If handled well, goals can narrow the gap between what the client wants and what can be delivered. They serve as a vehicle to draw together the aims of a client and those of the therapists and treating teams – which may be entirely different – and frame rehab in a real-world context.
All too often, however, goals are under-utilised in rehab – or miss the mark for various reasons; including overly complex aims, a lack of clarity, failure to feedback on progress and a mismatch between the client’s priorities and the goals set for them.
Here’s how to maximise the impact of rehabilitation on the lives of your clients – through the mechanism of a client-centred goals systems:
Mind the gap
Often there is a gap between what the client wants to achieve and what therapists are working towards. For example, you may have someone with a demanding career, such as an accountant, who just wants to get back to work.
All of this other stuff they are being presented with by therapists is just an
inconvenience. So, although improving mobility or expressive language may be obvious steps towards greater independence, clients may not be motivated by working on them in therapy.
The idea of getting back to work does inspire them, but they may not appreciate the immediate first steps.
Careful negotiation of goals
is required to close this gap. This means pausing various treatments and therapies, sitting down with the client and asking what they want out
Then objectives can be built for them, which the therapy team can break down into goals that enable a step-by-step approach.
In addition, a client lacking insight into their condition might present an obstacle to getting a realistic goal. In a sense, poor insight may increase the gap. Goals figure in the solution to this problem.
The collaborative setting of goals and reviewing of progress towards them, provides a forum to resolve discrepancies between the client and therapist’s different positions.
Watch your words
Having a consistent way of referring to goals throughout your team is essential. Make a clear distinction between goals and plans.
What some rehab professionals call goals are actually plans; and therefore, don’t present a clear idea of what the client is aiming to achieve.
For example, “to get a good assessment of the person’s cognitive ability” is not a goal. It is in fact part of a plan towards helping a client build a clear picture of their thinking skills.
This might seem pedantic, but carefully chosen language helps us to manage expectations. We cannot expect a client to be motivated to engage in an assessment.
A therapeutic goal, on the other hand, should be meaningful to the client.
It is also important to differentiate between short-term SMART goals (Specific, Measurable, Achievable, Realistic and Time-Limited) and long-term objectives.
For a young person, the former could be “to walk unaided for 50m”, compared to the latter e.g. “I want to be a footballer”.
The point here is to ensure as a team we are speaking a common language, again to manage expectations. So, we might expect the young person to be less motivated with a SMART goal, but when the link is drawn to the longer-term objective, this will optimise relevance to them.
Setting goals in concrete
Goals become more complicated when they move into the psychological world and tend to be less objective; although it is possible to have a subjective goal.
Equally it is possible to construct an objective goal out of something that seems at first sight to be a subjective state.
A typical goal with a parent of young clients could be “parents and therapist to come to a shared view about the reason my child is behaving like that”.
This could be made more tangible through discussion and sharing specific examples about behaviour.
Long-term goals should continually be kept within sight or hearing of the client.
During the day-to-day grind of therapy, and the more difficult moments of the rehab journey, clients should be reminded about where these activities are leading.
When things get tough, contextualising whatever they are doing in the framework of their wider objectives, and explaining the connection between smaller and bigger goals, is highly important.
By keeping tabs on the activities, short-term goals and the bigger objective, the meaning of all the hard work being done is clear.
Whose goal is it anyway?
Ideally clients work towards their own goals, rather than those placed on their shoulders by others – such as loved ones or healthcare professionals.
In the flurry of activity that surrounds busy and highly motivated therapy teams, however, ownership of the goal can be lost.
When goals are analysed, and clients questioned, it often emerges that goals were actually those of the therapists and not the client.
This isn’t necessarily a bad thing, but we must be clear up front about whose goal we are working towards. This enables us to manage our expectations about the feasibility of goal attainment.
Good working relationships between the client and those involved in implementing goals and plans can influence goal outcomes. Maintaining a strong rapport makes motivating the client easier.
Even though a therapist may feel pressure to get on with rehab by setting a goal early on, the time may not be right to do that yet. Time building rapport is well spent.
Why reviews rule
A symptom of the UK’s politically driven healthcare system is a widespread ‘goal-plan-do’ approach, with no ‘review’.
The value of review processes is often neglected. This manifests itself in rehab when goals are set without also having a goal review date in place.
Setting a goal is largely pointless without reviewing it to learn key insights and to establish whether the rehab plan has worked or needs to be adjusted.
Goal review systems are difficult to implement, especially in a community setting, and require skills, resources and ongoing learning.
The most sensitive measure of change in neuro-rehab is known as Goal Attainment Scaling (GAS), which was introduced in the 1960s in mental health treatment and has since been adapted for rehabilitation settings.
Its advantages include the involvement of patients and families in the goal-setting process, which is shown to improve results.
A GAS system encourages communication and collaboration among team members, stipulating that they meet regularly to discuss goal setting and review.
Because in GAS each goal is scaled, the measure is more sensitive to change in that it can capture ‘partially-’ or even ‘over-’ achieved goals.
Because of the client-centred nature of the goal setting, GAS is more able than standardised outcome measures to show change in areas that are relevant to the client.
One of the reasons people find goals aversive to set is the worry: “What if I don’t achieve them?”
Therefore, care should be taken when setting and reviewing goals and plans to have a culture of learning.
Goal review should not adopt a critical standpoint, allocating blame to non-attainment. Instead goals and plans should be reviewed within a learning culture: “That’s OK, what can we learn from this?” or “we set the bar a bit high there”.
Even over a short period of time, the client’s circumstances can change and goals can therefore become less relevant to them.
When this happens, it is advisable to write up what ground has been covered in working towards the goal, capturing any achievements along the way. New material can then be incorporated in the next goal cycle.
Dr Peter Tucker is part of the senior clinical team at Recolo (www.recolo.co.uk), which provides neuropsychological rehab to children, young people and their families.Contact him on firstname.lastname@example.org or business manager Lois Shafik-Hooper, on Lois. ShafikHooper@recolo.co.uk / 07715 104802 for more info.