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Theoretical aspects of goal-setting and motivation in rehabilitation

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DOI: 10.1080/09638280410001644932 · Source: PubMed

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 Motivation and Goal-Setting

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Theoretical aspects of goal-setting and motivation in rehabilitation

Richard J. Siegert*

&

William J. Taylor

Rehabilitation Teaching and Research Unit, Department of Medicine,

Wellington School of Medicine and Health Sciences, University of Otago

* Author for correspondence:

Richard J. Siegert

Department of Medicine - RTRU

Wellington School of Medicine & Health Sciences

University of Otago

PO BOX 7343

Wellington South

New Zealand

rsiegert@wnmeds.ac.nz

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 Motivation and Goal-Setting

RUNNING HEAD: Motivation and goal-setting

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 Motivation and Goal-Setting

Abstract

Purpose: The purpose of this article is to provide rehabilitation theorists and researchers with

an introduction to some key theories of goals and motivation from the field of social

cognition and to argue for increased dialogue between the two disciplines.

Method: The use of goals and goal-setting in rehabilitation is briefly surveyed and the

somewhat ambivalent attitude toward the concept of motivation in the rehabilitation literature

is highlighted. Three major contributors to the study of goals and motivation from the field

of social cognition are introduced and their work summarised. They include: (i) Deci and

Ryan's Self-Determination Model; (ii) Emmons' work on goals and personal strivings, and

(iii) Karniol and Ross' discussion of temporal influences on goal-setting.

Results: It is argued that there is a need for a greater emphasis upon theory development in

rehabilitation research and that closer collaboration between researchers in rehabilitation and

social psychology offers considerable promise. Instances where the three theories from social

cognition might have relevance to clinical rehabilitation settings are described. Some possible

directions for research are also briefly sketched.

Conclusion: Both rehabilitation and social cognition have much to gain from increased

dialogue.

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 Motivation and Goal-Setting

Theoretical aspects of motivation and goal-setting in rehabilitation

In a recent review of advances in rehabilitation Wade and deJong comment that all the

major advances in the field of rehabilitation to date, have been in the realm of service

delivery1. They compare this with other branches of medicine where technological progress

and the development of effective 'single treatments' have constituted the major advances.

Importantly, they argue that this difference has made it difficult for rehabilitation services to

compete for funding against other medical specialities that can point to their demonstrably

effective single measure treatments. Wade and deJong note that one of the major advances in

rehabilitation, has been the transition from a largely medical model emphasising pathology

and diagnosis, to broader psychosocial and socio-cultural models. They also suggest that

further progress in rehabilitation will stem mostly from the accumulation of evidence based

interventions. Hence they advocate rehabilitation approaches that are 'pragmatic, functional,

or task oriented in contrast with a theory-based, impairment oriented approach' (p.1387).

Wade and deJong's review is an excellent and concise summary of contemporary

rehabilitation practice. However, we believe that it exemplifies one weakness of the

rehabilitation canon - a tendency to overvalue pragmatism and empiricism at the expense of

theory development. Such an approach is hardly surprising given the nature of clinical

rehabilitation. Rehabilitation specialists are faced everyday with the daunting task of helping

individuals whose physical and social selves have been severely compromised by trauma or

disease. There is a desperate need in such situations for immediate and practical solutions and

not for abstruse philosophy. Any clinician who did not believe this would quickly be brought

back down to earth by their patients. However, the need for a pragmatic stance in the clinic

should not exclude the development of a rich theoretical foundation for the broader field of

rehabilitation. The central argument we wish to make in the present article is that

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 Motivation and Goal-Setting

rehabilitation needs theory development just as much as it needs an evidential basis, and

furthermore, that theory building is compatible with a tough-minded, evidence-based

zeitgeist. The point at issue here is that for rehabilitation to advance as a scientific discipline,

it needs conceptual and theoretical advances, not solely empirical ones. It is not enough

merely to ask "what works?" in rehabilitation. We also need a body of theory that explains

how an intervention works and that can guide the development of new and more effective

techniques.

In the present article we consider the use of goal setting in rehabilitation as a practical

but largely atheoretical 'specific intervention'. We also look at the controversy surrounding

the closely related concept of 'motivation'. Then we briefly review three important theoretical

approaches on goals and motivation from the field of social cognition, each of which, we will

argue, has relevance for rehabilitation. Finally, we speculate on how these three models might

have applied relevance for goal setting in clinical rehabilitation settings and also to drive

research.

Goals and goal-setting in rehabilitation

It is a sine qua non in rehabilitation practice that goals and goal setting are a

fundamental component of any sound rehabilitation programme. Moreover, goal setting is

assumed to be an essential part of every individual patient's rehabilitation. For example,

Barnes and Ward (p.8) state that 'the essence of rehabilitation is goal-setting' and that 'If

rehabilitation is to be taken forward, agreed goals and outcomes are essential' 2. On a similar

note McLellan advises that the measurement of outcomes is vital to successful rehabilitation

and that this demands the setting of precise goals by the rehabilitation team in conjunction

with the patient and their family 3. McLellan claims that 'many studies have demonstrated the

effectiveness of goal setting…' and is quite critical of goal setting where the goals are vague

and lacking in precision (p.235) 4. Similarly, Bower writing on rehabilitation and the child

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 Motivation and Goal-Setting

with multiple handicaps notes that 'Treatment goal-setting is at the centre of attempts to

reduce disability and resolve handicaps for children and their families.' (p.347) 5. Thus it is

widely accepted that goals and goal-setting are an essential and effective component of a

modern approach to rehabilitation.

A number of writers also advocate the SMART acronym as a guideline for goal-

setting. This acronym stands for a number of ideal criteria that should be considered when

setting rehabilitation goals. McLellan states that the ideal goal should be Specific,

Measurable, Activity-related, Realistic, and Time-specified. Barnes and Ward (p.9) give a

slightly different set of criteria - Specific, Measurable, Achievable, Relevant, and Time-

Limited. Another important feature of goal-setting which several writers mention is that it is a

collaborative process whereby the patient, the patient's family, and the rehabilitation team,

negotiate a set of shared goals. Barnes and Ward observe that there can be discrepancies, and

even conflict, between the goals that the patient, the family, and the rehabilitation specialists

view as important or realistic. They also comment that goal-setting is a 'dynamic process that

can be changed and adjusted according to progress' (p.8). Finally, some authors also stress the

importance of developing short, medium, and long-term goals.

It might seem then that goal-setting is a reasonably straightforward component of

contemporary rehabilitation practice. However, there is a growing body of research on this

issue that suggests that, while certainly desirable, goal-setting may be a more complicated

procedure than it has been portrayed. For example, Wressle, Oberg and Henriksson reported

a study which examined how treatment goals, as seen by stroke patients and rehabilitation

professionals respectively, were related to the discipline-specific interventions or treatments

provided, and also to the eventual outcomes 6. Their study involved 21 geriatric stroke

patients and a range of professionals (occupational therapists, physiotherapists, physicians)

directly involved in their rehabilitation. Qualitative interviews and diaries were used to track

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 Motivation and Goal-Setting

the relationship among goals and interventions longitudinally, and also to see how these

reflected the ICIDH categories of impairment, disability and handicap. The authors report a

number of interesting findings, among them that patients tended to adopt a passive role in

hospital and had minimal role in goal-setting. Wressle et al. observed a tendency for

professionals to frame goals in terms of physical outcomes primarily concerned with mobility

and physical independence. Goals that were essentially psychological in nature, were

relatively rare. The authors question whether rehabilitation goals are not largely driven by

economic factors and the demand to empty hospital beds as quickly as possible. They

concluded that 'the patient does not participate in the goal-setting process' (p.86). McPherson

et al. reported similar findings in a qualitative study that looked at what people with arthritis

considered were the most important outcomes in terms of their long-term health care and

rehabilitation 7. They concluded that health professionals and their patients differ notably in

what they consider are the good or important outcomes. Again, such a finding suggests that

goal-setting in rehabilitation is more complicated than has sometimes been suggested,

especially in terms of incorporating the patient or client's perspective.

It has also been suggested that the practice of goal-setting itself implies a set of

assumptions or a world-view that may not necessarily be shared by all clients or patients 8.

Kielhofner and Barrett have commented that "Goal-setting takes its meaning and ambience

from cultures that emphasize a strong future orientation and the attendant idea of progress

toward some definable good" (p.346) 8. They note further that "The occupational form of

setting and following up on goals belongs to a narrative in which people progress forward in

time, calculate steps of action, mark passages, and set objectives to get somewhere in the

future" (p.351) - perhaps reflecting the culture of the mostly middle-class professionals

involved in rehabilitation. Which is not to decry goal-setting, but rather to suggest that we

cannot apply it in a cookbook fashion to all our patients. Kielhofner and Barrett argue that

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 Motivation and Goal-Setting

"occupational forms", such as goal-setting, always operate within a social context and as such

are imbued with meaning by all participants. Consequently, for goal-setting to succeed, we

need to consider the client's understanding of the process and its meaning (the work of

Kielhofner is also a good example of the heuristic value of theory development for

stimulating rehabilitation research9).

Another important dimension of goal-setting that tends to be overlooked or

underestimated is the influence of the context in which it takes place. For example, in an

inpatient rehabilitation ward, or a stroke unit, the focus is primarily upon activities of daily

living. The individual must achieve maximal independence in such domains as mobility,

hygiene, continence, dressing oneself, eating, communication and personal safety. The goals

of rehabilitation are physically focused and primarily set by the rehabilitation team in

consultation with the patient. In contrast, when the patient is discharged back into the

community, their goals are likely to be broader, with more emphasis upon social functioning

and reintegration within their family and the community. Typically, the patient will be taking

a much more dominant role in goal-setting by this stage, and family members will be

increasingly involved. Factors relating to the individual circumstances of the patient, their life

history, their family background, social support network, and other community variables will

play a much more important role than in the highly structured inpatient environment. In fact,

there is evidence that one of the most common problems encountered in the goal-setting

process, is the lack of continuity from inpatient to community rehabilitation goals 10. Again,

we will argue that a more theoretically driven approach to goal-setting may go some way

towards addressing this kind of problem and provide a better fit between individual and

contextual factors in rehabilitation.

Motivation and rehabilitation

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 Motivation and Goal-Setting

A concept that is closely related to the idea of goals is that of motivation. Eccles and

Wigfield note that the word motivation stems from the Latin word meaning to move, and 'in

this basic sense the study of motivation is the study of action' (p.110) 11. They observe that in

contemporary psychology the focus today is on the study of 'the relation of beliefs, values,

and goals with action.' (p.110). Within the field of rehabilitation motivation is typically

viewed as an important concept, but also one that is difficult to measure objectively and

prone to value judgement. The clearest statement to this effect has been in the work of

Maclean and Pound and Maclean, Pound, Wolfe, and Rudd 12,13.

Maclean and Pound critically reviewed 'the concept of patient motivation' in the

physical rehabilitation literature (p.495). In this paper they observed that rehabilitation

professionals frequently evaluate their patients in terms of how 'motivated' they are, and also

that there is a widespread belief that the more 'motivated' patients have more positive

outcomes. At the same time they comment that the term itself is loosely defined and the

evidence is mostly anecdotal. In reviewing the literature on motivation they observed that

studies typically fell into three broad groups. The first group, which comprised mainly

‘clinical’ research, tended to view motivation as a personality trait. In other words motivation

is seen as a relatively enduring characteristic of the individual and their behaviour. It is

something that tends to be seen as 'inside' the individual and relatively unaffected by the

environment. The second group of studies in this review focussed mainly on the extent to

which environmental or social variables could effect motivation. Such studies tended to look

at how motivation might be influenced by qualities of the rehabilitation team itself or by the

patient's social support network. A third group of studies acknowledged the importance of

both the characteristics of the individual and also of their environment, and in some cases

even explored the interactions. Maclean and Pound are particularly critical of the first group

of studies that regard motivation as an aspect of the patient's 'personality'. The major problem

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 Motivation and Goal-Setting

here they observe is that such an approach is highly correlated with a 'moralistic' stance that

blames the patient.

Is motivation then a useful concept for rehabilitation, or is it as King and Barraclough

(cited in Maclean & Pound) have suggested simply ‘unhelpful’? Can we define motivation in

a precise and meaningful fashion that clinicians and researchers can agree on? Or is the

concept hopelessly subjective and beyond scientific analysis? There are a number of

practical reasons why it may be both premature and unwise to abandon the concept of

motivation altogether. First, as noted by Maclean and Pound this is probably unrealistic as

the concept itself is 'so deeply ingrained in the thinking of rehabilitation professionals'

(p.505). Another reason for not abandoning the concept of motivation altogether, is that,

notwithstanding the problems with defining the concept, there are numerous quantitative

studies suggesting that it can be a good predictor of outcome in rehabilitation 14,15. A third

reason for not abandoning motivation as a useful concept in rehabilitation is that motivation

and goals are inextricably linked (as we will attempt to demonstrate below). Thus, using

goals and goal-setting without any reference to motivational theory may rob it of a powerful

theoretical framework.

In the present paper we argue that goal-setting as a technique in rehabilitation will

benefit in the long term from developing a clearer and more complex theoretical framework.

In the next section we will provide a brief overview of some relevant ideas about motivation

and goals from the field of social cognition that could help develop such a framework.

However, the subject of motivation and goal-directed behaviour in contemporary psychology

already consists of a vast and diverse body of literature. We will not attempt to provide any

systematic review of this area and in fact several excellent examples already exist 11,16.

Rather, our goal is to describe a few examples of some theoretical and empirical models

drawn from the field of social psychology, that might be particularly relevant for theory

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 Motivation and Goal-Setting

building in rehabilitation. We will focus on three important theoretical approaches: (i) Deci

and Ryan's self-determination model; (ii) Emmons work on subjective goals and well-being,
16-18
and (iii) Karniol and Ross' ideas on temporal influences on goal-setting .

Goals and Motivation - The View from Social Psychology

Deci and Ryan's Self-Determination Model

Deci and Ryan have advanced a model of human behaviour which views human

beings as inherently active, self-directed organisms which have three fundamental human

needs: for autonomy, competence, and interpersonal relatedness16. Autonomy refers to

individuals' propensity to self-regulate and organise their experiences and to function as

unified, integrated human beings. Relatedness refers to a propensity to establish a sense of

emotional connectedness to other human beings and to seek the subsequent goals of feeling

loved and cared for. Competence refers to the propensity to establish a sense of mastery over

one's environment, to seek challenges and to increasingly master them. Paramount among

these needs they argue is the need to be autonomous or self-determining. Ryan and Deci

argue that it is through the fulfilment of these three basic needs that humans find

psychological growth and well-being 17. The fulfilment of the three basic needs is considered

to be 'a natural aim of human life that delineates many of the meanings and purposes

underlying human actions' (p.147).

One practical application of Ryan and Deci's model would be in providing a

framework for goal-setting and planning that is holistic in approach and avoids the criticism

that it is primarily concerned with emptying hospital beds quickly. This narrow focus is much

less likely if rehabilitation teams work with a patient to develop goals in each of the three

separate domains. Consider the example of a person with a spinal cord injury (SCI) who is

approaching re-entry into the community as a paraplegic. Goals within the competence

domain will initially centre around mobility, bladder and bowel function, grooming and

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 Motivation and Goal-Setting

dressing and other activities of daily living (ADLs). As these are mastered and competency

increases new challenges may be added, such as driving or involvement in wheelchair

sporting activities. At the same time, developing goals in the domain of relatedness will

ensure that social needs are not neglected. These goals might focus upon ensuring the person

has strong social support networks or providing counselling on sexuality issues after SCI. The

notion of autonomy suggests that the individual with the SCI is actively involved in setting

their own goals at all stages. It suggests also that the more control invested in that person, the

more likely that they are to achieve the goals.

Another central concept in self-determination theory is that of intrinsic motivation.

Deci and Ryan define intrinsically motivated behaviours as those 'for which the rewards are

internal to the person' (p.194). Such behaviours are inherently interesting to the person and

are rewarding because they produce feelings of competency and self-determination. They can

be contrasted with extrinsically motivated behaviours that are performed to obtain some form

of external reward such as money or praise. Involvement in behaviours that are intrinsically

motivating is thought to increase feelings of competency and self-determination.

The ability to fulfil these three basic needs for autonomy, competency and relatedness is

thought to contribute directly to subjective well-being.

One implication of this notion of intrinsic motivation for rehabilitation practitioners,

is that we need to get to know the client as a person, before we can assist them to set

meaningful goals. We need to attempt to enter their world view and garner their perspective

upon their current situation if we wish to establish what activities might be intrinsically

motivating for that individual. Consider the example of working with stroke patients who

have a mild aphasia to improve their language abilities. A more extroverted client who

thrives on the company of others may find conversation exercises in a group intrinsically

motivating. By contrast, a client who has always been rather shy and introverted may initially

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 Motivation and Goal-Setting

find such an approach aversive and punishing. However, they may thrive on a cognitively

challenging task that is less socially demanding, such as crossword puzzles. They can then be

gradually involved in similar tasks with a more social element - such as card games or

scrabble.

There are a number of other aspects of this theory that are relevant to the subject of

goals and goal-setting. For example, Ryan and Deci cite studies that suggest that positive

well-being is associated with goals that are challenging but not with goals that are too easy

nor too difficult. They also distinguish between approach (or positive) goals, such as wanting

to master a new skill, and avoidance (or negative) goals, such as not wanting to look foolish.

They cite a range of studies which suggest that higher subjective well-being is associated

with achieving approach goals whereas not so for avoidance goals. However, the most salient

aspect of Deci and Ryan's theory for rehabilitation and goal-setting, is the extensive body of

research which they have reported over two decades, on the effects of intrinsic and extrinsic

motivation 16,17 . In general, Deci and Ryan would argue that intrinsic goals are more

powerful motivators than extrinsic or externally imposed goals. Moreover, extrinsic goals can

actually serve to disrupt behaviour that is intrinsically motivated.

Emmons' Subjective Goals and Well-Being

Robert Emmons has described a theoretical approach to goals that emphasises the

relationship that goals have with 'personal strivings' and subjective well-being. Emmons says

that personal strivings are stable features of our personality that represent 'durable

concerns…expressed in a variety of situations' (p.315)18. For example, we may value physical

attractiveness greatly and devote much time and energy to our diet, exercise and grooming.

Or we might consider that a close and happy family is the most important thing in life and

behave accordingly. We might strive to be a 'good Christian' or a well-respected academic.

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 Motivation and Goal-Setting

According to Emmons, these personal strivings represent 'what a person is typically or

characteristically trying to do' (p.315)18.

Thus in Emmons' view, the kinds of personal strivings that characterise an individual,

will have a close relationship with the type of goals that matter to that person. Similarly, the

extent to which they achieve those goals will have an impact upon their well-being. In

Emmons' words 'goals play a central role in determining the degree to which a person is

satisfied with his or her life, and the degree to which that person experiences positive and

negative emotional states' (p.315). He considers that emotions serve three important functions

in the regulation of goal - directed behaviour: (1) they help us decide which goals are

important to us, (2) they energise us and help direct our attention and resources towards goal

attainment, (3) they provide feedback to us.

One important implication of Emmons' ideas for rehabilitation practice is that a

client's emotions and feelings are an integral part of the goal-setting process. Their emotions

help them to decide which goals are worth striving for in the first place, they provide energy

or drive (that component of motivation known as volition) and they communicate how well

the client thinks they are progressing toward their goals. Indeed, rather than treat the client's

emotions as primarily symptoms or problems that arise in reaction to their circumstances, we

need to closely monitor them throughout the rehabilitation process and acknowledge their

communication value. To take a not uncommon example, that of a young man recovering

from a traumatic brain injury (TBI), who is frequently hostile and aggressive toward staff on

a rehabilitation ward. While such behaviour can have diverse causes, it sometimes represents

an indirect message that the young man is unhappy with the goals he has supposedly set in

conjunction with the rehabilitation team. Mark Ylvisaker has eloquently made this point in

reflecting upon his years of experience of working with young male survivors of severe TBI.

He notes that the typical young, male survivor of a severe TBI, often led a life prior to their

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 Motivation and Goal-Setting

injury which was characterised by impulsiveness, substance abuse, risk-taking and other

stereotypically "macho" attributes. Ylvisaker comments wryly that the goals for social

rehabilitation with such young men frequently resemble an attempt to turn a Doberman into a

poodle, and not surprisingly they are frequently unsuccessful. It is Ylvisaker's contention that

in such cases successful rehabilitation hinges upon helping the young man with a brain injury

develop a new sense of identity. An identity that, while still broadly "Doberman" in nature, is

more consistent with pro-social values and a non-delinquent lifestyle. The point at issue here

is that successful goal–setting must incorporate the client's perspective and a firmer

theoretical perspective on goal-setting can facilitate this.

Emmons is very clear that our moods and emotions are affected by our 'goal strivings'.

However, he is less concerned with short-term mood states than with longer-term emotional

adjustment and life satisfaction - or subjective well being (SWB). He is as concerned with the

meaning an individual finds in their life as much as their happiness. For example, religious

saints and political prisoners have been known to sacrifice their own happiness in the search

for a meaningful existence. Emmons argues that long term SWB is not determined simply by

summing positive and negative mood states - but requires a broader and more durable sense

of meaningfulness and purpose in one's lived existence. Emmons puts it thus ' Meaning

comes from involvement in personally fulfilling goals, the integration of these goals into a

coherent self-system, and the integration of these goals into a broader social system'

(p.333)18.

Emmons' theory also involves detailed consideration of how goals differ among

people and how these differences (e.g. in their content) relate to SWB. However, space

precludes even a superficial account of this complex theory and we will focus on just one

further aspect of the theory that may have useful implications for rehabilitation. This is

Emmons' observation that personal strivings and goals can vary according to their degree of

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 Motivation and Goal-Setting

abstractness. An example of a more abstract or high-level goal that Emmons gives is a person

who wants to 'come to terms with suppressed feelings and emotions'. A more concrete or low

level goal described by Emmons is to 'keep my room clean' (p.320). 18

It is not difficult to think of similar examples of high level and low-level goals that

have more relevance to a rehabilitation setting. For example, a person with Parkinson’s

disease who has suffered increasing restrictions on their mobility and independence may wish

to continue their spiritual relationship with God and also deepen their social relationships

with their fellow parishioners. These are high-level goals - characterised by a high degree of

abstraction. They would probably not meet the SMART criteria. However, they may well be

able to strive toward these higher-level goals through quite concrete, lower-level goals. The

goals might be to attend one church service weekly and one parish social function each

month - simple, measurable, achievable, and realistic goals with time frames. In this sense,

the rehabilitation canon, exemplified in the SMART acronym misses the point somewhat. We

all have high-level goals, and they add meaning to our lives - and the best path toward

achieving such high level goals is through specific and achievable lower-level goals. As

Emmons puts it, 'The most adaptive form of self-regulatory behaviour may be to select

concrete, manageable goals that are linked to personally meaningful, higher-order

representations' (p.54)19. The real message here for rehabilitation practitioners is that goals

are hierarchical in nature. By organising lower level goals (i.e. SMART goals) in relation to

higher order goals, we keep the individual's existential self and personal values to the

forefront and allow for the role of meaning in life as a central focus in rehabilitation.

There is a close parallel with short and long term goals here: long term goals tend to

require a number of specific steps along the way, which may not always be obviously linked

to the long term goal. For example, a patient with stroke who wants to return to work will

need to identify precisely what it is that prevents him from working. It may be that the ability

16
 Motivation and Goal-Setting

to drive a manual gear-change car is necessary, in which case a short-term goal may be to

improve left arm function in order to operate the gear lever. Goals can often be broken down

into tasks, which when accomplished, lead to a new level of competence, and eventual

attainment of the goal. It may be that ‘tasks’ are more suitable than goals when applying the

SMART approach.

Karniol and Ross' Temporal Influences on Goal-Setting

In a review paper Karniol and Ross surveyed the importance of the role of time in

relation to motivation and goal setting 20. In particular, they were concerned with elucidating

the ways in which an individual’s personal history and autobiographical memory might

interact with their particular vision for the future, to influence their goals and motivation in

the present. Their article is an interesting and readable introduction to much of the literature

from social psychology on this topic. Once again, we will just select a few key ideas from

their review paper that might have particular relevance for rehabilitation. We recommend

their original article for a more in-depth overview of this area.

One central idea in Karniol and Ross' article is that goal-setting is not always just a

simple linear process that occurs in a void. Rather, individuals are influenced by their past

and also by their cognitive representations of 'possible futures'. Karniol and Ross state that

'In general, people imagine various futures, consider the advantages and disadvantages of

each, select their preferred end states, and then develop plans to achieve their desired goals

while avoiding negative outcomes' (p.595). In this process, the individual's memory of the

past, can also play a vital role in determining the range and the nature of the goals that

people will consider in the present, and how achievable they rate each goal. Karniol and Ross

call this 'the push of the past'. The role of affect or emotion is also seen as important in this

process with emotional factors influencing our choice of goals - and our success in meeting

our goals influencing our emotional well-being. Hence the process is a recursive one in

17
 Motivation and Goal-Setting

which emotions and goals influence each other, and our past and our conception of the future

can both impact upon our choice of goals.

For example, many people who develop a severe disability still wish to return to those

activities that they cherished before the onset of their disability. But over time, their valued

activities may change, especially if it becomes clearer to them that such activities are now

unrealistic. An example of this is a very good tennis player who has a brainstem stroke that

leads to hemisensory loss, vertigo and diplopia. Despite determined efforts, she remains

vertiginous with sudden movements so that playing tennis is clearly impossible. Following a

period of dysphoria and adjustment, she renews an interest in gardening - an activity that she

feels she is able to accomplish and one that has been enjoyable in the past. Thus, the process

of goal-setting often looks backwards to determine what holds meaning for the individual, but

is also informed by subsequent experience.

Another common clinical situation that illustrates how Karniol and Ross' ideas might

usefully connect with rehabilitation practice is that of the depressed patient who the

rehabilitation team is trying to engage in goal-setting. According to Karniol and Ross, an

individual's memory of their past plays a major role in their ability to generate or even

consider new goals. It will also directly effect how achievable they rate these goals. There is

an abundance of evidence now that depressed mood actually alters how individuals process

information 21,22. For example, depressed people may have better memories for recalling

negative information than non-depressed people. Consequently, depressed clients may have

some difficulty in actually recalling positive memories to use in the process of developing

new goals for the future. They may have similar problems in generating a mental construct of

a future "positive self", and they may tend to rate even relatively easy goals as quite difficult.

The practical implication of this for rehabilitation professionals in such circumstances is to

treat the depression assertively before attempting to engage the client in the more cognitively

18
 Motivation and Goal-Setting

demanding aspects of goal-setting, such as setting longer-term or more abstract life goals.

Rather, the initial focus of goal-setting should be on increasing the frequency of pleasant

daily activities aimed at improving the client's mood.

Conclusion

Goal-setting is an essential component of any modern approach to rehabilitation. It

provides a framework by which rehabilitation professionals and their clients can work

together to enhance the client's physical independence and psychological well-being.

However, much of the literature on goals and goal-setting in rehabilitation, has tended to

neglect theory and theory development, in favour of a pragmatic and empirical, and largely

atheoretical approach. We have argued that a scientific approach to rehabilitation must

incorporate both a rich theoretical foundation and a rigorous, empirical sense of inquiry. The

challenge of course, for rehabilitation researchers, is how to best integrate these two

dimensions of their work. In the present paper we have drawn from the social psychology

literature on goals and motivation, to illustrate that there already exists a rich and

sophisticated body of theory with a sound empirical base, that relates closely to goal-setting

in the field of rehabilitation. There are also real benefits for social psychology in a closer

dialogue between the two disciplines. Much of the literature in social psychology is based

upon research with North American college students. This severely limits the generalisability

and external validity of these theories. Emmons himself has commented that 'Rarely have

studies on goal content…included non-college-based samples' (p.318) 17. What better real-life

laboratory for testing scientific theories on goals and motivation than the rehabilitation

setting?

Developing a comprehensive research agenda that bridges the two fields is somewhat

beyond the scope of the present discussion. Consequently, we will conclude this article by

suggesting just a single example of a relevant research issue on goal-setting in rehabilitation,

19
 Motivation and Goal-Setting

that arises directly from each one of the three theoretical approaches to goals and motivation

that we have previously described. The work of Deci and Ryan makes some assumptions

about the relative merits of intrinsic versus extrinsic motivation. An obvious issue for

researchers here would be to determine whether goals in rehabilitation settings can, in fact, be

reliably categorised in these terms. Then, assuming that they can, it would be fruitful to see

whether intrinsic goals actually associated with better outcomes than extrinsic ones? The

work of Emmons emphasizes personal strivings, goals and subjective well-being. One

important issue that follows directly from this theory concerns the relationship between

personal strivings, the abstractness of goals and personal well-being. In other words, how do

we best establish a client’s meaningful, higher order goals and then help them to achieve

these through more specific and concrete lower level goals and tasks? Most importantly, if

we can achieve this fit, does it actually lead to improved psychological well-being for clients?

Finally, the Karniol and Ross highlight temporal influences on goal-setting. An interesting

research application of their ideas would be to study situations where clients who had been

making steady progress became "stuck" or reached an impasse. In these circumstances, we

might wish to examine whether reviewing the client's previous life experiences with them,

could help them to develop new coping skills or have relevance to their attempts to build a

new sense of self-identity. Clearly there are many other worthwhile areas of inquiry that

could be pursued to enhance the day-to-day practice of goal-setting in rehabilitation.

20
 Motivation and Goal-Setting

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