies, people who are given specific high-demand goals are more likely to use those strategies than people who are given either nonspecific goals, or goals that don’t really demand high performance.

Commitment to goals moderates, or changes the goal and performance relationship. This is most important when goals are difficult because they require persistence. As I mentioned yesterday, importance and confidence drive commitment to goals.

Some things seem, from Locke and Latham’s research, to increase commitment – being public about a goal can increase importance and therefore commitment (maybe because of a desire to maintain integrity in other’s eyes), others inspiring action and being supportive can create demand characteristics that can enhance commitment. Goals that are imposed on people may or may not influence commitment – it seems to be more about the way in which the purpose of the goal is given than whether the person participates in the goal setting process.

Self-efficacy or confidence is influenced by ensuring adequate training is available (so the person knows what to do, especially if that training leads to a successful experience prior to the goal), role models that demonstrate success, and through verbal communication that expresses confidence that the person can achieveit, including information about ways that goals can be achieved.

For more information on feedback, complexity and other factors known to influence goal-setting – come on back tomorrow!

For today, here is a specific goal – read one of the goals you have written with or for a client with chronic pain before tomorrow.
Check these four things:
1. Does your goal have specific actions that the client needs to do?
2. Does your goal include a timeframe?
3. Does your client think this goal is important?
4. Does your client believe he or she can successfully achieve this goal?

If you can answer these four questions, and feel like stretching yourself – check these things:
1. Does your client know exactly how to do the goal?
2. If this goals requires using skills that are new to the client, have they had a successful attempt with your support?
3. Has your client had an opportunity to see anyone else achieve this goal?
4. Has your client been given the opportunity to make his or her goal public? Have they told anyone?

Let me know in the comments section if you’ve been able to achieve these goals. More tomorrow!

Locke, E.A., Latham, G.P. (2002). Building a practically useful theory of goal setting and task motivation: A 35-year odyssey.. American Psychologist, 57(9), 705-717. DOI: 10.1037/0003-066X.57.9.705

Working with cognitive behavioural therapy – Introducing CBT to a client

For a therapy that has great empirical support and can be used by any and all members of the interdisciplinary team, you can’t really go far from cognitive behavioural therapy. Waaaay back in the olden days when I was originally trained as an occupational therapist, CBT was the province of psychologists only – and possibly there are a few out there who would like it to stay that way! But in pain management it’s vital to integrate CBT throughout the whole team so that consistent responses are made. So this week I’ll be covering some practical ways to use CBT within ‘other’ therapies – especially physiotherapy and occupational therapy.

I’m not going to review the many studies demonstrating support for CBT, this is a practical series, so the first step is probably working out how to introduce CBT to a client. Several key principles inform my practice – the first is that we are collaborating. That means I am no expert on what will work best for this client (and I don’t have a complete understanding of what is going on for that person either!). This helps me from ever thinking that I’m superior to him or her – we are in this together!
The next principle is that we are developing an understanding over time – the therapy process is really a journey of discovery. Some of the things I suggest may not be appropriate – or it may not be the right time to introduce them.
And further – eventually this person is going to do this for themselves. I don’t want to be a long-term therapist!
And finally, CBT in the management of chronic pain is not a personality overhaul – we’re not trying to make this person ‘different’, we’re hoping they will understand a bit more of what is happening, that they can learn new ways of viewing their situation, and that they can develop a range of ways to manage in their situation so they can choose.

A great book that has some lovely worksheets and puts CBT into a framework that I find helpful is Renee Taylor’s ‘Cognitive behavioral therapy from chronic illness and disability’ (2006) Springer:New York. ISBN-10: 0-387-25309-2
I’ll be dipping in and out of it throughout the week – as well as referring to some articles and other books I have in my library. (You don’t want to know how many books I have!!)

How do OT’s and Physio’s use CBT? It depends a little on the activities you are undertaking – so here’s my quick take on it.

  • There are opportunities to provide information (on request) about the effect of thinking on emotion and coping. Times such as when a person starts learning about factors that influence their pain – stress, fatigue, anger.
  • When introducing a form of activity pacing or working to quota often provides an opportunity to ask ‘what went through your mind when we started to talk about this?’
  • When the person starts doing an activity and demonstrates a shift in emotion/affect or similar – again, asking ‘what went through your mind when I suggested we do this?’
  • When the person has been invited to continue with an activity in between sessions and doesn’t manage it.
  • When providing information about a model of chronic pain.
  • When emotions are evident.
  • When helping the person generalise a coping skill such as self regulation breathing or setting goals

Do you get the idea that there isn’t really any time when you can’t use CBT?!

More about this tomorrow – in the meantime, consider this: When you start to think about thinking, what happens?

Relaxation training

For a very brief introduction to relaxation, click through to my Coping Skills section.

Relaxation training is a very popular component of pain management. By itself, relaxation can be an enjoyable experience, but when used as a way to extend activity and help a person maintain control, it becomes a very potent tool. It’s important that if the latter aspects of relaxation are to be a focus, relaxation must become habitual, well-developed so that it can be employed quickly, and then integrated into activity.

If relaxation remains a soothing withdrawal activity it can become just a passive coping strategy, encouraging reduced interaction with the ‘real’ world and feared activities.

There is a good deal of research into relaxation as a coping strategy – for the moment I’ll leave citing references as I want to focus on specific types of relaxation in future posts. Suffice to say that if you use Google Scholar and type in ‘relaxation chronic pain’ you’ll come up with a huge number of references (go on, try it – you know you want to!).

If you have a specific relaxation technique that you’d like to learn about (or want to share) – don’t forget to leave a message below, or drop me a line at my email – adiemus [at] clear [dot] net [dot] nz

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Take a look at this ‘oldie but goodie’ in the Coping Skills section of my blog.  Pacing is an often mis-used strategy for coping with pain. Don’t just assume you and your client/patient are talking the same language! Pacing is a part of rehabilitation, rather than a strategy for living with pain – although paced activity can help a person achieve medium-term goals, and the principle of ‘do no more on a good day, and no less on a bad day’ is a life-long strategy that can help people maintain preferred activities. Read on – and I welcome your feedback!