I started working in mental health in May 1983. During the second half of my career, I have reviewed numerous charts of psychotherapy patients. This professional work has included reviewing charts for process improvement and compliance, as well as for completing psychological evaluations that include chart reviews. In both roles, I am always struck by how a significant opportunity for patient growth is overlooked: The creative, collaborative act of goal-setting. I frequently read treatment plans with goals that do not seem individualized, relevant, or to have been developed through therapist-patient collaboration. Sometimes, goals from a given facility or agency are repeated across multiple patient charts and are selected by pointing and clicking in a computerized treatment plan generator or electronic medical record. This reduces goal-setting to clerical task.
To illustrate the point, I am going to tell a couple of anecdotes, with identifying information edited to preserve anonymity.
Clinical Anecdote One
I completed a psychological evaluation for a 17-year-old male who was receiving in-home psychotherapy and applied behavioral analysis deep in the US heartland. This high and costly level of service required psychological evaluations every six months to determine readiness for stepping down to a less intensive service or the need to continue the current level of treatment for another six months. The patient was an intelligent, shy, but friendly older adolescent. His mental health diagnosis was obsessive-compulsive disorder (OCD). He was sensitive and reacted to bullying; in-fact, he had been a target of bullying at his local high school. To avoid litigation, his school had agreed with his parents’ request that he complete his senior year of high school at the local community college. He drove himself there daily. He was not bullied there but he did not form friendships either. Reading his chart, the notes gave the impression that he was making some progress, but not enough progress to be discharged to a lower level of care. The message was clear: Continue services as presently billed and delivered. But progress toward what goals? His treatment plan listed his goals as complying with his parents’ rules without defiance and attending school daily. These were goals frequently found in this agency’s treatment plans because most patients it served met criteria for disruptive behavior disorders. Few were anxious or depressed without also being hyperactive and impulsive, or oppositional. I asked this young man if he was attending school daily, and of course the answer was “yes.” I asked the patient and his mother whether he cooperated with house rules and parental directions, and of course the answer was “yes.” Success! He met his two goals! Time to celebrate and discharge this young man. Of course, I am being facetious. And of course, the goals were cut and pasted.
When I asked this patient about how his OCD affected his life, he shared that he had intrusive obsessions about contamination from germs and that this prevented him from going places where he had little control over the environment. He could repetitively clean at home, but could not for example, at a restaurant or movie theater. I asked him if he ever dated, and he blushed. He said that he wanted a girlfriend but did not think that this could be possible. I asked whether this was because of his fear of potentially germ-ridden public spaces, social anxiety, or other, and we ended up talking about how hard it is to make out with someone if you fear their germs. Goals must be are individualized and relevant. Relevant goals are those that are related to the patient’s diagnosis, developmental expectations, and most importantly to the patient’s quality of life. He and I developed goal statements around his ability to go places other than school and home, his ability to form friendships, and his love life. These made it into the recommendation section of his evaluation report. He was agreeable to switching to outpatient mental health treatment, even though that meant going to someone’s possibly contaminated office.
Clinical Anecdote Two
I read a computer-generated treatment plan of an early adolescent girl discharging from an acute inpatient mental health unit. Her goals were to attend all her therapies, follow unit rules, and adhere to her medications. Of these three, only medication adherence has any relevance to a patient’s readiness for discharge and avoiding readmission. In the worst case scenario, staff view treatment planning as a chore; in that case, every patient had the same goals, and that no one ever looks at the treatment plans once completed. When every treatment plan is the same, they are considered a waste of time. But they did not have to be.
To personalize the treatment plan, the clinician can begin with a discussion with the patient and her family about how she came to be admitted, and what would need to change to avoid readmission. This conversation might lead to a very productive session or two, depending on the patient’s and family’s readiness for a conjoint session. Similarly, discussing how this patient wants her quality of life to improve would be productive. This collaborative and creative process could lead to insights and understanding, and meaningful goals against which to measure progress. Goal-setting would need to focus on individualization, collaboration, and a shared definition both of the problems the patient faces and what the outcome of this treatment episode should look like. This discussion might also lead to the identification of personal and systems obstacles to progress. For example, imagine that during a collaborative discussion about meaningful goals, this girl disclosed that her goal was to remain hospitalized as long as possible, because the hospital was the safest environment she experienced. How dramatically would this change the direction of treatment?
Is this process unfriendly to point-and-click computer programs? Yes. Is this investment of time and effort worthwhile? Sure. Imagine how empowering it is to an adolescent – who, like adolescents generally, probably believes no one is listening to be an equal partner in planning treatment. Imagine the power of goals to point treatment, the patient, the family, and the staff in a unified direction that everyone participated in planning.
Clinical Anecdote Three
When I was a predoctoral intern discussing the importance of goal-setting, a supervisor asked me whether I thought every patient can participate in setting goals. I responded that I did not know about every patient; for example, someone with Autistic Spectrum Disorder, Level 3, with Intellectual and Language Impairments might have difficulty. On the other hand, I imagined aloud that everybody he would see for individual psychotherapy could. He then gave me a challenge: How would I set goals for one of his patients, a 24-year-old male patient with schizophrenia who told his intern-therapist that he wanted to marry a specific famous pop star? Could I make that into a goal through collaboration with the patient? We brainstormed.
This patient was a young man who developmentally should want an intimate relationship (Goal 1). His disorder means that he has positive and negative symptoms that prevent this, meaning that he needs skills (Objectives for Goal 1). He wants a partner who is special, attractive, and someone he can admire, and needs to know how to appreciate these qualities in women he is likely to date (Goal 2). He needs to have the judgment and insight to realize that not everyone he admires can be his partner. He also needs to know the consequences of reaching out to a celebrity (Goal 3). Finally, he needs to grieve the loss of his unrealistic and dangerous ideal partner (Goal 4). Of course, the patient was not present, so these were hypothetical goals for the purpose of explaining goal-setting to a skeptic, not actual goals.
Note that collaboration around goal setting does not mean that the patient dictates and the therapist passively records what the patient wants. Collaboration goes in both directions. Part of the discussion about this patient’s goals for an intimate relationship would have to focus on what the patient probably does not want but needs anyway – to give up the fantasy of marrying the famous pop star. However, this patient would have had the opportunity to pick the life domain to focus on, namely intimacy. This might mean that the patient learns to maintain hygiene, to adhere to medications, to accept “no” as an answer from a woman, and other skills of interest to his treatment providers – all in service of the patient’s goal of finding a partner.
How SMART Goals Can Result in Directionless Therapy
I would guess that if you have attended an in-service training about goal setting, it focused on a preferred format for goals, SMART goals. Here is the problem: You can take the most thoughtless goal imaginable and write it perfectly in a standardized format. Sometimes, I think we become too closely wedded to the format. If the treatment goals are going to be reviewed for compliance or as a measure of your performance based on format, then you will produce SMART goals, even if they are unhelpful. Compliance gets what compliance measures. We spend a lot of time discussing SMART goals without delving into the literature. In the literature, there is no empirical support for SMART goal formatting in terms of patient outcomes, persistence in treatment, or satisfaction with treatment.
There is, however, a literature about goal-setting, and specifically Goal-Setting Theory. It does not focus on the format for writing goals but on qualities of goals. This literature originated in industrial-organizational psychology, and this is not a literature familiar to most clinicians. To illustrate this point, Goal-Setting Theory has its roots in improving the productivity of wood pulping workers. I seldom devote time to reading about the psychology of wood pulping, and I do not think that I am alone. The father of Goal-Setting Theory is Dr. Edwin Locke, who is a Professor Emeritus at the University of Maryland. His research, very briefly summarized, indicated that goal-setting is motivating when the person responsible for achieving the goal (in our case our patient) can appreciate the rationale for their goals, when goals are challenging and both difficult and attainable, when the criteria for success is “doing your best” rather than meeting a specific and objective measure of performance, when the patient is taught strategies for attaining their goals, and when the goals are specific and relevant to the context in which the goal is to be attained. Further, goals are motivating when progress towards goals is reviewed, and feedback offered about what is working well (Locke & Latham, 2019). Consequently, goal-setting is not a once-and-done exercise.
The issue of goal difficulty is interesting. As a student in both psychology and education classes, I was taught that task analysis was an extremely important tool because it permitted development of small, easily attained steps towards a larger goal. In contrast, Goal-Setting Theory, and research that has tested this theory, suggest that when goals are moderately difficult, people will develop more alternative strategies for meeting the goal. In contrast, this skill is unimportant if a patient is given baby steps to complete.
The person who will work towards the goal brings to the exercise their own personality and level of cognitive complexity. Is the patient conscientious? Does she have a belief in her own efficacy? Does she succeed at developing alternative strategies? (Locke & Latham, 2019). Addressing these mediating variables can represent meta-goals as part of treatment as well.
One of Locke’s findings is pertinent to relevance of the context in which the patient works towards a goal (Locke & Latham, 2019), or ecological relevance. I tend to think of relevance in the context of lifespan development. My 17-year-old patient with OCD was at the first moments of early adult transition. This transition involves completing education, making vocational decisions, becoming more autonomous, achieving financial independence, living independently, developing his own friendships, and forming intimate attachments (Levinson, 1986). As with every stage of development in Western Culture, the task of separation and individuation is the underlying direction of maturation. However, this patient’s original goals to be more compliant were at odds with developmental expectations. Relevance also means relevant to the individual including his or her mental disorder and skill deficits and strengths. Finally, goals should be relevant to quality of life issues. The sole purpose of treatment cannot be to reduce symptom severity, although this is of great importance for alleviating suffering. Treatment should also improve quality of life. It is very likely that each patient has a private image of what quality of life means that is different from each therapist. This is why individualization and collaboration are so important to goal setting.
Measuring Goal Progress for this Article
The objective for this article was to raise consciousness that goal-setting should not be seen as a compliance requirement, drudgery, or a clerical task, but as a creative therapeutic task that aids in building an alliance, giving treatment a direction, and motivating patients. Goal setting stimulates patients to develop strategies, and helps identify obstacles to progress including skill deficits, and personality traits that hold patients back.
by Stephen M. Lange, PhD, HSP (Psychologia-Texas, Inc.)
References
Levinson, D. J. (1986). A conception of adult development. American Psychologist, 41(1), 3–13. https://doi.org/10.1037/0003-066X.41.1.3
Locke, E. A., & Latham, G. P. The development of goal setting theory: A half century retrospective. Motivation Science, 5(2), 2019, 93–105. https://doi.org/10.1037/mot0000127.