Open Talk is a framework designed to support open decision-making between children, young people and mental health professionals in inpatient and community mental health services. It helps guide practitioners to have collaborative discussions about their wishes, motivations and goals in mental health to facilitate better decision making. Once a goal is reached the goal-based outcome (GBO) tool can be used to monitor progress.
A full slide set describing the Open Talk framework can be downloaded here
Great to see the interest in the goal-based outcome (GBO) tool across the globe in 2019. The tool is now translated into: Portuguese, French, Norwegian, and Japanese. Welsh, Irish and Russian versions in progress and soon to be followed by Italian and Spanish. If you are interested in translating the GBO and/or the guidance notes , get in touch using the contact form below.
Many people, involved with mental or physical health settings, might get input from more than one person in a team, at the same time. This is certainly true for people with more complex needs and particularly those who require inpatient services, but may also be true for people with severe issues.
I am often asked how best to work with setting and tracking goals for people who get input from a team and not just an individual practitioner. In mental health, this could be a young person involved with a Mental Health Support Team, based in a school, or a young person who is seen by a clinic-based team. If the young person has severe anxiety for example, they may see a practitioner for individual CBT, but also be involved in a family intervention with a systemic therapist, and see the psychiatrist for medication. The issue the team is working on with the young person is related to their anxiety, but each clinician is working on a different aspect and bringing a different set of skills to help the young person and their family. The overall goal of the young person may be “to be able to get back to school”,or “go out with friends”,or “go on a school trip”.The team input is to work to help them manage the impact and/or reduce the symptoms of the anxiety, in order for them to be able to reach their goals.
In physical health, this could a person suffering a fractured hip that may require surgery, psychotherapy and input from a pain specialist to aid their recovery. Again, the presenting issue is the same but each individual within the multidisciplinary team (MDT) brings something different to the persons recovery.
In both these cases it would be possible to set goals with the person at a team-level or an individual practitioner-level. For example, the overarching goal at a team-level for a person with a fractured hip may be, “to get back to being able to walk effectively”.At an individual practitioner-level, the sub-goals may for: the surgeon to complete a successful hip replacement, the physiotherapist to help improve mobility after surgery, and for the pain specialist to help manage the discomfort along the way. In this example it is easy to see how the team could set and track team goals with the patient“I want to be able to walk effectively again”or the individual practitioner-level goals of “get my hip replaced”,“Improve movement in my leg”, “reduce the pain” respectively.
Often, in mental health settings, the individual practitioner’s specific role may seem less clearly distinct within the team although their mechanisms for helping will be different: CBT, family-work, medication. However, the same possibilities of goal setting at a team-level: “I want to feel less anxious”or at an individual practitioner-level are possible and applicable: “I want to be able to manage my unhelpful thoughts”, “I want my family to help me challenge the habits I use to feel less anxious”, “I want to reduce the extreme fear that stops me challenging my thoughts and habits”etc.
Which is best?
The next question is, “Which is best?”: is it better to set team goals or individual practitioner level goals? The answer to this question is that it depends on what the purpose is for setting and tracking goals, and what information you want to get? What do you want to know as a team, what might individual practitioners want to know and, most importantly, what will be helpful to the person receiving the service?
There are real advantages to setting team goals – particularly when working with young people in mental health settings. We know young people tend to feel responsible for their mental health issue and setting personal goals might increase anxiety as young people often feel that they are solely responsible for making progress to their goals. Young people often feel that they are failing they aren’t making quick and positive goal progress, yet we know as therapists, that progress (or lack of it) in therapy is down to a range of different factors: the context in which the young persons difficult exist (social deprivation, housing, social care issues), the level and quality of help form others around the young person (professionals, family and peers), as well as the young persons personal attributes. Setting goals that make it clear that there is a team working with that young person can help reduce anxiety around goal progress – it is no longer down to how good I am, it is down to how good my team is. (See the great resource ‘Mapping team goals’ from Vicky Eames and David Denborough)
The other reason for choosing to set team-level goals relates to the information you want to get from tracking goals: are you more interested in understanding if the ‘team’ is being helpful? This is often the important question for service leads and commissioners. They are usually more interested in knowing if the team is helpful, on the whole, and don’t usually want, or need, to know about individual practitioners. In this case setting and tracking team-level goals may be the way to go. Or, if you are more interested in knowing if individual practitioners are being helpful, then setting goals at an individual practitioner-level may be the best thing to do.
Practitioner-level goals help answer the question, “How helpful am I being?”or, at least, “How helpful is this approach?”. These are really helpful questions for practitioners to ask, to help assess if there is something different they might need to do to be more helpful. Discussing this with the young person is really helpful – and an often underestimated clinically skilful thing to do well! And, taking these questions to supervision with information from tracking goals using the goal-based outcome (GBO) tool, to support the discussion, is a great idea too.
Of course, it is perfectly possible to set and track both team-levelandpractitioner-level goals – as we saw from the two examples at the start of this piece. There is much written on setting and tracking practitioner level goals (see Law (2019) The goal-based outcome (GBO) tool: guidance notes here). Setting and tracking team-level goals requires a little more planning to do it well.
Setting team-level goals
If you do decide to go down a team-level goal setting it is important to think through how this will be done, when and by whom? In services that use the Choice and Partnership Approach (CAPA) (See here for more information) this is usually done at the ‘Choice’ appointment but could be easily done at assessment, in more traditional setting. The team would need to be clear who would need to be involved in the appointment where team-level goals where set. The meetings would need to involve team members who understand what was possible for the team to offer and for the agreement on goals to have authority across the whole team. The actually process of setting team goals is the same as setting practitioner-level goals – i.e. it should be within a collaborative, shared-decision making framework (see the great resources from Open Talk).
Once you have your team-level goals there is nothing to stop individual practitioners setting sub-goals with a person about what they might specifically hope to achieve to help the young person reach the team-level goal. It might be helpful to think about a hierarchy of goals, with the team-level goal being of a higher order than the practitioner-level goal (see Cooper and Law (2018) for more discussion on this issue).
Tracking team-level goals
Once a goal has been set it is possible to use the goal-based outcome (GBO) tool to track progress in the usual way. With team-level goals you just need to think through when these will be reviewed. In in-patient settings, team-level goals are reviewed at weekly ‘ward rounds’, in community work, goal progress can be tracked at ‘review’ meetings. What is important is that young people don’t get overloaded by every practitioner they see asking them to rate a team-level goal every time they have contact with them. In some services this could be daily, which would probably not be helpful and certainly get a bit annoying for the young person!! Again, it just needs a bit of planning and coordination – but there are no hard and fast rules on this.
Sharing your experiences
We hope you found this blog useful and we would be really keen to hear your experiences of setting and tracking team-level goals. Please level comments to this article or even better, consider writing a blog of your own and we can link it this one. In this way we all learn from each other – and that’s how things really start to improve!