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Guidance notes for using the goal-based outcome (GBO) tool

Introduction

The goal-based outcomes (GBO) tool is a simple and effective method to measure progress and outcomes of an intervention.  It grew out of work with children, young people and their families in mental health and emotional well-being settings but can be used in any setting, that is change-focused and goal-oriented – including adult and physical health contexts.

The tool tracks what is arguably the most important thing to measure in any intervention: “Is this helping you make progress towards the things that you really want help with?”

The term ‘young person’ is used throughout this document. It is used as shorthand to refer to any young person: ‘child’, ‘youth’, ‘parent/carer’, ‘adult’, who may come into contact with your service.

This guidance is adapted and updated from Law and Jacob (2015) and Law (2018).

When referencing this document please cite as:  Duncan Law (2019) ‘The goal-based outcome (GBO) tool: guidance notes’ 

This Guidance is soon to be published in hard copy in early 2019.  Please follow http://www.goals-in-therapy.com to keep up to date with publication details.

Guidance Notes

1.   Primary purpose

  • The goal-based outcomes (GBO) tool is a tool to help facilitate collaborative goal-oriented conversations & to help track progress towards goalsand facilitate further collaborative goal-oriented conversations.

2.   The goal-based outcome (GBO) tool

  • The GBO tool is a simple and effective method to measure progressand outcomes of an intervention.
  • It can be used in any settingthat is change-focused and goal-oriented.
  • It can be used to track progress session-by-session, or just as an outcome tool
  • The GBO is a tool that measures the changes most important to the personyou are working with.
  • The tool was devised in children and youth mental health services in the UK but has been used successfully internationally and across adult and physical health settings

3.   Shaping and setting goals

  • Goals should be agreed collaborativelybetween the therapist, counsellor, clinician or practitioner, working with the young person or family and the person asking for help.
  • Once a goal has been set it is possible touse any suitable (preferably evidence based) interventionto reach it.
  • Thefirststep is to identify potential goalsand then shape these into agreed goals for the intervention
  • At the point where you feel the young person/family have told you enough initial information it can be helpful to start to introduce goalsby saying something along the lines of:

“That has been really useful to help me understand a little about what has brought you here today; next it might be helpful for us to think together about what your hopes for the future might be”

  • What comes out of the following discussion can begin to be shaped into goals:

“So, from what you have told me so far, what would you say your main goals are from coming to this service? If we were to work together in a very helpful way, when we agree to stop meeting, what things would you hope to be different in the future from how things are now?”

  • Once a goal has been agreed it is useful to write it downin a sentence that summarises it – ideally using the young person’s own language
  • Helpful goals tend to be future-focused, positively framed and realistic
  • Helpful goals could focus on:
    • Change goals– goals that focus on something someone wants to be different or change in their lives – most therapy goals are ‘change goals’
    • Learning goals–getting ideas that might help with the issues even if these might not lead to (immediate) change
    • Exploration or understanding goals– these might be goals that focus on the young person wanting to understand themselves better, or to explore who they are. These may lead to change but this is not the primary focus of the work
  • Make sure the goal is safe for the young person and others
  • Set up to three goals
  • You can write the agreed goals on the GBO ‘goals record sheet’

4.   Rating goals

  • Once a goal has been set the next step is to get the initial (time 1 or baseline) rating for the goal.You may want to say something like:

“Ok, now we have agreed the goals you want to work on, it would be helpful to get an idea of where you are now with each of the goals. This will help us get an idea of where we are starting from, and what you have already managed to achieve, and it can help us keep track of howfar you have moved on, at a later date”.

  • You maywantto specify at this point how oftenyou would expectto review progress towards the goal – every session, at review, at the end of the intervention, etc.
  • You can invite the young person to rate their goalsby saying something like:

“Taking your first goal: on a scale from zero to ten, where ten means that you have fully reached your goal, and zero means you haven’t even begun to make progress towards it, and a score of five is exactly half way between the two, today what rating would you give your current progress towards this goal?”

  • It can help to make the scale visualby showing the young person the GBO rating sheet with the numbers on, or by drawing a line on paper or a white board
  • Younger children might prefer a visual metaphor such as a ladder with the numbers 0 – 10 on the rungs
  • It is important to have the ending of therapy in mind at the first rating of goals. Make sure the young person understands that you do not expect goals to reach ten-out-of-ten, but you intend the work to help them move at least a little way along the scale
  • Write the agreed ratings on the GBO goal rating sheet

5.   If goals change

  • Goals can changeduring the course of an intervention and the work should change focus accordingly, if this is helpful
  • Use your clinical judgement,in conversation with the young person, before a decision to change focus is agreed
  • Consider how clinically helpful it really is, if goals change regularly throughout an intervention
  • It can be helpful to discuss potential changes in goals with a supervisor or a colleague
  • Depending on the type of intervention you are working on with a young person, you may want to formally reset the goals and start rating the new goals
  • Use your judgement as to whether it is helpful to continue rating the original goals

6.   Session-by-session monitoring of goals

  • Goals can be rated every sessionusing the GBO to track progress throughout an intervention
  • Use your judgement, in conversation with the young person, about when in a session the right time to rate goals might be – usually this would be in the first half of an appointment
  • It might be helpful to introduced rating of goals each sessionby saying:

“OK, let’s have a look at where you feel you are at, with the goals we agreed on at the start of the work together. Let’s look at goal one first, which was to… (insert goal summary sentence) – on a scale from zero to ten…etc…, today how would you rate your progress on that goal?”

  • Once the rating has been obtained it may be helpful to compare it to last week’srating and discuss as appropriate
  • Keep a record of progress by writing the ratings on the GBO goal progress chart
  • By connecting the ratings on the GBO goal progress chart you can create a simple run chart that can be shared with the young person and/or in supervision
  • Tracking and discussing progress regularly allows the therapist and young person to monitor progress together
  • When using the GBO session-by-session, the intention should be to rate goals every time you meet with the young person. However, there may be times when it is not possible, or when it does not feel clinically helpful to rate goals in a session – use your clinical judgement, in conversation with the young person, to decide whether to skip rating for a session
  • Sharing the information in sessions can lead to helpful discussions about what, and who is helping the young person to reach a goal and how this progress can be maintained. Conversely it can flag if there appears to be no progress, or if things appear to be moving away from a goal. This can lead to helpful discussions about what or who else might help.

7.   Lack of progress towards goals

  • If there is a lack of progress towards goals it can be helpful to revisit the goals themselves:
    • Are the goals set at the start of therapy still relevant to the young person?
    • Has the context around the young person changedand affectedtheir goals?
    • Are the goals too ambitious?
    • Are they focusedenough?
    • Does the young person understand how the therapy might help them reach their goals?

8.   Psychometric properties

  • The GBO is an ‘ideographic’measure, this means that as everyone’s goals are different and unique to them, so what is measured using the GBO is unique or particular to that person
  • The GBO scoring is ‘ipsative’meaning that changes in ratings are compared to the initial ratings by the person. You are comparing the ratings with themselves, rather than to some external ‘objective’ change score
  • The tool has good ‘face validity’, in that it makes sense to people using it, that it is measuring progress to their goals
  • Changes in GBO ratings have been shown to correlate well with symptom change measures using other tools such as the SDQ (see Wolpert et al 2012)
  • The GBO has a suggested reliable change index (RCI) of 2.45. (Edbrooke-Childs et al. 2015) 

Using the GBO as a measure of single-session interventions, consultations & advice

The Goal Based Outcome (GBO) tool is most widely used as a tool to monitor progress across a series of sessions or as an outcome measure used at the start and end of an intervention.  However, is is becoming increasingly well used as a measure of change or usefulness of a single-session. 

Increasingly health practitioners (both in mental and physical health) are providing single-session interventions. Most typically these are one-off sessions to offer advice to a person or family. These might be in the form of drop-in sessions where the client comes to seek specific advice or knowledge about an issue or problem; or they might be more exploratory sessions where a person comes with a concern or issue and wants to think through possible options that might be available to them.  In the language of the Choice and Partnership Approach (CAPA) (York and Kingsbury 2016) the latter might be thought of as a ‘choice’ appointment  – where the person and practitioner talk together about the issue to understand it better and think through possible options about what might help to change things – these might include self-help or community based interventions, or professional support though health, social care or education. Or they might be in the form of one-off consultations to other professionals. Either way, using  the GBO can bring clarity and a quick and easy way to monitor the effectiveness even of a one-off session.

Drop-in advice sessions

As with any intervention it is helpful to monitor the usefulness of the approach.  With single-session interventions the GBO can be used at the start of the session and again at the end to track how helpful the person seeking advice or help has found it.  The goal is set by a brief discussion at the start of the session about what the person’s hopes or goals of the session are. These are likely to be shaped around the context of the service. For a drop-in service, goals might be shaped around the helpfulness of the ideas given, in addressing the issue the person had come for help with.

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For example, a health visitor might hold a single session drop-in service for under 5s, and a parent might come with concerns about their child’s sleep. The health visitor would ask, as usual, what the person was coming for help with. The parent might respond that they are concerned about their child’s sleep and want some advice  – a goal is easily shaped by asking “if this drop-in session is helpful what do you hope to go away with at the end of the session?” The parent might respond “I want to leave with ideas about how to help my child get to sleep at night”.  This is a clear goal for the session and can then be easily rated by asking, “So if you were to rate how many ideas you feel you already have around getting your child to sleep – on a scale from zero to ten where ten means you’ve got all the ideas you need and zero means you don’t feel you have any and five is exactly half-way between the two – where would you say you are at this moment?” Asking the question serves to suggest that the parent might well already have some ideas and also serves as a baseline of where the parent is at the start of the session compared to where they might be at the end.

The session then runs as normal but in the last minute the goal is re-rated by asking “Remember right at the beginning of this drop-in session I asked you to say what would make it helpful and how you rated where you were at, where would you say you are now, using the same scale…….?”. Once again, asking the questions serves a clinical purpose of demonstrating care and interest, and by rating it on the GBO scale it also allows this ‘usefulness’ to be quantified and recorded to monitor the effectiveness of the drop-in session and over time, of the service as a whole.

Choice appointments

The same ideas can be used to track the usefulness of choice appointments in offering people the understanding and options to move forward with an issue. In this case the goal might be more around “I want some understanding about my issue and options as to what might help” (these could be rated as one overall goal of the session or could be split into two goals: one about ‘understanding’ and one about ‘options for help’). The rating would take place in the same way as above: asking the person to rate their understanding and ideas about options for help they already feel they have and then re-rating these in the last few minutes of the session. The goal setting and rating takes a matter of minutes and by making the session goal explicit in this way brings focus to the task of the session that both practitioner and client can agree and be clear on.

Professional consultations

Exactly the same approach can be used in professional consultations  – asking about goals at the beginning of the consultation session brings clarity and focus and agreement on the consultation task at hand. Using the GBO scale at the beginning and end of the consultation can quickly quantify the usefulness (or otherwise) of the consultation without the need to use often cumbersome and rarely completed, follow-up measures.

Using GBOs in Derby Integrated Family Health Service – Leanne Millard

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The 0-19 Integrated Family Health Service introduced GBOs in October 2016. This was in response to our Commissioner’s becoming increasingly interested in receiving evidence that the service they commission is effective, and value for money. We had also identified that as a service we weren’t so good at monitoring and evaluating what we offered. The introduction of the GBO’s supported us with this and we have since been able to evidence the excellent service and the positive difference that we are making to the children, young people and families within the City.

 

Using goals in one-off/ drop-in contacts

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In terms of measuring short term goals, we have adapted the GBO tool to capture the positive difference we make to children and families in one-off / drop in contacts.  This allows us to capture the impact of the information we deliver to families such as breastfeeding information, behaviour support, healthy eating, sleep advice etc. We have also utilised these outcome tools in one off school health drop in sessions which have been effective if evaluating our methods of service delivery and again evidencing impact to our Commissioners.

 

As a service we hope continue the use of the GBOs and outcome tools as we recognise the importance of them and the significant positive outcomes for the children and young people in the city.

Case examples

The staff within the service have embraced this way of working. Here are some case examples where the GBO and other tools have been effective.

A referral from school was received into our Central Point of Access in March 2018 requesting support with behaviour for a young person. The behaviour was uncontrollable, he had assaulted a Teacher and other Pupils, it was having a detrimental impact on his learning, and the young person was on the verge of permanent exclusion. All previous interventions the school had implemented had not been effective. A referral to a Safe Speak Service had been made but there was a lengthy waiting list.

The young person’s Mum was fully engaged with Professionals and there was a Team Around the Family (TAF) in place. It was highlighted at a Professional’s meeting that the Young Person’s Father was suffering with post-traumatic stress disorder, he also had high anxiety levels. The young person’s parents had separated, and there was a history of domestic abuse in the relationship.

The young person was seen By the School Health Team. An RCADS was completed which evidenced a high level of anxiety and depression.  An Outcome Star (My Star) was completed. The Young Person engaged well with the completion of the tool and was able to communicate his feelings well. It was evident that he was pleased he was being listened to.

Weekly contacts followed to explore the young person’s emotional responses, his coping mechanisms, exploring mindfulness activities and relaxation techniques with him. He was able to discuss how major events in his life had affected his relationships and friendships with peers. Once he had been able to reach this point and see how things had affected him, he felt it was a “turning point” and was able to work with the School Health Practitioner and work towards actions and goals to move him forward.

The young person has now shared that he feels happier and calmer. His relationships in and out of school are improving and he is able to engage better with his learning in school. He is also looking forward to starting secondary school in September.

Through the use of the GBO and outcome tools the young person was able to be at the centre of his journey, he was able to visually see his achievements and how the interventions implemented had made a positive impact upon his emotional wellbeing.

 

Another case a 16 year old that was self-harming highlighted that she needed support with her emotional health. Through initial assessment there was no indication that the young person was drinking alcohol. The School Health Nurse then introduced an outcome tool. By implementing this way of working, the young person was herself able to share that she was drinking significant amounts of alcohol, and that it was having a detrimental impact upon her life. The School Nurse felt that this would have not been highlighted as early, or at all, without the use of the tool.

The young person was then supported to the relevant service to address her drinking.

 

Leanne Millard, is the Locality Manager (area 1 & 5) for Derby Integrated Family Health Service, Derbyshire Healthcare NHS Foundation Trust

 

If you want to share your experience of using goals and the GBO please contact us using the form below:

Goals and GBO in Norway

Duncan Law, will be  travelling to Tromso in Norway in October to work with the children’s mental health services there to deliver a lecture and workshop on working with goals and the the GBO with children and families.

Duncan said: “I am very much looking forward to the visit – Tromso is very innovative when it comes to working with children and youth with mental health difficulties. I can’t wait to meet the team there and work with them and learn from them about their experiences using goals and the GBO”

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There will be a Norwegian version of the GBO published soon  – it  will be available for download here later this month.

Introducing goal-based outcome (GBO) measures to Japan – Natsuko Ukai 鵜飼 奈津子

I first received permission to translate and use the GBO in Japan from Duncan Law in 2014. I started work on the project as soon as I returned to Japan, having spent the previous year researching in London, and was actually using the Japanese version of GBO by the autumn of 2014. Time flies, it is will soon be our 5thyear of using it!

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I work at Osaka University of Economics within the faculty of Human Science where we offer a 2-year full-time masters course training to be a clinical psychologist.  Such training courses in Japan usually have a clinical psychology/psychotherapy service for local people and my idea was to use the GBO to enhance our service.

As a UK Qualified Child & Adolescent Psychotherapist, I teach basic psychoanalytic theory and child psychotherapy to the masters’ students to practice it in our service. I developed a consultation service for children and families in 2011 modeled on the Under 5 counseling service at the Tavistock Clinic, NHS foundation Trust in London. We typically offer 10 sessions, usually with a specially assigned clinical psychologist and myself, together with some masters’ students sitting in on the session to observe and learn. These sessions include listening to the child’s life history; past and current difficulties, as well as occasionally offering psychometric/developmental tests. The service users are up to 18 years of age and they have a wide range of problems such as impediments in their development, and / or relationship difficulties at school and home. In the 10thsession, we review the sessions together with the family sometimes including the child themselves, and try to make as much sense as possible of what might be going on with the child and family. At this stage, if we think it appropriate, we suggest ongoing psychotherapy for the child along with parent work.

We then discuss the GBO with those children and families who agree to accept the ongoing psychotherapy and parent work offers. The psychotherapy and the parent work are offered by the assigned clinical psychologist and trainee graduates from our masters course as well as the current masters students. We take the SDQ at the same time so that we are able to consider the child’s outside life as well as life inside the therapy. We use the GBO and the SDQ forms every 6 months during the ongoing psychotherapy and parent work.

The benefit I feel in using those forms are that both the children/families and the therapists are able to ‘see together’ what their difficulties are, and are able to share clearly why they are continuing /discontinuing the therapy. It becomes a very useful opportunity especially when the children/families and the therapists don’t agree with the goals and/or the GBO scores, as they can discuss their feelings and thoughts and sometimes reach agreements. Even when they don’t reach agreement, they can share their different ideas more positively for future prospects. What is important here seems to be the process of discussion itself through the means of the GBO form rather than simply setting up goals or agreeing with the scores.

As our service is basically a training base, there haven’t been a large enough number of service users for us to process it statistically. However, I have received some interest in using the GBO from some other universities’ equivalent services as well as ones in the public sector. I am therefore hoping to collect data together with those other services, to consider the benefits of using the GBO further.

A free to download PDF of the Japanese version of the GBO can be downloaded here GBO Japanese version 2014

Natsuko Ukai 鵜飼 奈津子  is a Professor in the Faculty of Human Science at the Osaka University of Economics, Japan. Contact email: nabwork@osaka-ue.ac.jp 

 

If you want to share how you use goals or goal based outcome tools in your therapeutic work please contact us using the form below