Ah, goals. We all set them for ourselves. Do I even need to tell you how many times I have vowed to get up 15 minutes early to meditate every morning or given up cookies? More often than not goals require too much additional energy and not enough failsafe measures to be sustainable. Human nature dictates that we be slightly more optimistic about our ability to achieve plans than is warranted; and there is something so lovely about this optimism.
But, as clinicians, we are bound to serve patients better than we serve ourselves, guiding a more practical goal-setting process with our eyes on incrementally better health and well-being. Tethering ourselves firmly to reality, we teach that sustainable change is microscopic, intermittent, glacially slow and of course, SMART (specific, measureable, achievable, relevant and time-based). Unfortunately, setting a goal to eat at least 3 servings of vegetables each day just doesn’t pack the same dopamine punch as declaring oneself Paleo. We have a marketing problem in behavioral health—the approach that works lacks something– and many patients are going to pass on it in favor of more extreme steps (think 3 weeks straight of eating only kale) or doing nothing at all.
How do we sell incremental change to patients facing weight gain, obesity, diabetes, hypertension, insomnia, depression and more? When we break the news that sustainable change involves the gradual adoption of new behaviors over an extended period, how do we convince patients not to disengage and how do we help make follow through more likely? Of course, the answers are multiple and complicated but I propose that success is more likely when we add two more “S” words to our acronym: sex appeal and support. Sure, it makes a terrible acronym unless you love hissing sounds (say SSSMART aloud right now), but it puts our clinical education and experience to good use every time.
Sustainable change involves the gradual adoption of new behaviors over an extended period
Let’s talk about sex appeal. I don’t necessarily mean getting laid (though it is certainly ok if consensual sex is a driving force for the patient). More broadly, the term can indicate that something has potential to interest or excite an individual. It takes SMART’s “r” (relevant) to the next level. Most people, unless they are clinically depressed, can identify something that engages or excites them. It may take some evocative questioning but there is often a hobby, event, experience or person—be it bird-watching, a cherished friend or partner, dancing at an upcoming wedding or a trip to a far-off place—that creates a spark of interest. Once the patient has identified their spark, drawing a connection between it and a health-promoting behavior is relatively easy. “Oh, you would love to dance all night with your partner at your daughter’s wedding but you are worried you will get too tired? You have 5 months, let’s break that down into steps to help you get there.”
Our other S, Support, can sometimes be more challenging to identify but is worth the time and gentle questioning it takes. The question, “who can you tell about your plans to do (insert step/goal)?” is a good start. I sometimes follow it with questions about if the new behavior is something they can do with their support person (ideal), if they will provide encouragement (also great) or if they are likely to criticize them if they do not accomplish it (I try to avoid patients using this type of person as their identified support). Above all, this “S” reminds us that context and environment are everything and if nobody can be identified as a natural support for the new behavior the chances of success are much lower.
I am always aware that at least half the time I may not see the patient in front of me again—life happens, after all. While I encourage returning for another visit in a few weeks for additional support, goal-setting and problem solving, I am always sure to type their SSSMART goal in their after visit summary. I like to joke that if they fold it in half it would make a reasonable bookmark—aware that within the back and forth march toward change you never know when a long-forgotten bookmark will become a reminder of what is hoped-for and possible when we take it one step at a time.
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