Today I had the challenge of working with a new group of participants in the Pain Management Programme. They’re with us for three weeks, and at the beginning of this time I say to them that if their lives are no different six months from then, it’s not worthwhile attending. Usually they’ll all nod happily in agreement, and I think to myself ‘good, now let’s get on and work out what they want to be different’. After we’ve worked our way through ‘get rid of my pain’ (and I make the quip about the magic wand in my office that’s a self management wand made of plastic), we start to work on goals.
My first step is to ask people to go through a list of possible areas that people with pain often want to focus on – things like learning to relax more, have a more consistent level of activity, communicate better with my family, accept my pain. Most people want to tick all the boxes on the list and end up with this enormous number of potential goals, so we have to whittle the list down a bit. I do this by asking them to choose maybe three goals that catch their eye – and emphasise that these goals are not the final ones they may choose to carry out at the end of the programme.
The main problem with these type of goals is that they’re not goals. Well, they are vague areas for learning about, but they can’t really be used as goals that can be achieved. They don’t have the characteristics that have been identified as most effective. The problem I find is that so few participants in the programme have ever learned how to set good goals. AND most people are both used to having someone else ’set the goal’ and turn a dream into a series of actions, and fail to achieve these goals – I wonder sometimes if people are a bit fearful of the whole process.
A few months ago I started to look at goalsetting and whether it has been researched in pain management (there is a tiny bit of research, but not a lot) or researched in rehabilitation more generally (a little bit more, but again not a whole lot). I also looked at how well health professionals go about developing goals – whether participants generate goals, how long therapists spend establishing goals, and whether there was any consensus amongst team members about how to establish goals. Sad to say, there is a little research out there but it’s not a very popular topic, and what is known shows that goal setting is actually a high-level skill that many of us as health professionals either pay lip service to, or we focus on what we think should be achieved rather than what the person really wants.
The problems I’ve observed working with people to help them set goals are these:
many haven’t set goals before and find the whole process challenging
many haven’t looked forward for a long time, living day by day with pain as the dictator, so maybe feel fearful of committing to goals
some have learned through past experience (like New Year’s Resolutions) that ‘goals don’t work’
some have lived lives that drift and are relatively undirected, calling it ‘being flexible’
some have no idea of what they CAN aim for
some are grappling with accepting limitations to what they can achieve (this goal is too EASY they cry!)
many don’t know how to break a goal down into steps they can do
many have outcome goals that depend on other people’s actions, rather than looking at the things they can do (process goals)
Setting a goal up to be a series of actions that can be done takes a lot of time, knowledge about what each step needs to be, and for some people it’s the whole ‘pen and paper’ component that makes it challenging.
I’ve pondered whether it’s a good idea to establish a ‘real life’ goal at the beginning of a programme or nearer the end – I still don’t have a clear idea of which is best. I do find, though, that participants resist setting ‘real life’ goals at the beginning of the programme – perhaps fearing being tied to something they may not achieve, perhaps because they don’t know how to go about them. My current strategy is to work through the process I described above, then pick an arbitrary goal for the whole group (there is usually a common theme) and use it as an example as I work through the ‘SMART’ goal format. Actually I have another acronym, ‘SPART’ – Specific, Positive, Actions, Recorded and Timetabled’. This week I’m using ‘to identify one pain management strategy that can be used over the weekend at home’ as the goal. Then that strategy can be used as ‘the goal’ for the weekend – giving another opportunity to write and achieve a goal.
I’d love to hear others talk about their experiences establishing goals, especially goals that are not about exercise, because I think those goals are reasonably straightforward. It’s the ones about communication, developing good relationships, re-establishing a social life, developing an effective relaxation strategy and so on that I find more difficult to develop. Let me know what you do!