Module 2 A.E.M. van Wordragen 2100382
MODULE 2: GOAL SETTING AND PLASTICITY
BOOK WILSON 2011; CHAPTER 5
o The goal of rehabilitation is to maximise the person’s ability to participate in activities
that are valued by that individual and to maximise well-being despite the presence of
some form of impairment.
If this broad definition is accepted, then it is accepted that the goals of a
rehabilitation programme will depend on what is valued by the individual
being treated.
o One reason for setting rehabilitation goals is simply so that everyone is clear about the
aim of the rehabilitation intervention.
o There is strong evidence that goal setting improves performance.
Goals serve a directive function, directing attention towards goal-relevant
activities and away from goal-irrelevant activities.
o Self-regulation theorists have suggested that behavior can be seen as a dynamic
process of moving towards goals, and away from threats, with faster than expected
progress towards goals leading to positive affect, slower than expected progress
leading to negative affect, and expected progress being associated with neural affect.
o Seligman’s PERMA model of well-being defines well-being as arising from Positive
emotion, Engagement, positive Relationships, Meaning, and Accomplishment.
In terms of engagement, Csikszentmihalyi’s concept of ‘flow’ refers to a state of
engagement in which a person is using his/her character to meet the demands
of an activity that has clear goals and is challenging, but within the ability of
the person to achieve.
o For people with cognitive impairment there are many reasons why it may be difficult
to self-motivate, self-direct, and self-regulate and therefore a goal-setting process
might contribute to motivation and help people stay focused on achieving the things
they want to achieve.
Deficits in executive function may mean that it is difficult to spontaneously
formulate goals and monitor progress towards goals.
Deficits in awareness may make it difficult to identify realistic goals or
appreciate that needs to be done in order to achieve goals.
Difficulties with affect and emotional regulation may impact a person’s ability
to feel a sense of energy or drive towards achieving goals.
Components of goal setting in NR
Goal negotiation
o The two most commonly stated principles were that the process should be
collaborative and client-centered.
o Compared to usual practice, enhanced patient involvement resulted in greater
perceived autonomy in the rehabilitation process.
The number of goals did not differ but goal-setting methods with increased
patient participation have led to greater goal achievement.
o Several methods have been described that aim to support clients in identifying
personally meaningful goals through discussion of values.
The Rivermead Life Goals Questionnaire (RLGQ) provides clients with a list of
life goals areas and asks them to rate which are the most important to them.
,Module 2 A.E.M. van Wordragen 2100382
This showed that the most consistently endorsed life goals are related
to relationships with a partner, family and friends, with personal care
next.
o Identity-orientated goal setting involves asking the client to identify activities of
interest and then to identify an individual related to those activities who is admired.
o PoPsTAR intervention participants are asked to identify their character strengths
from a set of 24.
The character strengths are not ‘skills’ or ‘talents’, but are described as valued
aspects of a person’s personality.
After identifying their top five character strengths, clients are asked to identify
activities that enable them to use their character strengths in new ways, and
this forms the basis of goal setting.
Is has been found that being able to disengage from unachievable goals
and re-engage with new goals improves well-being.
Goals setting
o Having identified personally relevant goals, the next task is to turn these into clear,
specific, and measurable goals.
o The SMART acronym states goals need to be Specific, Measurable, Achievable (but
challenging), Relevant/Realistic, and with a Time Frame.
o For some goals it is relatively easy to make them specific and measurable and to
define what would be challenging.
For other goals this can be much more challenging and trying to make them
specific means that rather arbitrary targets are set, which do not really reflect
that abstract nature of the goal.
o In some complex situations, setting ‘learning goals’ rather than specific outcome goals
may lead to better generalisation of skills.
This does not mean that the goals are not specific and measurable, it is just
that the actual goal is framed as learning a skills or specific set of knowledge.
o Having identified the long-term goals for the rehabilitation programme, it is often
helpful to break these long-term goals down into a set of short-term goals.
There is evidence that a combination of long-term and associated short-term
goals leads to greater goal achievement than just having a long-term goal.
o One approach to goal setting is Goal Attainment Scaling (GAS) which is a method of
writing personal scales to measure progress/outcome in relation to personal goals.
GAS involves setting a rehabilitation goal and then setting levels of
performance outcome that reflect both better than expected performance and
worse than expected performance.
One of the features of GAS is that the goals are also weighted and then the
level of overall goal achievement is calculated by summing the weighted scores
and then deriving a T-score as a means of representing goal achievement with
a single standardised score.
Action planning and developing coping plans
o Plans of action specify who will do what and when. This includes what members of the
rehabilitation team will do, as well as what the client will do.
o It is recommended to spend time thinking about possible challenges to implementing
plans and developing coping plans.
o One potential barrier to goals having the motivating and directing effect for clients is
if goals are not remembered.
o Teams should consider how to support memory for goals with e.g. providing regular
reminders of goals via smartphones or recording goal-setting sessions on phones.
, Module 2 A.E.M. van Wordragen 2100382
Appraisal and feedback
o Common cognitive deficits in memory, attention and executive functions are going to
reduce the likelihood of being aware of progress towards goals.
Most rehabilitation teams meet regularly to review progress of clients, though
the actual frequency will depend on the number of clients in service.
Challenges, solutions and conclusions
o It is often said that the problem with goal setting is that it takes up too much clinician
time, taking people away from delivering interventions.
The counter to that is that there is a danger without a client-centered goal-
setting approach that rehabilitation team members will spend too much time
focusing on activities and interventions that are not a priority for the client.
o The extent to which goal setting is client-orientated can be evaluated with a scale
referred to as the Client-Centeredness of Goal Setting (C-COGS).
The C-COGS has three subscales:
1. Goal alignment: explores clients’ perceptions concerning how important
goals are to them, their therapist, and significant others.
2. Goal planning participation: measures clients’ perceived participation in
goal planning and decision-making on goals as well as the extent of
involvement and including in goal planning.
3. Client-centredness of goals: measures the meaningfulness, relevance and
ownership of the individual goals, as well as clients’ motivation to work
towards them.
ARTICLE: CICERON ET AL. (2019)
o In this meta-analysis, some of the reviews have maintained a pragmatic, clinical focus
while others have emphasized the methodological rigor of studies and often reached
the conclusion that there is insufficient evidence to guide clinical practice.
This represents a form of therapeutic nihilism that ignores a basic tenet of
evidence-based practice.
o This meta-analysis included a range of outcomes representing physiologic function,
subjective report or objective measures of neurocognitive impairments, activity
limitations, or social participation among participants examined during either acute
or post-acute stages of recovery.
