Goals: So little clinical research

Despite the frequency with which the terms ‘goals’ and ‘goal-setting’ is used in many health professions, to find good clinical research demonstrating effectiveness of different ways of setting goals, or even the origins of goal-setting is actually really difficult to do.  I’m grateful for the work of Dr Diane Playford and colleagues who have written about goals within a neurology inpatient setting (the Neurological Rehabilitation Unit at the National Hospital for Neurology and Neurosurgery, London, UK), because in terms of clinical research, this unit has produced some helpful material.  Otherwise the pickings are quite slim.

Most of the research relating to the mechanics of goal-setting comes from the occupational or work context, along the lines of the work by Latham and Locke (e.g. Locke & Latham, 2002).  I posted about some of their findings a few months ago here when I first started my personal review of goals and goal-setting within pain management.  Unfortunately, I don’t know how well research from a workplace perspective translates into a healthcare setting.

There are some similarities, I suppose.  In a workplace setting, there is typically a supervisor or manager who identifies the objectives and direction for the workers.  Once these objectives are in place it’s clear to the workers what they are there to achieve and goal-setting is established accordingly.  In a similar way within a healthcare setting, the clinical team is usually clear about the ultimate objectives of treatment, and goals are set in place to achieve them.

Or that’s the theory – of course now that healthcare has moved from a ‘top down’ paternalistic model to a collaborative one, this doesn’t quite fit as well with the occupational model.

But the clinical relationship isn’t the same as an employer-employee relationship.  The goals are not simply about what happens ‘at work’ or ‘in the clinic’ – they need to be transferred into the real world of the patient.  So I’m guessing there is much more at stake, the goals are much more complex, the contexts in which the goals are played out are much more varied, and often the patient has to maintain the new behaviour without direct contact with the clinician.

I can see some parallels between skill development in pain management and training systems in an occupational setting.  For example, often the skills developed in pain management are learned in a clinic context (a bit like a classroom context in occupational training) and are then carried over into the real world.  In an occupational training paradigm, training learned in a classroom is usually supported by contextual training in the real workplace.  Cues such as posters, mnemonics to help remember the actions to take, training of the supervisor to provide support and so on are included because it is recognised that it’s very difficult to recall new learning in the real world.  I wonder how often we think of this in our skill development in a clinical setting.  How many times do we ask patients to go off to their home context without any written material to support their recall, or without contact between one clinic session and another?

How does this training talk relate to goals and goal-setting?  Well, in research on improving training outcomes, it has been found that clear objectives, written in terms of what needs to be done, how it needs to be done, when it needs to be done and most importantly, why it needs to be done, helps dramatically improve outcomes.   So I’m guessing that carrying out a similar process in therapy would also be helpful.

Some differences?  Well, for some patients, goal-setting is foreign – to them, goals are all about the employment situation, and represent nasty things like ‘performance management’, and ‘monthly targets’, and can become flavoured with negative emotions.  Another difference is the motivation – goals in therapy need to matter much more than goals in a workplace, simply because the goals in therapy need to carry over to every part of life rather than simply one or two processes at work – this means that personal buy-in must need to be greater so that the new behaviour isn’t forgotten in the different contexts.  It also means the goals are likely to be more fatiguing to achieve – after all, at least when you leave work to go home, you can forget about doing things ‘differently’.  You can’t exactly do that with monitoring thoughts, or using activity scheduling!

I’ll be carrying on with this writing on goals and goal-settings in a few weeks (probably after Christmas).  But for now I’m leaving it because I’ve found it so difficult to find anything clinical relevant to patients and chronic pain.

If you’ve enjoyed this ramble through goals and goal-setting, and have some comments to make – please do! Any references you know of would be great to hear about.  You can subscribe to this blog by clicking on the RSS feed above, or bookmarking and visiting.  I love comments and yes, I do reply! and I write most days, except during the weekend.

Locke EA, Latham GP. Building a practically useful theory of goal setting and task
motivation. A 35-year odyssey. Am Psychol 2002;57:705–17.