Unmotivated Patient? A New Perspective on Goal Setting

In this blog entry we’ll continue to delve into insights shared in the book The Switch by the Heath brothers. Their general insights into personal change could prove beneficial in our work as physiotherapists. I believe that refining our change behavior skills can make us more effective in helping our patients become healthier and more resilient.
And this brings us to their next axiom: Point to the Destination.

Are SMART Goals Enough?

So really, it’s as simple as giving our patients goals, right? Well, not quite. I think we’ve all been exposed to the SMART goal paradigm. It seems that if we have goals that are specific, measurable, attainable, relevant, and time-bound that we should be well on our way to meaningful, lasting change. But as the Heaths’ explain:

The specificity of SMART goals is a great cure for the worst sins of goal setting—ambiguity and irrelevance. But SMART goals are better for steady-state situations than for change situations, because the assumptions underlying them are that the goals are worthwhile. SMART goals presume the emotion; they don’t generate it. And so how do we get goals to generate that much needed emotion; the emotion that will help our Elephant to start moving?

A BHAG (Big Hairy Audacious Goal) engages people-it reaches out and grabs them. It is tangible, energizing, highly focused. People get it right away; it takes little or no explanation.
As the Heath brothers point out, a BHAG would be a little impractical for a lot of the changes that people need to make as we need to operate in much smaller time frames. And I think this is especially true within a physiotherapy framework. We need to be able to help coach patients in identifying healthy goals that they can begin to experience in weeks and months, not decades.
 
 

Vivid Descriptions

As we’ve discussed, the goal needs to be infused with energy and emotion. Collins & Porras identify that the long term vision or BHAG needs to include a vivid description-something that is ‘vibrant, engaging and specific’. They encourage translating the vision from words into pictures; something that they can keep with them throughout the day. In their description of the vivid description the authors are emphatic that it must be passionate, carry emotion and conviction for it to be meaningful.

The Heaths coined the term Destination Postcard to create a vivid description that is more short term in nature than the terminology and mindset developed by Collins and Porras.
So you may be thinking “This is great. So we need to have our patients engage in emotionally meaningful goal setting. But what does that look like? I’m not a psychologist, and I don’t have 30 minutes to explore their passions and goals. And I’d agree, how do we translate the concept of a “Destination Postcard” into clinical practice?
 
I think there are a few strategies that we can employ to help our patients build their Destination Postcard.

1. Know Your Patient.

First off, we need to get to know our patients. This is sometimes easier said than done. It takes time and energy and often we can feel like we’re lacking in both. But if delve into more than just what they do for work or the weather we can begin to uncover what gives meaning and significance to our patients. This may mean taking those five minutes giving an ultrasound, or spending a few minutes sitting with our patients as they share something important in their lives. When we know what gives our patients meaning we can help direct and guide our patients in creating an emotionally charged and meaningful goal.

2. Become in Tune with your Patient.

As therapists we have a lot of competing demands on our time and on our presence of mind. It seems that we can be pulled in a lot of different directions and often the patient standing in front of us can be seen as the next hurdle to overcome in getting through our day.
The challenge with all these distractions is that we may lose our ability to connect and miss out on key ‘signals’ from our patients. And those signals can give us valuable information into what can be meaningful for our patients. Dr. Siegel, in his book The Mindful Therapist, calls this process of awareness and connection: Attunement. He shares:

True attunement is risky business. It is “easier,” for example, to perform a physical exam on a patient and simply look for specific clinical diseases to rule out as you would click off the boxes on a checklist….Attunement is quite different from bulldozing your way through a questionnaire. We are open to the patient, not certain of what is happening within the subjective side of the interior of this person. We must be willing to go on a journey of discovery to find out what is really happening, being attuned to ourselves in the process, letting go of a feeling that we know everything or that we are in control of outcomes.

For this process to take place, we need to be open… willing to allow things to unfold as they unfold. And I believe to foster those moments with patients we need to be present in the moment. The patient that is waiting in the next treatment room, the uncompleted chart notes all need to fade into the background (even for just a few moments) so that we can allow ourselves to tune into the reality of our patients.

3. Dig a Little Deeper.

The right question can help cut through cluttered thinking in a hurry. And sometimes we need to dig a little deeper and cut through the noise of someone’s pain, their frustration with treatment progress, etc.
One potentially good question to ask your patient could be:

If you could wake up tomorrow morning and your [fill in the blank: pain, stiffness, etc] was gone what would you do tomorrow that you’re not doing today?

Depending on the answer, it then may be worthwhile and fruitful to ask the patient an additional: Why? as this can often get to more of the fundamental motivation.
This questioning can help form the foundations of your patient’s “Destination Postcard”. Here are a few more suggestions:

• Ask your patient to write a paragraph outlining in present tense description of what their “tomorrow” will look like.
• Encourage them to use colourful, engaging language.
• Frame this homework as an “exercise”.
• Encourage them to review this Destination Postcard often.

Closing Thoughts

Helping our patients stay motivated in reaching their goals isn’t always easy. Actually getting better as a patient can be hard work. But if we can engage our patients to develop emotionally powerful goals then we have a fighting chance to help them achieve greater lasting change.

Past Comments:

This article was originally published on the previous version of IgnitePhysio. The following are a selection of comments from the original instance:
Derek says: Hi Andrew,
What are some ways to keep a patient motivated to stick with their exercises?
What are some obstacles physios must acknowledge that are demotivating patients from continuing their exercises?
Thanks
Andrew says: Hi Derek,
Some great questions. In terms of your first quesiton. There are a number of different straegies to help with keeping patients motivated, but there’s a lot of factors to consider: personality, age, level of internal motivation, chronicity of condition, just to name a few. I think one of the keys is understanding a patient’s “why”. If you can connect the value of doing exercises to what they really want to do then you’re well on your way. Connecting an exercise to somethingi you discovered during your assessment will help patients understand why an exercise is important.
To answer your second question, I think there are a number of obstacles. Specifically, giving too many exercises (and not discharging existing ones!) can be a big demotivator for many patients. Also from my experience, not giving a time frame or a specific goal you’re trying to achieve with an exercise (e.g. We’re going to do exercise X until you can do this specific test well) can be demotivators for patients.