10-Minute Mini Lesson Three:  Goal Setting

10-Minute Mini Lesson Three is designed to provide a basic understanding of how to help members set achievable goals as part of their pain management treatment.

WHAT MAKES GOAL-SETTING DIFFICULT?

Most of us are good at identifying changes we would like to see in our lives. However, effecting these changes is often more difficult than identifying what they are — easier said than done, as they say!

Sometimes we feel overwhelmed by the size of the goal before us, and we simply do not know where to start. Other times we try to achieve a goal, but it just doesn’t work out. In these situations, it’s easy to feel discouraged and give up.

USING THE ACRONYM “SMART”:

The acronym SMART can be an important part of identifying appropriate goals and steps. This stands for:

Specific. Suggest patients be as specific as possible so they can tell when they have completed a goal or step. “Get more exercise” is vague, but “Walk around the block on Monday, Wednesday, and Friday” can be easily checked off.

Measurable. Suggest they make goals and steps measurable. Then they can track their progress over time. In the example above, specifying the “3 days” gives them a way to measure any change in their exercise habits.

Achievable. Make sure they pick a goal they can actually be attained. If it is NOT achievable then suggest they select a smaller step. For example, “Walk to the corner and back on Monday and Friday”

THE PRIMARY LAW OF CHANGE: If they are NOT achieving their goal, they haven’t selected a SMALL ENOUGH step.

Relevant. Make sure the goal they have chosen is in line with what they want to accomplish overall. Learning to be a better public speaker is a great goal, but perhaps not the most relevant if your greater aim is to make more friends.

Timely. Make sure that now is a good time to work toward their goal. For example, are they physically able to walk to the corner or around the block? This may have to wait until they have a walker or more strength in their legs.

HERE IS AN EXAMPLE OF GOAL SETTING:

Tom has been very athletic in the past and is very depressed about being relegated to his recliner because of his pain. He comes in with the goal of being able to take his usual five-mile run in the morning.

1. ACKNOWLEDGE HIS OVERALL GOAL of returning to his usual exercise regime.
2. Help him IDENTIFY A START POINT. He needs to be honest and ask himself, “Where do things stand now?” His answer: I can walk to the bathroom or kitchen. I need to rest after 5 minutes of walking or the pain is too much.
3. Help him break down his “goal” by IDENTIFYING ALL OF THE STEPS it would take to get from his start point to his goal. Suggestions that could be made to Tom:
4. Track how many times you walk to the bathroom or kitchen. Increase that by 2-3 more trips each day. Remember that EACH trip matters as a step toward your goal. These early steps are important. Congratulate yourself.
5. Add walking outside (e.g., to the backyard, front yard, or outdoor hallway) but limit it to 5 minutes. Do this with a partner if it seems scary to you.
6. Time your trips and add ONE minute each day. This means you would more than double your stamina in less than a week.
7. Track all your trips and times. This is your training schedule and will help you reach your goal.
8. Once a day, do more than what you think you can do. Then you can feel proud of yourself for going above and beyond.
9. Help him CONSIDER POTENTIAL OBSTACLES and how to work through or around them:
10. He says, “I can’t imagine going outside.” Suggestion: Suit up, put on your walking shoes, and just stand outside your front door. This is the trick: Almost everyone goes for the walk once they are outside their front door.
11. He says, “But it hurts too much.” Suggestion: Remind him that the pain could lessen once he gets his body more active or that he can hurt on a walk as easily as he can hurt in his recliner and it will be more fun and more distracting from the pain. Ask what he’d like to see on his walk—a good way to encourage getting outside.
12. He says, “I’m afraid I’ll fall.” Suggestion: This is a realistic concern. Offer to help him obtain whatever walking aid would decrease his fears.

CAN GOAL SETTING HELP IN ADDRESSING EMOTIONAL OR BEHAVIORAL DIFFICULTIES?

Goal setting can also be helpful when addressing emotional or behavioral difficulties. For example, someone who is depressed and isolated may work toward a goal of increasing the number and strength of his friendships. Someone experiencing anxiety related to her job may work toward exploring a career change or making time more often for relaxation and leisure. Because goal setting strategies are often used in CBT, this therapeutic approach is particularly helpful for those struggling to meet their goals, regardless of what those goals may be.

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AS A REMINDER (from the Introduction to this series on CBT for pain management in the primary care office):

CBT is the “gold standard” psychological treatment for individuals with a wide range of pain problems. It can reduce pain, distress, pain interference with activities, and disability. And it may well have positive benefits for common comorbid conditions such as depression, diabetes, and cardiovascular disease. It has been shown to be effective regardless of the particular licensing or background of the provider, as long as they have an understanding of basic CBT concepts and skills, and can even be effective in web-based applications. Brief in-office CBT is not designed to replace referral to a professional mental health provider with his/her diagnostic skills and therapy and/or medication options when this seems more appropriate.

CBT is not just for the licensed behaviorist! These CBT Mini Lessons can be used by:

1. The PCP him/herself (using appropriate billing codes to cover the extra 5-10 minutes),
2. Office staff such as nurses, medical assistants, behavioral health providers (using Health & Behavior codes billed to PHC)
3. A co-located Beacon-credentialed behavioral health provider (billed to Beacon)

Having practiced as a cognitive behavioral therapist for 40 years, I’ve seen CBT techniques used effectively in individual and group settings, in both clinical and psycho-educational venues, and provided by both professional and para-professional providers.

What are the advantages of bringing CBT into the primary care office?

1. PCP is best qualified to understand Member’s medical history and current needs.
2. Interventions are made when the Member is most motivated for change, i.e., the very moment when they are asking for help
3. Providing behavioral alternatives allows the PCP to manage the Member’s pain more safely
4. CBT interventions with home practice recommendations and handouts are quite effective in the primary care setting
5. Avoid the stigma and wait time sometimes associated with referral to a behavioral health specialist

What are the basic goals for using CBT for pain management?

1. Improved relationship with health professional—Member not shuffled off elsewhere, workable alternatives to medication changes
2. Increased functional activities—Focus changes from Member saying, “I can’t…” to Member asking, “How can I…?”
3. Improved mood and quality of life—Decreased depression, more optimism and self-confidence, less risk of side effects from medication
4. Improved symptom control—Better awareness of pain cycles, reducing use of unworkable strategies for managing pain
5. Improved self-management—Reliance on self rather than others to provide solutions
6. Reduction in unnecessary visits—Reliable self-management options rather than unnecessary appointments when pain increases

FUTURE BLOGS on CBT for Chronic Pain in the PRIMARY CARE OFFICE:

10 Minute Mini Lesson Four – Scheduling Fun, Enjoyment, and Achievement

By Karen Stephen, Ph.D., PHC Mental Health Clinical Director