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.
TABLE 1: SMART Goals
S: Specific, significant
M: Measurable, motivational, meaningful
A: Achievable, attainable, appropriate, ambitious
R: Relevant, realistic, reasonable
T: Timed
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.
