This is a concept that has been stewing within me for some time. Bubbling beneath the surface, slowly making its way up.
Part of the reason that I think it’s taken some time to express itself is that in many ways it runs counter to our cultural beliefs, as well as what we’re directly taught during our training.
It finally surfaced in the form of a question that appeared in my mind recently as I was taking a walk:
Is it possible that goals hinder progress?
In this article, we’ll discuss
Some limitations of goals
How to implement this shift in thinking into our practice and our lives
Limitations of Goals
Let’s start with the most pressing thing— what’s wrong with goals?
There are a few important limitations of goals.
1. Goals restrict our happiness
They do this by tying our happiness or our feeling of success to an outcome, and outcomes always exist in the future.
When we focus on the future we’re taking the stance that the present isn’t enough, that we need more in order to feel happy or successful. We’re essentially creating a narrative in which life isn’t good enough right now, and it will only be good enough once we achieve some future thing
This is not a recipe for happiness. Quite the opposite in fact.
2. Goals create a binary relationship with success
When we have a goal—a particular outcome that we want to achieve—we create the dichotomy of success or failure. Even if we make tremendous progress toward this goal, if we don’t fully reach it, we’re often disappointed on some level because we had a goal (an expectation) that was not fulfilled.
All-or-nothing thinking like this tends to not be very helpful, in part, because it’s not concordant with the way the world actually works. In reality, everything is a spectrum, a gradient. Nothing is truly black or white, all or nothing.
3. Goals often lead to the finish line effect
The finish line effect refers to what happens when we reach our goal: we often stop.
As physical therapists, we see this time & time again: a person is in PT, doing their exercises, moving and grooving. Then they reach their goals, get discharged from PT, stop moving (and more tragically, they stop grooving), and the problem returns.
This is because the focus was on the goal, the outcome. Once the goal is reached, there’s no longer something to focus on & the whole thing falls apart.
So why do we do this? Why do we engage in this cycle of hope and disappointment, victory and disarray?
Why do we focus on goals so much?
It’s no surprise that we tend to focus on goals so much. There are many forces at play that lead to this phenomenon. Let’s look at some of them.
For us PTs, one main reason is because of the systems that we find ourselves in.
For the majority of our profession who is not in a cash model, it’s a basic requirement to prove to the payer (the insurance company or government agency) that what we’re doing is effective. This is largely done through tracking outcomes. When we’re tracking outcomes and seeking to optimize outcomes, we naturally focus on the outcomes.
2. Our training
In school, we’re taught the importance of goal-setting. Specifically, setting goals that are measurable and set for a particular timetable.
I can only speak for my program, but goal setting, and especially ‘proper’ goal setting was drilled into our heads. As a result, my patients’ goals (where we want them to be in the future) were at the forefront of my mind quite often when working with them.
3. Our culture
In western culture, we tend to focus on what we want over what we have. Getting more, achieving more, being more are built into our everyday lives in the most basic of ways.
In this cultural context, it’s quite natural for us and our patients to focus on the goals—the hopes, the expectations, the desires for the future.
And so, with our goals & the patient’s goals in the forefront of our mind, we march forward, intent on making things better. Better than now, maybe even better than before. But definitely better.
But this isn’t the only option.
Instead of focusing our attention on the goals, on the future, what if we focused our attention on what’s right in front of us?
What if instead of the outcome, we focused on the process?
Benefits of a process-focus
Focusing on the process provides many obvious benefits, which fall into three categories:
We simply have more control over the process than we do the outcome. Why? Because the process is here right now, while the outcome is out there in the future.
When we focus on the future we tend to miss the present. We’re less nimble, less able to learn and adapt to the present circumstances because our awareness is not here and now.
Focusing on the process allows us to learn from and adapt to the circumstances as they come and as they change.
Perhaps the most distressing aspect of an outcome focus is that because it’s out there in the future, it can feel out of reach, and provides us with no guidance on how exactly to get there.
This can be distressing for the patient, as well as for us. I can clearly remember the pangs in my chest as my mind compared the patient’s current state to their goals, “How can I possibly get them from here to there?” my mind would wonder as it sped up with anxiety.
The process, on the other hand, is actionable. It’s something to do, not just something we want. Focusing on that which we have some control over and taking steps is anxiety-reducing.
Focusing on the process allows us the flexibility to change our mind.
When we’re laser-focused on some far-off goal, we might not often stop and ask— do I still want this? When we’re focused on the process—on what’s happening right now—we might discover that our priorities are shifting, as they tend to do over time.
As we loosen our grip on the outcome we can let the process guide us, allowing our priorities and desires to move and change as they do naturally.
“When you fall in love with the process rather than the product, you don’t have to wait to give yourself permission to be happy.” -James Clear
The real problem with goals
Ok so now’s the time for some clarification. This is the part where we talk through some nuances of this concept:
1. There’s nothing wrong with having goals
The desire to change and grow can be a healthy force in our lives propelling us to become that which we know we can be.
The real problem arises with the attachment to the goals, or the focus on the outcome at the expense of the process.
Focusing on the outcome at the expense of the process can quickly become counter-productive, as we waste our energy thinking about the future instead of taking steps to get there now.
2. There’s nothing wrong with tracking outcomes
Outcomes give us feedback, help us learn, and are useful for research.
Again, the problem arises when our focus becomes the outcome at the expense of the process. It’s absolutely possible to track outcomes without over-focusing on them.
3. A process-focus is not a renunciation of goals, hopes, or aims
In fact, the beauty of a process focus is that the goal is built-in.
Because without an aim, there would be no process. You can’t have a process for nothing, leading nowhere.
So of course the first step of the process is deciding what you want, but then the focus must shift from the what to the how; and there it should stay until the what changes.
How will we know if the goal changes if we’re focused on the process and not the outcome? Simple: we will lose the desire to engage in the process to get there.
So while the goal sets the direction, and is a necessary step, the process is what actually leads to progress.
Simple but not easy
As straightforward as this sounds, staying focused on the process can be quite tricky
Just pay attention the next time you exercise. Let’s say you’re bench pressing and you have the goal of performing 8 reps, or maybe you’re running and you have the goal of running 3 miles.
Pay attention to how many times your mind jumps to the future:
“Oh this is easy, I can definitely get there.”
“This is getting harder, will I make it?”
“I’m not sure if I can.”
“I can do it, I’m tough.”
“Am I tough enough?”
Or pay attention the next time you have a goal related to work. Let’s say you have a presentation coming up and you want it to go well.
As you engage in the process of creating the presentation, pay attention to how many times your mind jumps to the outcome:
“Oh I hope this goes well.”
“They’re going to love it.”
“What if they ask hard questions?”
“They’ll be supportive.”
“But what if they ask a genuine question that I don’t know the answer to?”
Or simply pay attention the next time you eat. When we eat, we often have the implicit goal of getting full, which makes sense; it’s part of our biology to get enough calories to survive and thrive.
As you engage in the process of eating, pay attention to how many times your mind jumps to the outcome:
“Do I have enough?”
“Will I get enough?”
“I hope I don’t eat too much.”
“This is so good, I’m definitely going back for seconds.”
Some of our inner dialogue is encouraging and positive, some of it isn’t. Positive, or negative, focusing on the future pulls our attention away from what’s happening right now, making us less able to adapt to the present circumstances
What if we were able to stay with the process without the imposition of the future? How well could we perform? What could we accomplish? Could we have a more peaceful relationship with life?
How to shift the focus
So how do we do this? How do we help the people we work with maintain a focus on the process so that they can have more control, flexibility, and peace? And how do we get a slice of this for ourselves?
Let’s talk through some ways of doing this.
1. Cultivating Process Awareness
In order for our patients to focus on the process, they must gain awareness of the process.
This requires us to be aware of the process and to share it with them. One way of doing this is by sharing our specific processes (how we operate) with them.
Specific process awareness
For example, whenever I meet a new patient I ask them if they’ve been to PT before, and I tell them what the initial visit looks like:
“We have 90 minutes together.
We’ll start out by chatting to get a picture of what’s going on.
Then we’ll do some movement and testing, and likely some treatment.”
We can also share our process of examination and treatment with people.
For example, before I start the physical exam, I give the person a run-down of what the examination process looks like:
“So first I want to get a clear idea of what you’re feeling right now, this is called your baseline.
As we test, I need to know what you’re feeling and how things are changing. So we’re going to be returning to the baseline as well as some other tests throughout the process to see if things are changing.
The most important thing is that you pay attention to what you’re feeling as we go through this process.
Does this make sense?”
And when explaining the treatment process, I often revert to a simple analogy
“The beautiful thing about the body is that it adapts to the stressors that are placed upon it.
Stress is actually good for our bodies, but it needs to be the right amount of stress. Too much, or too little stress can lead to problems.
So what we need to do is find your Goldilocks zone and stay in it.
Sometimes that means doing more of some things
Sometimes it means doing less of some things
Almost always it’s a combination of both.”
All of these mini-discussions about the various processes we encounter in PT serve to anchadaor our attention on the now—on the process. They also help the person become aware of my processes so that they can learn my processes and eventually use my processes on themselves.
As mentioned earlier, before we can share our processes with people we must first be aware of what our processes are. This often requires some healthy reflection about what we really think we’re doing with people and why.
General process awareness
Another method of building process awareness is by speaking about processes more generally. I have a metaphor that I like called The Mountain Metaphor, which goes a lil something like this:
“When you’re starting to climb a mountain, where should your focus be?
Should your focus be on the peak of the mountain & how many steps you’ll have to take to get there? No, that’s not so helpful
Should your focus be on the base of the mountain & how few steps you’ve done so far? No, that’s not so helpful either
So where should your focus be? Probably on the step right in front of you.
I’m your sherpa. I’m climbing with you.
I’ve never climbed your mountain, but I know how to climb mountains, so we’re going to figure it out together, one step at a time.
The closer we get to the peak, the more you can lift your gaze, but it’s important to continue to focus on the step right in front of you.”
Metaphors can be great for understanding concepts because they use imagery to paint a vivid picture.
Additionally, when metaphors are introduced, they can be returned to again and again to help us stay on track. During times when my patient falls back into an outcome or future focus, a simple excerpt can help bring them back to the process.
“The mountain’s looking tall, huh?”
“Yea, we’re still just beginning to climb the mountain, what if we just focus on the steps we’re taking now?”
2. Setting (& Tracking) Process Goals
Another key way we can cultivate a focus on the process vs. the outcome is to set process goals.
Instead of the outcome goal: Patient will walk 1 mile with normal gait mechanics and without worsening of pain.
We could set the process goal: Patient will walk 3 days/week, starting with 5 minutes and progressing by 10% each week.
The process goal includes where the person is right now and allows for them to continue with this goal long after they meet the arbitrary 1-mile mark.
And the simple act of tracking process goals keeps us focused on the process rather than the result.
As this person continuously shows up for their thrice-weekly walks, tracking this will create evidence of success. They will see the evidence of their commitment and their progress amass.
A simple habit tracker can be a very powerful tool for staying motivated.
When we shift focus to the process, the goal becomes progress, not perfection.
3. Responding to Future-Focused Talk
Another simple way we can help people stay anchored in the present is through our communication.
How many times have you heard some variation of the following statements?
“I just want the pain to be gone.”
“I just want to be able to walk.”
“I don’t know if I’ll ever be able to work again.”
“I don’t know what I’d do if I couldn’t run anymore.”
All these outcome-focused statements are understandable, and they give us a window into how the person feels and what they want. But ultimately, they don’t help the person very much because they have little to do with what can be done right now.
So when we hear outcome or future-focused statements, one way we can respond is by asking an open question that redirects them to the present.
Using the example, “I just want the pain to be gone.” We could ask:
“What do you think would help right now?”
“What do you feel that you need right now?”
“What do you think the pain is telling you in this moment?”
Using the example, “I just want to be able to walk.” We could ask:
“What steps can you take right now to get there?”
“How can you move toward that today?”
Infused in all these questions is language that is anchored to the present, beckoning the person’s attention to the here and now, where something can be done to change things (if that’s what they want).
While it can be helpful to redirect someone’s attention to the present, I believe it’s even MORE important to make sure that they feel heard. So please don’t think that you need to redirect every future-oriented statement to the present.
There’s an episode of the show Parks & Recreation in which every time one character (Anne) vents to her boyfriend (Chris), he tries to fix it. Eventually, she says to him, “Sometimes I just need you to say, ‘that sucks.’”
Sometimes when someone says to me, “I just want the pain to be gone.” I’ll just say, “I hear you.”
4. Formal Practices
Formal practices can be a useful tool for cultivating the skill of presence. When done consistently they become a habit, which can lead to a more baseline level of presence or process-focus.
One such practice that I learned from a PT friend of mine, Justin Ternes, is called checking in. He does this with pretty much all of his patients and reports great results.
The practice is very simple:
You start by checking in with the body, naming out loud 2-3 sensations that are present in the body
You then check-in emotionally, naming 2-3 emotions that are present
The intent isn’t to change anything, but merely to become aware of what is already there.
This can be done formally, by starting and ending each session with a check-in and peppering them throughout when needed. This can also be done informally, by inquiring about what the person is experiencing at a given moment.
For instance, if you notice distress in the person you are working with, you could ask:
“What are you feeling right now?”
“What’s coming up for you?”
“What does that mean to you?”
Formally or informally, checking in anchors our attention to the present, where the process lives, and can get us unstuck from the future, where our fears and expectations live.
Another method for cultivating presence, process-focus, or mindfulness—another word for it—is meditation.
Mindfulness meditation is simply the practice of becoming aware of what’s going on right now, which involves continuously bringing the attention back to the present moment when it drifts off.
A little experiment that I love is to see how many breaths you can count without getting distracted. To do this, simply bring your attention to your breath and count each inhale-exhale cycle. See how many you can count in a row without losing focus on the breath, even for a moment.
Give it a shot right now.
On a good day, I can get about 1 before my attention is drawn elsewhere. As my practice has deepened over the years, I’ve noticed that I don’t get lost for nearly as long (fractions of a second vs. several seconds or minutes), but I still lose focus quite quickly.
This is the nature of the human mind. Maintaining complete uninterrupted focus is extremely difficult, especially volitionally.
The practice of meditation is not to learn to control the mind, it’s to become more aware of it so that even if we are lost in thought about the future or the past, we are aware that we are thinking. This is a process focus in the truest sense.
I do prescribe meditative practices to my patients when it’s a good fit. I will provide them with app recommendations, written instructions, or my own guided meditations depending on what works best for them.
If you’re interested in reading more about meditation, check out my article on clinical reasoning where I deep-dive into meditation.
Modeling is perhaps the most important, and the most subtle method for helping people change their behavior.
The principle here is that the more we are anchored in the present, the more those around us will follow suit. Or perhaps the opposite is easier to conceptualize: we shouldn’t expect our patients to be more present or process-focused if we ourselves don’t have such presence or focus.
The beauty of modeling is that when we ourselves are living what we are helping people with, we not only lead through example, but we understand on a much deeper level what it takes to do what we say, and thus we can better help people navigate the intricacies. We also tend to have more compassion for their challenges, because we’ve been and go through similar challenges on our own path.
Questions we can ask ourselves in this context are:
In what areas of my life do I have an outcome focus? What would it look like to shift my focus to the process?
What does it feel like to have an outcome focus?
What does it feel like to have a process focus?
The more we become the living example of what we are intending to help people with, the more seamlessly this will occur. This is never more true than when talking about presence, because the more we’re focused on what’s happening now, the more we can flexibly adapt to the present circumstances and provide our patients with high-quality care.
Some of the problems with goals are that:
They restrict our happiness
They create a binary relationship with success
They often lead to a finish line effect, where we stop engaging once we reach our goal
We tend to focus on goals:
Due to the systems we find ourselves in
Because we’re taught to in our training
& because of our culture
A focus on the process is beneficial because:
We have more control over the process than the outcome
Focusing on that which we have control over and taking steps is anxiety-reducing
And focusing on the process allows us the flexibility to change our mind
The real problem arises not from merely having goals, but from focusing on our goals at the expense of the process
Once the direction is set, the focus should become the process. This is what leads to progress.
Ways of shifting the focus to the process include:
Cultivating process awareness
Setting and tracking process goals
Asking questions that lead to the present circumstances
Engaging in formal and informal practices
Modeling presence to our patients
Thanks so much for reading!