By Dershnee Devan
Something all of us face but seems worse with persistent pain?
I have used activity scheduling and goal setting many times with my patients over the years. This works to target the boom bust cycle and fear avoidance that people who suffer from persistent pain often engage in. This tool is helpful when it works, however, there are times when it seems that goal setting itself is really difficult to do.
This may be due to a possible lack of skill in communication skills, and the ability to engage in true shared decision making with the person suffering from pain. The article by Claes and colleagues however brings a different perspective that I found intriguing (Claes, Vlaeyen, Lauwerier, Meulders, & Crombez, 2018). It made me question what underlies the change in behaviour for all of us.
So what is goal conflict? It’s defined by the authors as:
“A situation in which the pursuit of one activity or goal competes with the attainment of another, equally valued goal and which creates at least a temporary stalemate, characterized by an indecisiveness and hesitancy before deciding which activity to pursue”
The research study reviewed compared goal conflict in fibromyalgia sufferers with a group of matched controls who were healthy individuals. The groups were mostly evenly matched for age, gender, education level and marital status. The one significant difference was that the fibromyalgia sufferers were largely unemployed when compared to the control group. I believe that this was a significant factor when interpreting the results.
So, goal conflict is something that all of us struggle with, not just people who have persistent pain. Is the key then perhaps to understanding why goal setting does not always work as well as it should?
The methodology involved a semi-structured interview using a technique called the day reconstruction method attributed to Daniel Kahneman and colleagues (Kahneman D., Krueger AB., Schkade DA., Schwarz N., & Stone AA., 2004). This involves keeping an activity diary that can then be used to help with goal setting.
They used the interview instead of an activity diary to guide participants in identifying the activity goals and conflicts experienced around these goals. These goals were then categorised by the participants according to categories:
- pain control, pain avoidance and reduction,
- social, work/education,
- household,
- leisure,
- general physical and mental health,
- Intrapersonal, financial and other goals.
Thereafter the participants assessed the conflict experienced by conflict strength, worry, pain related worry, stress, support necessary, solution of the goal conflict and satisfaction with this solution, as well as the emotions experienced during this goal conflict.
Possible study bias could have been caused by interviewer influence on views about goal conflict and the participants recall of their days. Recall of activities is a common problem if you are using this tool in therapy, so it’s important to be aware of it.
The results were interesting but not very surprising. Both groups experienced the same amount of goal conflict but differed in the type of goal conflict experience. The fibromyalgia sufferers reported more pain related goal conflicts. I feel this is to be expected for a population of people suffering from persistent widespread pain. They reported less work related goal conflicts. Again, I would expect this, given the majority of sufferers with fibromyalgia were unemployed. These sufferers also reported less social and pleasure related goal conflicts. Often, in my experience, people with persistent pain withdraw from social and pleasurable activities while still experiencing a need to reengage in these. Thus goal conflict arises.
The pain goals mostly conflicted with household, social and intrapersonal goals. The authors believe this may be related to the fact that the fibromyalgia group comprised of mostly women who were unemployed. Lastly, this group reported experiencing the goal conflict more strongly than the control group. I question whether this is related to emotional connection. People who experience persistent pain often lose their roles and identity when they become disabled. Specific goals related to this loss of role and identity may have a strong emotional connection.
So in the end, what does this all mean for the use of goal setting for people with persistent pain?
The awareness of goal conflict can help us understand how people with persistent pain make decisions, when faced with changing their daily activity patterns and goals, and why they struggle to do so.
The authors suggest “goal pursuit in the face of pain, may deplete resources in an already vulnerable population, which may in turn result in more pain and fatigue, or feeling more hampered by it” (Claes et al., 2018). They attribute the goal conflict to the interpretation of the goal conflict situation as catastrophic, with thoughts and anxiety as main contributing factors. This may be true, but does it apply to all people with persistent pain?
I gained insight into the experience of persistent pain from this study. I acknowledge the difficulty associated with improving your activity participation when you have persistent pain on a daily basis, and all your decisions are in conflict with your pain related goals.
All of us experience goal conflict on a daily basis, and we overcome these conflicts to lead productive and mostly happy lives. For a person with pain, goal conflict can be the one thing that paralyses them, as they have to choose between what they would like to do, and what they feel will improve their pain experience. Overcoming goal conflict then becomes a daily battle if they want to lead more active lives.
As clinicians, we should appreciate this, and acknowledge how difficult this is for them. It is reasonable to experience this difficulty when they choose activities to engage in for rehabilitation.
References:
Claes, N., Vlaeyen, J. W. S., Lauwerier, E., Meulders, M., & Crombez, G. (2018). Goal conflict in chronic pain: day reconstruction method. PeerJ, 6, e5272. doi:10.7717/peerj.5272
Kahneman D., Krueger AB., Schkade DA., Schwarz N., & Stone AA. (2004). A survey method for characterizing daily life experience: the day reconstruction method. Science, 306(5702), 1776-1780. doi:doi 10.1126/science.1103572