Goal-setting – more than just for the New Year

Yesterday I had the pleasure of catching up with some of the participants from our three-week pain management programme.  It had been six months since they attended the programme, and it was time to see how they had got on.  Sadly for some it seemed that best intentions hadn’t lead to results, but for one in particular, life was very different.

As I listened to her talk about how life had changed, a comment she made really stood out.  She said ‘I looked back at what I had written six months ago and I thought how different things are now.  I’ve done everything I said I would do’.

The power of goal-setting – and not just setting the goals, but writing them down, then, as a certain brand of sportswear says ‘Just do[ing] it’.

One of the amazing things about her situation is that the last six months have not been plain sailing for her – she had two health set-backs that could have distracted her from her goals and been used as a great reason for not achieving.   But she drew on the skills she had developed from the programme, and turned the set-backs into opportunities for developing in other areas, then simply began again.

This person also talked about how the goals she had achieved made her feel.  She said that she was in control, she knew what she wanted and was going to do it, instead of pain, her case manager, her family’s needs, or even her health dictating what was important to her, she did.

A few weeks back I talked about goal-setting theory, and this woman’s experience is a great demonstration of how the theory works.

Just to review, 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.’

Latham proposed there was a positive, linear relationship between difficulty and level of performance, and that having a target seems to work better because people have something to aim for, and are clear on what needs to be done.

Why goals work:They are directive, they energise, they affect persistence, they affect action indirectly by leading people to discover relevant information and strategies that they can use to achieve the goal.

Importance and confidence drive commitment to goals, and commitment is increased by being public about a goal, others inspiring action and being supportive, and seeing success along the way. A goal serves as the standard for evaluating one’s own performance, so the higher the goal, the higher the demand from the person, the less satisfied a person is with their current situation.

Self-efficacy or confidence is influenced by ensuring adequate training is available, and verbal communication that expresses confidence the person can do it. The combination of goals plus providing feedback is more effective than just setting goals – it’s important to monitor goals and record achievement.

With encouragement, people who start to develop new skills will find ways to extend themselves by setting themselves new goals.

When learning a new skill, specific instruction to ‘use your new skill to complete this task within 20 minutes’ will be more demanding but help learning and achievement much more than ‘complete this task as well as you can’. The pressure of getting the job done ‘as well as you can’ forces the person to revert to old habits which then interfere with learning the new methods – and ultimately slows the goal achievement too.

Small goals that are relevant to a longer-term goal will assist achievement and increase self efficacy – but often smaller, immediate goals are poorly formed and don’t actually contribute to the end-goal.
A good example of this is the use of exercise programmes for people who are on their way to returning to work with chronic pain. Exercise programmes may be great for increasing fitness and confidence to move despite pain – but to many people they become the focus for achievement instead of a step along the way to returning to work.

Exercise programmes are often provided in the assumption that a factor interfering with returning to work is general fitness. In fact, it seems that fitness per se is not the problem, it’s much more about confidence to carry out work tasks – which can only happen in the workplace. People don’t seem to generalise from a fitness setting to a work setting.

To return to the woman I described at the start of this post: she had written goals that were specific, she had smaller goals that she developed to help her achieve her long-term goal. She focused on what she had to do rather than the outcome (ie she said she wanted to be out looking for a job rather than ‘be in paid work’) – this is important because she can focus on her actions rather than having an outcome dependent on other people. And her actions are known to increase the chance of the end-goal being achieved.

When she had a set-back, she knew how to go about setting her own goals, how to use positive self talk, and how to monitor her progress. She was held to her goals by her family who supported her goal, and by returning to the review with us where she wanted to be able to tell us what she had achieved.

Learning for the day? Given the tools to do it, and goals the person thinks are important and that they feel confident they can achieve – not a lot can get in the way!

You can subscribe to these posts using the RSS feed above left, or bookmark this blog and come on back! I blog every day during the week – but not during the weekends… And today is Friday, so there will be a Fabulous Friday Frivolity shortly!

The impact of pain management on quality of life

What exactly is quality of life? And what is pain management? This article, presented at a 2002 Roundtable on ‘The role of coxibs in successful pain management’ is written by a medical researcher, which should give you a bit of a clue about how pain management is defined for the purpose of this paper (i.e. pain control). Much of the discussion about quality of life measures, however, is useful, and the article itself is reasonably short – and it talks the language of doctors, which I thought gives an interesting slant.

Firstly, the point is made that quality of life involves assessment over multiple dimensions, with the World Health Organisation’s ‘Domains and factors of quality of life’ being used as an example of the domains that can be considered. For those who haven’t reviewed this recently, there are six domains:
1. Physical
2. Psychological
3. Level of independence
4. Social relationships
5. Environmental health
6. Spirituality
and a final ‘general’ facet that evaluates ‘overall perceptions of health and quality of life’.  This link to WHOQOL leads directly to the Seattle Quality of Life Group website.

The point is made that pain affects cognitive, motivational, affective, behavioural and physical components, and quality of life has a similarly all-encompassing nature. Katz points out that ‘quality of life … can be defined as an individual’s ability to perform a range of roles in society and to reach an acceptable level of satisfaction from functionoing in those roles’, but at the same time recognising that quality of life research is relatively new, and the effects of pain on quality of life is only just beginning to be investigated.

When we’re choosing any assessment tool, there are some practical things to consider – quite apart from the psychometric properties of the instruments we may think of. Katz nicely identifies some considerations:
1. Which is more applicable – a disease-specific or generic instrument? He identifies that there are both advantages in specific measures (for example, able to detect more subtle change) as well as disadvantages (difficulty comparing across patient groups). The SF-36 (Medical Outcomes Study Short Form 36) is suggested as a general health status measure that combines the ‘best’ of both worlds.
2. What dimensions of quality of life need to be measured? Katz acknowledges that quality of life measures are multi-dimensional since ‘an instrument that does not include several dimensions will make it impossible to determine the nature of a score change’. The areas of physical, psychological, social, somatic, and spiritual are thought to be important, and again the SF-36 is identified as a key contender because of the breadth of dimensions included.
3. How much responder burden is acceptable? This refers to the amount of work needed to complete the questionnaires – an important consideration when we recognise that many people don’t like paperwork, or have relatively low reading levels.
4. What administrative issues need to be considered? Ahhh, now that’s an excellent point! A very comprehensive database that I know of has been abandoned from time to time because of difficulty obtaining clerical time to score and enter questionnaires, and in the mists of time, some of the original scoring ‘rules’ have been lost… Questionnaires used in pain outcome measurement need to be applied at least twice, more appropriately three or four times – and ‘compliance’ or the number of people who complete all of the measures all of the time reduces over time…
5. Has the instrument been validated, and is it reliable? Well, this goes without saying… and should be a ‘given’ for people working in the area of pain management.

There are a number of issues that this paper does not cover well.
Firstly, there is an assumption that if quality of life is reduced when pain is experienced, an individual’s quality of life should improve simply by reducing pain intensity. While this intuitively makes sense, it assumes that pain intensity alone is responsible for loss of quality of life. Reports of pain intensity are influenced by things like psychological distress, fear of injury, fear of being out of control, low mood, health anxiety and so on (e.g. Severeijns, Vlaeyen, van den Hout & Weber, 2001). When analgesia is used, while it may reduce pain intensity it may not address underlying issues such as low mood, health anxiety, and most especially fear of injury. The latter is one reason some patients tell me they don’t want to take medication, because it ‘masks’ pain!

Katz suggests that ‘analgesic agents should be compared … incorporating the use of symptom distress scales, which may be the most sensitive way of discriminating among analgesics in effects of quality of life’. I suggest that distress scales may not be the most appropriate measure of effectiveness in quality of life, and in fact changes across several domains such as Physical, Psychological, Level of Independence, and Social Relationships should be observed before an intervention should be considered ‘successful’.

Another issue is that although Katz indicates that taking repeated measures is important, he makes little mention of the need for longer-term followup. At least part of the initial response from any intervention is likely to be due to the ‘meaning response’, or expectancies or placebo response that people have simply from having been given a treatment. As a result, it’s important to measure changes in quality of life (and any other outcome measure) some months or even years later after the treatment is first initiated. The risk otherwise is that an initial lifting of mood, sense of hope, even physiological changes secondary to placebo can subside over time – and in the end, it’s the effects that are sustained that are important.

However, it’s difficult to argue with Katz on this: quality of life measures should be included as a key variable in future pharmacological research. Personally, I think it should be included as an outcome measurement of any pain management intervention.

For further information on a broader range of outcome measures that are being considered for pain management, this article by Dworkin and colleagues provides some insights into the areas that the IMMPACT group recommend: (1) pain; (2) physical functioning; (3) emotional functioning; (4) participant ratings of improvement and satisfaction with treatment; (5) symptoms and adverse events; and (6) participant disposition.  Worth a read – and they’re continuing to publish more on this area.

Katz, N. (2002). The Impact of Pain Management
on Quality of Life. Journal of Pain and Symptom Management, 24(1S), S38-S47.

Severeijns, R., Vlaeyen, JWS., van den Hout MA., & Weber, JWA., (2001)Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. The Clinical journal of pain vol. 17, n^o2, pp. 165-172

Working with goals

I mentioned in my post yesterday that it’s not easy to help people work out goals.  Most people have a fairly general idea of how they’d like their life to be, despite pain, but have lost sight of the possibility of how life might be in the future. I spoke about this with a person this morning who told me that he has lost confidence that life can be anything different, so when he was asked ‘what do you want from pain management’, he was floored!  He told me that he has lived ‘from day to day’ for so long that he had lost sight of considering where he was going in his life. I don’t think this is uncommon for people living with long-term pain, before they start accepting pain as chronic and start ‘living’ with their pain.

So the first step may be to use a menu approach as I suggested yesterday, but somehow this needs to lead in to longer-term ‘life change’ goals, so the new knowledge can be integrated and retained.  My vision for people learning to live with pain is that they move from thinking of themselves as ‘patients’ and move to thinking of themselves as ‘people’ – and more importantly, that they are people who are doing things. That way their pain condition becomes no more important a part of them than their height, ability to do maths, or interpersonal skill: just part of who they are.

We’ve discussed the menu approach, which helps people to look at things they’re interested in.  Then quite often we help the person develop the pain management skills are linked to the clinical hypotheses we, as clinicians, developed about the factors that we have assessed as influencing their pain presentation.  These are may be things like activity management, relaxation training to reduce physiological arousal, communication skills and so on…

Then the part that I think is vitally important, but not always recognised: change management in ‘real life’.  Some people call this ‘goal setting’!

The ‘wish list’ (I promise I’ll feature this tomorrow!) asks people to identify general areas they’d like to see change in their lives.  This goal-planning worksheet is one way to help people develop specific ‘next steps’ to take, and ways to identify and measure the actions and resources they need to take to make it happen.

Click on it, and you’ll be able to see that in the centre is the ‘goals area’. I’ve described this as ‘I want to…’ with lots of space to draw or write exactly what the person wants. If they can’t be very specific, that’s fine because details are refined as part of this worksheet process.

Starting at the top, working clockwise, are a series of headings that the person can complete that will help shape up the way to achieve the ‘I want to’ part. Going in order is important (from top, clockwise), because each section builds on the others.

Step one and probably most helpful for retaining motivation is ‘Why is this important to me?’. We know that internal motivation is drawn from values, or reasons that something is important. By helping the person think through why they want this change, we help them generate their own reasons for change, rather than reasons we might generate.

Step two is about time frame: often this depends on the level of confidence the person has for acheiving their goal.  The time frame also may determine the steps the person may take, and reflect other people’s actions or proceses (eg case manager). It may be helpful to revisit the time frame once other areas are completed and adjust, but it’s useful to work out what the person believes is possible first.

Step three is about where the goal will be achieved – for example, at home, at work, in a clinic… This may help determine the strategies that can be employed.  Some activities can be used in one setting, but not another, while it may be important to help the person see that they can achieve in one setting before generalising to another (eg using relaxation at home to enable them to complete vacuuming, before developing the skill to self-regulate at work, where it can be much more difficult).

Step four asks about general resources the person may need. This can be revisited also, but is often the real action phase of goal setting.  It’s OK to not know all the resources required – this may, in fact, be one of the sub-tasks required to achieve a goal.  So it’s fine to put down ‘I don’t know what resources are available – I’ll need to identify these as my ‘next best step” – which is one of the other steps in this process.

Step five identifies the ‘people’ resources the person has to help them achieve their goal. This can range from speaking to their partner, family or friends, right through to asking for a referral to see a specialist career counsellor.  If the person is receiving compensation, and has a case manager, then the case manager must be one of the ‘people’ identified in this step.  You, as health provider, should also be listed.

Step six is about what the person can do to recruit help from people – because it is all about self management and self responsibility.  What does this person need to do to get the help they want? Do they need to write letters? Meet with someone? Leave notes? Arrange regular phone calls?

Step seven identifies ‘what are my next best steps?’. This can be about finding out resources, contacting people who can support them, maybe identifying where the goal can be carried out, or even refining the time frame.

Finally, (and next to ‘why’, the most important part of this process) is ‘how will I know I’ve achieved my goal’. This is often the most challenging part of this whole process, because it provides the person with a specific way to measure achievement. This may require additional input from you as health care provider.

It’s not very easy for someone to think about how they will know whether they have achieved a goal – quite often the person hasn’t thought about the goal in more than general or vague terms.

For example, a goal may be ‘to sleep better’.  This isn’t precise enough for anyone to decide whether the goal has been achieved or not.  Remember that subjective feelings ‘sleeping better’ are often determined by proximal experiences (a bad night’s sleep or two close to the day the person is asked about their sleep will likely influence them to say it is no better), and by demand characteristics of the person asking (a treating clinician will obtain a different answer than if the person’s partner asks), as well as a number of other response biases.

It’s far more effective to ask the person ‘how will you (know) measure that your sleep is better?  Is it that you sleep all the way through the night, every night of the week?  That you wake up feeling like you’ve had a good sleep, five days out of seven?  That you no longer use any sleeping medication to help you get off to sleep?’

These latter measures help identify the different ways that ‘success’ can be achieved, and as a result both reduce the chance for measurement biases as well as determine just what the ‘end point’ will be (at what point will the person be personally satisfied with their progress?).  It’s much more client-centred, as well as more easily recorded and reproduced.

Have a go at using this worksheet for a person goal for yourself.  What would you like to see different in your life?  Then work out how you’ll achieve it using this step-by-step process.  Let me know how you go!