Goal setting is a crucial component of any successful rehabilitation program, with reports of goal setting promoting treatment efficacy, adherence to treatment and self efficacy of the person. As a core component of a consultation delivered to a person participating in rehabilitation, one would assume that we ensure that the process of goal setting be a key competency for allied health professionals.
Traditionally, we are taught through our tertiary studies to set S.M.A.R.T goals. While SMART goals give us a system to work towards a goal with our client, goal-setting in rehabilitation can be more complex than commonly portrayed, with patients often taking a passive role, and professionals primarily focusing on physical or highly specific outcomes.
This makes sense when we look into the history and conceptualisation of SMART goals in 1981 by George Doran (source) who sought to find a better way to write management's goals and objectives.
Specificity: SMART goals require goals to be highly specific. While specificity can be beneficial in some situations, it may lead to overly narrow goals that don't consider the broader context of a patient's needs and aspirations. We rely on buy in from the patient when turning their broad goal into a specific goal, again forcing the patient into a passive role of their goal setting endevour
Measurability: Measuring progress and outcomes can be challenging, especially in rehabilitation where progress may not always align neatly with quantifiable data. Some aspects of recovery or improvement may be challenging to quantify accurately or conversely we may measure too many variables related to improvement, watering down the specific component as mentioned above.
Achievability: While SMART goals emphasize setting achievable goals, there's a risk of setting goals that are too conservative. In some cases, patients might be capable of more significant progress than initially anticipated. Alternatively,
Relevant: SMART goals may not always consider the patient's values and motivations fully. If goals are not aligned with what matters most to the patient, motivation and engagement may suffer.
Time Constraints: The time-bound aspect of SMART goals can sometimes create pressure and stress for patients, particularly if their recovery timeline doesn't align with the set deadlines.
If we consider the SMARTER acronym we do see a shift from characteristics of a goal towards interaction with the goal
Engaging: evidence exists that confirms that individuals are much more likely to support those things they help to create. Having a person create strategies to engage them with their goal (eg. home exercise program, joining a class, increasing physical activity parameters) adds a layer of autonomy and flexibility towards their goal
Rewarding: Rewards can give the expectation that we must find an external reward for achieving our goal or various milestones towards said goal. Following theories of self determination, intrinsic rewards are much more likely to increase motivation and self efficacy. For example, research suggests that physicians are motivated far more by internal rewards such as an intellectual challenge, a meaningful purpose, and a sense of accomplishment rather than external rewards.
To begin utilising a different framework in our setting we must first understand that our patients are fundamentally attempting to change something within themselves.
While SMART goals provide a structured approach to goal setting, there are alternative frameworks that may be more suitable for rehabilitation settings, where the focus is often on holistic well-being and patient-centered care. The concepts of self regulation theory and self determination theory can be useful guides to set frameworks for client goal setting. Both theories work to understand what motivates an individual to work towards a goal or behavior in the absence of external influences based upon their beliefs, attitudes and experiences. These theories supports our Biopsychosocial approach to rehabilitation, and embracing uncertainty.
Find their why, using the person’s relationships, core values, worldview, identity and inner posture to learn with genuine curiosity why they want to change themselves
Prior to setting a goal we must understand from the individual their global meaning. Global meaning refers to the general orienting systems that guide people in living their lives. Ie. our fundamental beliefs, goals and attitudes. In clinical practice we are quick to explore a patient’s medical history and in that context, their beliefs and attitudes around said history (or reason for presenting to us). This surface level questioning reflects the person’s Situational meaning, which denotes meaning making in a particular situation. By diving deeper into the individual’s global meaning we can gather greater context for goal setting to inspire change for the individual. Again, for some individuals (source)
Set the goal, which performs like an anchor, which they can move themselves towards or away with flexibility
Once we have established global meaning, we can link this with medical concerns and functioning (through our clinical assessments and findings) to collaborate with the person to establish a meaningful goal. When a person sets a goal, they set themselves an anchor.
They can move further away or further towards the anchor (goal). If the practitioner has taken the prior step, a person may reasonably set multiple meaningful goals as the actions taken to progress towards these goals should lead towards these multiple goals simultaneously (eg. getting stronger to improve my walking so I can rejoin my social walking group, however also so I can bend down to tend to my garden).
Goal directed behavior or actions can be taken that are anchored to the goal and why (the meaning) they are working towards it. Questions to be agreeing on with the person include
WHAT WILL THEY DO?
WHERE WILL IT GET DONE?
WHEN WILL IT GET DONE?
HOW MUCH WILL THEY START WITH?
HOW OFTEN WILL THEY DO IT?
Co-create specific actions that move in the direction towards the goal and give the person the tools to turn actions into habit. Allowing for options that create autonomy and flexibility
Finally, goal setting requires planning. Planning involves creating habit formation and repeated actioning towards the goal. Actions should be specific and linked to the person’s anchor, or goal. Formulating a plan for how to make the action obvious, attractive, easy and satisfying can allow for a person to have greater success with the plan. Effective planning involves plan B’s, what if scenarios and re-evaluation of the goal to create and maintain habits that link towards achieving the goal.Actions and habits are closely linked in the context of behavior change as an action is something you do. Whereas a habit is something you do repeatedly.
In summary,
we need to graduate from SMART or objective based goals if we aim to assist people in rehabilitation and grow towards long term health changes. Using goal setting frameworks based upon theoretical concepts of self determination theory allow more autonomy, flexibility and motivation towards one’s goals. A short acronym to help the busy practitioner with the time constraints imposed by healthcare settings could be as follows. MAP.
Further readings