Goal-setting in Psychotherapy
by Vidar Husby
We know that therapy works. It can help our clients achieve their goals. The trouble is that sometimes we don’t know what those goals are. Therapy can feel like aiming for a goal that’s constantly moving or hidden. In these cases, clear and empathic goal setting is a vital step for successful treatment.
A shared understanding of the goal for treatment is correlated with the client´s outcome (Norcross & Lambert, 2019). This is true regardless of which model you work with. The goal fuels the work with direction and helps motivate the client and therapist. This Deliberate Practice exercise helps when patients ‘de-rail’ from the goal. Below are the skill criteria for the exercise with three examples. Good luck!
What’s the practice for: Facilitating a collaboration aimed at clarifying the goal for therapy.
Level of difficulty: Can be adjusted. To make it easier, start with one of the three criteria and combine them later on.
Instructions: One participant role-plays the client, and the other practices as therapist.
Client statement [example]: “Let me start by telling you about my history, which has a lot of loss and trauma in it.”
Therapist improvises a response based on the skill criteria.
End of role-play. Client monitors if the therapist met criteria a, b and c. Therapist monitors if the difficulty was too easy, a good challenge or too hard.
Give brief feedback to each other and adjust difficulty if needed.
ONLY when the client statement feels easy to respond to, proceed to the next client statement. Repeat these five steps again.
a) VALIDATE OR REFLECT THE CLIENT´S STATEMENT
b) DEMONSTRATE INTEREST IN THE CLIENTS STATEMENT
c) STEER COLLABORATION TOWARDS CLARIFYING GOAL
Example responses
Here are some example therapist responses to these challenges, following the skill criteria. You may prefer to use other words – improvise your response following the skill criteria - and make way for your own words.
Note that the three examples represent three ‘types’ of goal avoidance by clients.
Example 1:
Client statement (anamnestic from the get-go): “It started when I was five years of age. After that, I´ve had 12 therapists and been on so many medications that I lost count”.
Therapist response: “That is a lot of treatment (a). I would really be interested to hear more about your history (b). Still, may I suggest that we still start somewhere else? I think we first need to find out together what we are aiming for here. Would it make sense for you if we start with your goal for the work we´re embarking on?”(c)
Example 2:
Client statement (vague goal): “I just want peace of mind”.
Therapist response: “That makes sense (a). I´d be curious (b) to see what that would look like. What about you and I start off by trying to figure that out together – what the first subgoals on the way to peace of mind specifically would look like for you? (c)”.
Example 3:
Client statement (problem, not goal): “It’s like Cobain said: I hate myself and I want to die. It´s too bad, but that´s where I´m at and it´s been like that for two years more or less now”.
Therapist response: That is a long time feeling that intensely bad (a). I´d like to learn more about how it´s been like to be you (b). What you´re describing tells us what we want to go from. Does it make sense to you if we start out with exploring what direction to go to – meaning, what your goal for our collaboration should be (c)?
CLINICAL CHALLENGES:
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1) Client: “Let me start by telling you about my history, which has a lot of loss and trauma in it.”
2) Therapist improvises a response based on the skill criteria.
3) End of roleplay. Client monitors if the therapist met criteria a, b and c. Therapist monitors if the difficulty felt too easy, good or too hard.
4) Give feedback to each other and adjust difficulty if needed.
5) ONLY when the client statement feels easy to respond to, you may proceed to the next client statement and keep following these five same steps.
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1) Client: “I´ve been down for so long I have forgot what joy feels like.”
2) Therapist improvises a response based on the skill criteria.
3) End of roleplay. Client monitors if the therapist met criteria a, b and c. Therapist monitors if the difficulty felt too easy, good or too hard.
4) Give feedback to each other and adjust difficulty if needed.
5) ONLY when the client statement feels easy to respond to, you may proceed to the next client statement and keep following these five same steps.
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1) Client: “I don´t know where to start really. I can´t really imagine that anything ever will change. It all just feels hopeless.”
2) Therapist improvises a response based on the skill criteria.
3) End of roleplay. Client monitors if the therapist met criteria a, b and c. Therapist monitors if the difficulty felt too easy, good or too hard.
4) Give feedback to each other and adjust difficulty if needed.
5) ONLY when the client statement feels easy to respond to, you may proceed to the next client statement and keep following these five same steps.
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1) Client: “My drug use has received a lot of attention from my partner lately. She keeps nagging about it.”
2) Therapist improvises a response based on the skill criteria.
3) End of roleplay. Client monitors if the therapist met criteria a, b and c. Therapist monitors if the difficulty felt too easy, good or too hard.
4) Give feedback to each other and adjust difficulty if needed.
5) ONLY when the client statement feels easy to respond to, you may proceed to the next client statement and keep following these five same steps.
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1) Client: “I came here because I´m tired of being this anxious all the time.”
2) Therapist improvises a response based on the skill criteria.
3) End of roleplay. Client monitors if the therapist met criteria a, b and c. Therapist monitors if the difficulty felt too easy, good or too hard.
4) Give feedback to each other and adjust difficulty if needed.
5) ONLY when the client statement feels easy to respond to, you may proceed to the next client statement and keep following these five same steps.
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1) Client: “It´s a curse. Whenever I get close to my partner, my anxiety rises sky high. When alone, I feel safer – but super lonely.”
2) Therapist improvises a response based on the skill criteria.
3) End of roleplay. Client monitors if the therapist met criteria a, b and c. Therapist monitors if the difficulty felt too easy, good or too hard.
4) Give feedback to each other and adjust difficulty if needed.
5) ONLY when the client statement feels easy to respond to, you may proceed to the next client statement and keep following these five same steps.
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1) Client: “I just want to feel good.”
2) Therapist improvises a response based on the skill criteria.
3) End of roleplay. Client monitors if the therapist met criteria a, b and c. Therapist monitors if the difficulty felt too easy, good or too hard.
4) Give feedback to each other and adjust difficulty if needed.
5) ONLY when the client statement feels easy to respond to, you may proceed to the next client statement and keep following these five same steps.
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1) Client: “I just want to feel free, that everything is just easy you know?”
2) Therapist improvises a response based on the skill criteria.
3) End of roleplay. Client monitors if the therapist met criteria a, b and c. Therapist monitors if the difficulty felt too easy, good or too hard.
4) Give feedback to each other and adjust difficulty if needed.
5) ONLY when the client statement feels easy to respond to, you may proceed to the next client statement and keep following these five same steps.
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1) Client: “I think too much. I analyze, re-analyze and triple-check everything I do or say”
2) Therapist improvises a response based on the skill criteria.
3) End of roleplay. Client monitors if the therapist met criteria a, b and c. Therapist monitors if the difficulty felt too easy, good or too hard.
4) Give feedback to each other and adjust difficulty if needed.
5) ONLY when the client statement feels easy to respond to, you may proceed to the next client statement and keep following these five same steps.
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1) Client: “Why don´t you tell me what the goal for this therapy is? This is like going to the doctor and then the doctor asks you to dig up medicine!”
2) Therapist improvises a response based on the skill criteria.
3) End of roleplay. Client monitors if the therapist met criteria a, b and c. Therapist monitors if the difficulty felt too easy, good or too hard.
4) Give feedback to each other and adjust difficulty if needed.
5) ONLY when the client statement feels easy to respond to, you may proceed to the next client statement and keep following these five same steps.
