Bridge the Gap Between Goal and Attainment

The Patient

Mrs. Adams is a 62-year-old retired woman who has rheumatoid arthritis (RA) and lives alone. Her daughter is a single parent with a 12-month-old child named Alison. The daughter relies heavily on Mrs. Adams to provide daily child care for Alison when she is working. Mrs. Adams’ physician has referred her to occupational therapy (OT) because she is having difficulties taking care of her granddaughter after a recent flare of her RA. Mrs. Adams presents with stiffness and weakness in her wrists and hands and a significant level of fatigue. She tells Amy, her occupational therapist, that she is concerned about her symptoms and joint problems but does not have the time to attend OT appointments.

Scenario 1

Amy: Based on your evaluation and what you’ve told me, I recommend that you come in two times a week. As you said, it’s hard for you to do some things for yourself and your granddaughter. My recommendation is that we work on your hand and wrist range of motion, strength, and dexterity so that you can take care of yourself and your granddaughter. From what you’ve told me, you’ve been quite inactive for an extended period of time and have lost a lot of strength. We need to get you stronger to improve your overall endurance so that you can take care of your house and complete your errands. I’d also like to make a splint for you to wear at night when you’re having problems and show you some adaptive equipment that you can use every day to make things easier for you at home. Being in therapy will address all of this. How does that sound?

Mrs. Adams: Some of your advice makes sense to me, but I really don’t have the time to come here. I’ve always managed to get better on my own in the past. I only came today because I told my doctor I would come, but I think he’s worrying too much.

Amy: It is extremely important for you to do your therapy so that you don’t have even more trouble in the future, especially taking care of yourself. It sounds like it’s important to you to be independent.

Mrs. Adams: It is. I would like to come to therapy if it would really help, but I’m torn because my daughter depends on me right now, and I don’t see how wearing a splint or learning about adaptive equipment will help me to take care of Alison. No, I think I’ll be able to use my hands and get my strength back over time like I always do.

Amy: I understand it’s hard to make it to these appointments because you have responsibilities to others. I can help you get back to where you were faster than you would on your own. If you came to therapy, what would be your goal?

Mrs. Adams: I would want to feel better. I don’t want this arthritis to stop me.

Amy understands that Mrs. Adams has mixed feelings about wanting to attend therapy and feels that she should place the needs of her family above her own. Amy wonders how she can describe in her written note the goals that are truly client centered and motivating while still meeting the documentation requirements for reimbursement. What is required may not exactly reflect Mrs. Adams’ thinking and therefore not be valuable or meaningful to her as a client.

The Role of Motivation

Goal setting in rehabilitation is an important guiding force behind therapeutic efforts. Setting goals can motivate clients to put forth a focused effort—however, motivation can be elusive. The struggle to understand and capture the concept of motivation has led to volumes of work, particularly in the field of psychology but also in the realm of rehabilitation and health promotion. The roles of self-efficacy and personal control have been theorized to influence motivation. Bandura stressed the importance of personal competence and personal expectation of success in social cognitive theory. Ryan and Deci stressed not only competence but also personal control as a way of influencing intrinsic motivation in their self-determination theory.¹

In the interaction model of client health behavior, Cox hypothesized that individualized interventions facilitate positive outcomes by recognizing the importance of the relationship between the clinician and the client and the client’s freedom and ability to make choices about his or her own health.² Finding alternate ways in which to help motivate clients to set and achieve goals is the challenge we set forth to meet.

The History

The Patient Bill of Rights, conceived and enacted in the 1970s, was the starting point of a focused effort to deliver client-centered care. This Bill of Rights was founded on the premise that clients are entitled to knowledge of their condition and the options that are available to them for care. This knowledge would then aid them in making informed decisions about their health.³ As such, clients are encouraged to be actively involved in the provision of their own care. Central to the client-centered care philosophy in rehabilitation is the process of setting individualized and meaningful goals, a philosophy strongly embraced by occupational therapy practitioners.⁴ It is through the process of setting client-centered goals that practitioners seek to discover client motivation.

The concept of goal setting in rehabilitation started with research and theory development in industrial/organizational psychology, specifically, goal-setting theory that was proposed by Locke and applied to rehabilitation by Schut and Stam.⁵ Locke theorized that the act of goal setting led to better task performance by streamlining efforts towards a specific endpoint. This work led to the development of “SMART” criteria to assist teams to set goals.

One interpretation of the SMART acronym, set forth by Schut and Stam is “specified, motivating, attainable, rational, and timed,” although there are a number of variations.⁶ (See Table 1, above.) Importantly, in relating the benefits of successful goal setting to rehabilitation, Schut and Stam emphasized that clinicians should carefully monitor the relative value assessment of the goals from both the clinician and client perspective and cautioned that goals need to be of value to the client.

Goal Setting

The perceived benefits of setting goals are numerous for clients and their rehabilitation teams. A discussion of goals allows the client to get feedback from the clinician about his or her status and clinical recommendations for treatment. Clients are afforded the opportunity to relate and prioritize which goals are most valued and intrinsically motivating. The goal-setting process allows clinicians to focus therapeutic efforts toward a specific outcome and to communicate targeted outcomes with the interdisciplinary team. Goals also create an objective standard to monitor and report client progress, which in turn provides documentation of improvement and support for third-party payers for reimbursement of continued services. Rehabilitation teams use SMART goal principles to systematically document medical necessity and to report progress so that the clients continue to receive the services that can provide benefit.

Conflicts may emerge, however, and clinicians may find themselves walking a fine line between true client-centered philosophy and the practical need to document medical necessity for reimbursement. In a recent analysis of documentation practice and rehabilitation, Granger and colleagues noted that the method in which “medical necessity is documented is crucial” and “insufficient documentation leaves the facility vulnerable to denied claims.”⁷ Providing sufficient clinical documentation of medical necessity may result in goal setting that does not truly reflect the client’s primary concerns or that may be worded in ways the client does not understand. Clinicians run the risk of setting clinical goals that clients find irrelevant or that conflict with competing priorities. This situation may ultimately decrease client engagement with therapy and lead to poorer functional outcomes and lower client satisfaction.⁸

As Schut and Stam point out, goal setting “may be a powerful management tool, but setting goals is a delicate process.”5 Specific guidelines to assist clinicians in establishing goals are limited, although the need for such guidelines is well documented.^6,9 It is hypothesized that the most effective goals are grown from the ability of the clinician to establish a therapeutic relationship with the client, pursue individualized and client-centered objectives, and honor and support self-efficacy. Although some clients may come to therapy quite focused with specific goals, others are ambivalent about therapy or have limited insight into their needs. Motivational interviewing principles can help guide the goal-setting process by honoring client autonomy in light of clinical feedback and recommendations and by supporting a client’s willingness to put forth effort to make a change.

Motivational Interviewing

Motivational interviewing is a client-centered counseling style that is directed at discovering and enhancing a client’s intrinsic motivation for change. It is not a standardized technique to learn, but rather a directive method of interaction based on a spirit of collaboration, evocation, and respect for client autonomy. The relationship between the clinician and the client is considered a partnership rather than a more hierarchical relationship in which the clinician acts as an expert and the client acts as the recipient. The clinician using motivational interviewing principles structures the conversation to elicit and promote the client’s own motivational statements for a desired change or goal. These statements are known as “change talk.” The clinician selectively reinforces the client’s intent to change by reflecting upon and affirming the client’s change talk. This is done through the use of open-ended questions, affirmations, reflective listening, and summarization (OARS).¹⁰ (See Table 2, above.)

Use of each OARS component is carefully interwoven throughout the conversation to guide and emphasize the client’s reasons, needs, and desires to work on specific objectives.

Open-ended questions allow the clinician to gain a great deal of knowledge in a short time. An open-ended question invites the client to share what he or she feels is important and may help to establish a therapeutic relationship. To gain insight about a client’s perspective of his or her situation, a clinician may ask such questions as, “How has your arthritis pain affected your work?” or “What bothers you most about the stiffness in your fingers and wrists?” Such questions shape the conversation while allowing the client autonomy to address his or her concerns directly.

Affirmations are positive recognition and support of a client’s strengths and efforts toward a goal. Clinicians use affirmations to relay empathy, bolster client self-efficacy, and underscore client autonomy.

Reflective listening allows the clinician to direct the course and content of the interaction. Clinicians skillfully reflect the content of a client statement to express empathy, build rapport, identify and reinforce motivational statements, and explore ambivalence.

Summarizing what has been said provides the clinician a natural transition point in an ongoing conversation. The clinician is able to once again reinforce the client’s own motivational statements and to ensure that both the client and therapist are in agreement.

The four basic clinical principles of motivational interviewing are expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy.¹⁰ (See Table 3, below.) The clinician fosters a collaborative environment in which pressing issues and intervention plans are explored. The therapeutic principles of motivational interviewing fit well with the foundation of occupational therapy, which focuses on volition and habituation in a client-centered context. Making a desired change in behavior and then sustaining it can lead to clients being satisfied with their progress towards achieving their goals.

The use of motivational interviewing can help clients to set realistic and attainable goals. In the following scenario, Amy, the occupational therapist, uses this counseling style to elicit more information from Mrs. Adams, including barriers as well as facilitators to making a change. Notice how the outcome of their conversation changes.

Scenario 2

Amy: How has your arthritis affected you lately?

Mrs. Adams: I had a lot of pain and swelling earlier this month, but I’m feeling better now. I just have a hard time gripping things, like when I try to button my blouse or cut up my granddaughter’s food. Changing Alison’s diapers is so hard right now, and I’m exhausted all the time.

Amy: You’re frustrated that the effects of your arthritis are really stopping you from doing the things you need to do.

Mrs. Adams: I’m very worried about that. I can’t let it stop me though. I have too many responsibilities.

Amy: You seem to be a very busy woman. Tell me more about that, if you will. What is a typical day like for you?

Mrs. Adams: I get up early because my daughter drops off Alison every morning at 6:30 a.m. She is a single mother, and I take care of Alison while she is at work because she cannot afford day care. Alison is with me all day. I bathe her and dress her. I have to do everything for her, and I worry that I can’t do these things because of how my hands feel and how tired I am.

Amy: You have serious obligations to your family. You feel that you can’t let them down.

Mrs. Adams: Yes, and I’m scared that I won’t be able to do what they need me to do because I get stiff, and it feels like I’m getting weaker. As I said, it’s hard enough to take care of myself right now. I have a hard time even pulling up my pants because it seems like I don’t have the strength. Buttons are hard, and it’s really hard to tie my shoes.

Amy: What other activities fill your day?

Mrs. Adams: That’s about it. I try to clean my house while Alison is asleep. Otherwise, I have to do all my errands in the evening. I take public transportation, and I have to walk a long way to the stores and laundromat. I’m too tired to do that now.

Amy: Let me see if I have this right. You’ve recently had an increase in arthritis activity. It has primarily affected your hands and wrists, and since you live alone, you have to find ways to get your cooking, cleaning, and shopping done, not to mention taking care of yourself. Perhaps most importantly, in your view, is that you’re having a hard time taking care of Alison, and you don’t want to let her or your daughter down. You need to be strong for them.

Mrs. Adams: That’s exactly how I feel.

Amy: Let me tell you what I’ve found in your evaluation, and then you can tell me what you think about what I’ve said.

Amy relates the specific findings from the evaluation and how it relates to Mrs. Adams’ overall health and functional ability.

Amy: How do you feel about that?

Mrs. Adams: I think all of those are serious problems, but since I look after Alison every day, I don’t see how I’ll find the time to come to therapy.

Amy: Your day is packed from the minute you get up until the time you go to bed. Yet you appreciate how all of this affects your health and where these problems stop you from doing what you need to do.

Mrs. Adams: You’re right. I am concerned, especially about the future.

Amy: How important is it to you to be able to take care of yourself and Alison on a scale of 1 to 10, with 1 being not important at all and 10 being extremely important?

Mrs. Adams: I’d say an 8, definitely. I have to be independent.

Amy: Using the same scale, where would you rank your motivation to work on these issues?

Mrs. Adams: Probably a 7, but only because I would really have to figure out how I can do all of this.

Amy: And by “all of this” you mean …

Mrs. Adams: I mean that I should work on some of those things you recommended. I think it’s important to find a way to come to therapy.

Amy: How will you do it, if that is what you decide to do?

Mrs. Adams: My daughter said she’d either change her schedule around to give me more time or take Alison to day care while I’m at my appointments because she could afford an hour or two a couple of times a week. I didn’t want to ask her to do that because I felt guilty. But now that we’ve talked about it, I think that this is very important. Getting stronger and getting my hands working will help me because I won’t have to struggle getting both Alison and myself dressed, which is something I have to do every day.

Amy: Is that when you know you’ve made progress?

Mrs. Adams: Yes, I’ll be able to get us both dressed—buttons, zippers, pants, shoes. I need to do that on my own.

Amy: Let’s see what we have here. You’d like to work on your flexibility, strength, and endurance because that would mean you wouldn’t struggle to cook, clean, and run errands. You want to work on getting your hands stronger because you need to get yourself and Alison dressed. If you can do that, you can probably do other things. It seems like you’re open to other options, like using a splint if you need to and learning about adaptive equipment. You’ve decided that it’s worth taking your daughter up on her offer to make alternative plans for Alison so you can come in. You’ve really thought this through. Are you ready to start?

Mrs. Adams: Yes I am. Let’s go.

Through the selective use of open-ended questions, reflections, and summarization, Amy is able to establish a quick rapport with Mrs. Adams. Amy guides Mrs. Adams to create meaningful goals by honoring Mrs. Adams’ right to make her own healthcare choices and conveying empathy to her situation. From this conversation, Amy feels Mrs. Adams has resolved her ambivalence about being in therapy and is motivated to come in. She can document Mrs. Adams’ goals while also meeting the standards for reimbursement.

Our Experience

Clients have responded readily to the process of motivational interviewing. Initially, we feared that asking open-ended questions and using reflections would slow the evaluation process. Instead, we found that this approach quickly directs the conversation to what is meaningful and motivating to the client. With this information, we are able to frame our clinical feedback and recommendations in a way that makes sense to the client. Furthermore, less time is spent negotiating goals, because clients generally do not feel the need to fight to be understood. We have seen how motivational interviewing has helped move people to a point of clarity in terms of their healthcare, often creating new insights about what it is they want to accomplish and their ability to do so.

Motivational interviewing is a complex, challenging, and dynamic process that requires insight and discipline in order to be used effectively. When successful, motivational interviewing elicits a positive response that is rewarding for both the client and the clinician while increasing motivation to continue to strive towards goals and cementing a therapeutic relationship in the process.

Interested readers are encouraged to review the reference Motivational Interviewing in Health Care: Helping Patients Change Behavior¹¹ or the Motivational Interviewing Network of Trainers website at www.motivationalinterview.org.

Connelly is a clinical research coordinator at the Rehabilitation Institute of Chicago. Dr. Ehrlich-Jones is a clinical research scientist at the Rehabilitation Institute of Chicago and president of the ARHP.

References

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