Working with Goals

Goal-setting

Setting goals is a collaborative process, best done within a shared decision-making framework. If we listen well to our clients, their goals emerge from the stories they tell us about their lives, their difficulties, and things they would like to be different.  Listening to these stories is part of what we all do in good, everyday therapeutic or clinical conversations. Once the goals have emerged from conversation, we might help the client shape them, agree them together, and write them down to check we have both understood them. Once agreed we can be curious about where the client feels they are at in their journey towards making the changes in their lives that are important to them.

A goal is simply what someone wants to change by engaging in an intervention. It is important to set collaboratively agreed goals with a client before setting out on the journey of therapy. Sometimes, when (or if) we ask someone what they want, they give us something that describes a process rather than an endpoint of change. Process goals can be fine and useful but they can lead to difficulties unless both practitioner and client are completely clear and agreed that they are working together on a process rather than working towards an endpoint of change.

‘Vehicles’ or ‘Destinations’

A simple travel analogy might help us understand the importance of this idea better: imagine for a moment we were travel agents and a client walked into our shop. We might ask them, “Where do you want to go on holiday?”. We would expect them to say something like “Zanzibar” or “Blackpool” or “somewhere hot” or “somewhere I can ski”. We would expect them to give us some kind of ‘destination’. We would be very surprised and possibly puzzled if they answered the question: “Where do you want to go on holiday?”, with “on a train” or “by bike” or “fly” - i.e. they answered the question by describing the ‘vehicle’ and not the ‘destination’. As travel agents, we would reasonably ask, “...and where do you want the train/bike/plane to take you?”. This would give us the destination goal and we might then help the customer think about other vehicles that might get them to where they want to be. For example, if our travel customer who said they wanted to go ‘by bike’ paired this with their destination goal of ‘to New York’ we might want to understand their reasons for wanting to cycle to New York, but we might also help them consider other vehicles such as a plane or a boat that might get them there more effectively. Once the destination and vehicle are agreed we can then help with some sub-goals: “Have you got a passport? Do you need any foreign currency? Do you have a suitcase? Etc.”

This process seems obvious if we use the analogy of travel and yet it seems more complex in clinical settings, but the process is the same. When we ask clients some variation of, “what do you want to change?”, we might be given a ‘vehicle’ or process by the client: “I want my child to be diagnosed with ASD” or “I want CBT” or “I want to lose more weight” - all these are processes or ‘vehicles’ that are important to the client, but to work together effectively, we need to understand what changes the client hopes the diagnosis / CBT / weight loss will result in; we need to understand the destination or change they hope these processes (vehicles) will lead them too.

If we are presented with a process (vehicle), the question to ask, is some variation of, “…and what do you hope will be different if you get: the diagnosis / CBT / to lose more weight? ”to which the answers might be: “I will understand my child better and can be a better parent / I’ll be less anxious / I will feel happier”. Part of the task of setting goals is to make sure the task alliance is around a destination goal and not just the vehicle goal.

It is important to avoid the potential traps of setting goals that confuse vehicles and destinations. Otherwise, we may end up working with apparent goals that may be, just a statement of a process for reaching a goal but not a goal in itself. By reflecting on whether a stated goal truly is a therapy goal that can be worked on collaboratively we are more likely to build a working alliance with the client and achieve a better outcome.

Highly specialist services, assessment services and goals

The confusion around vehicles (processes) and destinations (change goals), is also driven by practitioners and services. This is more likely to occur in very specialised services where only one form of therapy is offered (only CBT or only psychodynamic psychotherapy etc.) or in diagnostic services that do not offer treatment themselves (e.g. ADHD assessment clinics or learning disability diagnosis services).

If we return to our travel analogy: single therapy services and clinics are a bit like travel agents that are specialists in one form of transport or vehicle: a train company or an airline. In these services the vehicle is ‘fixed’ by the context of the speciality of the services – you can go anywhere you like but it has to be by train/plane. But even here it would be unimaginable not to ask the traveller: “where do you hope to get to on my train/plane?”. And yet in clinical services we sometimes do forget to ask this fundamental question.

Some clinical services are so specialised that they only offer one very specific thing e.g. autism spectrum disorder (ASD) assessment. In travel terms, this is like having a very high-tech train that only goes to one destination (a bit like the London to Paris Eurostar perhaps). If someone booked a ticket on this service, even a seasoned travel agent might be excused for not asking, “where do you hope to get to by riding this train?” - the answer is so obvious the question is all but redundant. This may be why in highly specialist services the client’s goals might not be asked about – if your service only does one highly specialised thing, then it may seem redundant to ask about a client’s hopes for the assessment. The question may seem redundant to the clinician but it is far from redundant to the client! The assessment process (vehicle) may be fixed and the destination (as for as the service is concerned) is also fixed (a positive or negative diagnosis) but for the client or family, the diagnosis is only a stop-off on the way of a much longer journey. If we keep the bigger picture in mind, we are more likely to ask, “what are your hopes for this assessment?”, this opens up an opportunity to discuss the client's longer-term destination goals – these might be surprising to the assessment service and might helpfully manage expectations of where a diagnosis on its own can take you. It can help focus aspects of the assessment and the subsequent report, to help the client with their onward journey.

A word on language

It is helpful to see the word ‘goal’ as ‘technical language’, in the same way we might see ‘assessment’ or ‘formulation’ as technical language. Technical words are useful shorthand for often complex processes and ideas that are not likely to be used or well understood by most of the clients we work with. These technical words need explanation in everyday language , for example we might describe an ‘assessment’ as, ‘getting a better idea of the difficulties you are experiencing’ or ‘formulation’ as, ‘getting a better understanding of why you are experiencing these difficulties at this time’. Once we have given the everyday explanation of the technical word, we might then be able to use it as shorthand. The same it true with the word ‘goal’, it should only be used once an everyday explanation of the work has been offered, ‘getting and understanding of the things you might want to be different in your life’. we could go on to say, ‘we might want to call the these things you want to be different in your life, your ‘goals’ as a quick way of describing what you want to be different’. If the client understands the technical word ‘goal’ then is it fine and helpful to continue using it. The bottom line is to use language that best fits with what makes most sense to the person you are working with. We can use the idea of ‘goals’ without ever having to use the word directly.