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Goals and goal setting in pain management

Posted Dec 02 2008 2:58am

This is the first of a couple of posts about goals and goal setting in pain management.

I’ve been curious about the use of goals in pain management, because although in New Zealand under ACC contracts, goals are required for every pain management programme, it’s not a direct requirement for treatments provided to non-ACC patients.  And I haven’t been sure of the literature about the use of goals and goal setting for people with chronic pain, and have wondered whether it’s something like the assumption that ‘doing activity is good’ or ‘pacing is good’ - thought to be ‘a good thing’ but not actually ever empirically tested.

Well, I’m happy to report that there is some specific research on goals and goal setting in chronic pain, and I hope to review some of this during the week.

First up though, some definitions of what a goal is, and some practical concerns about the patient experience during goal setting.

What is a goal?

  • Merriam-Webster online dictionary defines a goal as ‘the end toward which effort is directed’.
  • Wikipedia defines a goal as ‘ A goal or objective consists of a projected state of affairs which a person or a system plans or intends to achieve or bring about — a personal or organizational desired end-point in some sort of assumed development’

A much more convoluted definition including the use or purpose of goals comes from self regulation as used in sports psychology. In this context, goal setting is seen as integral to how we aim for a specific outcome through monitoring progress of where we are today against where we would like to be. For a brief review of Self Regulation, head to here for a paper written by Luke Behncke, RMIT University, Melbourne, Australia. This paper is directly related to sports, while this one is from Educational Research Institute (ERIC) and is more generic.

So, goals are seen as an important part of helping people to focus their efforts on specific areas of activity to achieve a certain outcome. It is seen as a ‘mark’ or set-point against which the person compares his or her current situation, and develops ‘next best steps’ to help him or her to move closer to that outcome.

I’ve blogged before that people who are ‘high achievers’ tend to be less satisfied with their current situation - and as a result, set goals that are fairly high or discrepant with their current situation, so they can become activated to do more.

Over the past four pain management programmes I’ve worked on, I’ve asked the participants several questions.

  1. What do you want from the programme?
  2. How will you know if the programme has worked?
  3. If I can’t take your pain away, what else would you like to improve in your life?

I also ask whether they set goals.  Most look pretty blank at this point.  People attending this programme have had roughly 5 years of chronic pain, many have attended pain management programmes before - but not many have any specific training in how to set goals, and haven’t set goals for themselves, but instead had their goals set for them.

To be precise, there have been 22 participants completing the last four programmes.  Of these 22, only 5 have had prior specific training in how to set goals. And none of them actually set goals on a regular basis.  (Mind you - do you?!  I admit that I do set goals each year, but perhaps I’m unusual!)

As for the other questions?

Whenever I ask people what they expect from attending the Pain Management Centre, there is one answer I know I’m going to get - ‘Oh just take away my pain’ (or reduce it, give me a magic wand, or something like that!)  We know that most people who have chronic pain hope to have their pain reduced, and when that isn’t possible, it can be difficult for them to envisage what they would like to aim for.

At this point I usually ask them something like ‘how would you know if pain management had worked’? or ‘If I can’t take your pain away, what else would you like to improve in your life’?

This starts to clarify what areas of life the person really thinks is important - but like every personal interaction within a health care setting, it’s often driven by what the patient thinks I, as a clinician, want to hear.  This can make setting goals quite difficult - for example, it doesn’t take much input from me to ‘guide’ a person to consider certain areas and not consider others.  If I was unprincipled, or naive, I could strongly influence the direction of rehabilitation - and the outcomes - for the patient, rather than being truly client-centred.

There are probably two main goal focuses - and perhaps they’re not mutually exclusive.

One is the outcomes the person really wants to see change - things like sleep, relationships between the person and others, increased time and energy for hobbies, returning to work etc.

The other is related more to therapy aims - things like reducing catastrophising, developing a relaxation response, developing activity scheduling and planning.

The reason for the therapy aims are to help the person achieve personal outcomes - hopefully.

The problems I see with patient-established goals are these:

  1. Often they don’t know what area to prioritise - is sleep more important than a better relationship? is exercising for an hour more important than returning to work?
  2. Often they don’t know what is achievable - if you haven’t achieved a goal in a long time, your aims are probably not very high - or they could be well in excess of what can be achieved within a certain timeframe.
  3. They might see an endpoint but don’t know what needs to be done to achieve that endpoint - for example, they want to return to work, but don’t recognise that to achieve this, they might need to develop a whole series of sub-goals that are indirectly related to the end goal.
  4. They may focus on pain reduction to the exclusion of goals that can be achieved without pain reduction coming first - for example, they may focus on pain reduction then consider return to work, when the two can occur concurrently
  5. They may never had any concept of setting goals at all - and therefore not know how to go about setting goals, and have vague or non-specific goals, goals that don’t have a clear end-point, goals that are about things that can’t be changed etc  Non ‘SMART’ goals…

I hope to cover some ways to set goals, and to help patients/clients/people with pain set goals over the next few days.  I hope you’ll join me as I review what I’ve found and put those findings together with my own thoughts from hy practice - and then hopefully you’ll comment and we can discuss this!

If you’ve enjoyed this introduction to goal setting, or you’d like to see more, please either bookmark the blog, or subscribe using the RSS feed above.  Simply click and follow the prompts, and you can get the feed through the magic of the internet.  And I do love questions and comments - please feel free to do so, and I’ll do my best to answer - or at least let you know I don’t know!  Anyway, I hope to see you back when I post the next instalment about goals and goal setting.

goal. (2008). In Merriam-Webster Online Dictionary.
Retrieved December 1, 2008, from http://www.merriam-webster.com/dictionary/goal

      
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