In chapter 2 we focused on assessing your client’s problems and strengths and on how to explain CBT. Did you try using Questions to Explore Your Client’s Problems? Did you see your client’s strengths differently after using any of these questions? I am curious whether you have started noticing your own thoughts. Has this made a difference in your life?
When clients complete their homework, therapy is more effective and clients are more likely to make real changes in their lives (Rees, McEvoy, & Nathan, 2005). Similarly, the extent to which you incorporate CBT into your own work will depend on how much you use the material in the book and practice. The homework at the end of each chapter is simply a structure for encouraging you to practice.
If you did not have a chance to do the homework from chapter 2, try to identify what factors got in the way. Maybe you did not see any clients, or you were particularly busy. Sometimes therapists’ thoughts get in the way of trying the homework with their clients. Did you have any of the following thoughts?
Did any of these thoughts stop you from doing the homework and practicing your CBT skills? Did you have other thoughts that got in the way of practicing? The reality is that you won’t know whether doing the homework is helpful unless you try. What if you were surprised and the homework really helped? If you are worried about feeling awkward the first time you try an intervention, you are right; you probably will feel uncomfortable because you are doing something new. I would guess that the first time you tried any new skill you felt awkward. What would your life be like if you gave up whenever you felt awkward?
What would help you complete the homework for this chapter? Remember, the more you practice, the easier it will be. If you did not do the homework from chapter 2, before starting this chapter, try these two exercises:
CBT is an active form of therapy where the therapist and client set goals in the beginning of therapy and work toward these goals.
Goals are different from problems. Problems describe what is wrong in your client’s life. Goals are how your client would like his life to be different, or what he would like to work toward. Setting effective goals is a key element in CBT.
It is important that the therapist and client agree on the goals they are going to work on, or the sessions will tend to wander and feel as though nothing is getting accomplished. In addition, the therapy relationship is strengthened when your client feels that you understand his goals and that therapy is going to focus on those goals that are important to him.
Having goals in therapy is similar to starting out on a road trip. If someone asks me which road I want to take, I have to first know where I want to end up. The road I would choose to get to Toronto is different from the road to Detroit. The more specific and clear the goal, the more I can plan how to get there. Goals give direction to therapy.
If a client identified two problems, you would most likely set goals for both problems and then focus on the one he identified as his first priority. However, clients often have multiple problems. In this case, you and your client need to pick one or two problems that he wants to work on first and develop goals for those problems. Later in therapy, when the client is ready to start working on a new problem, you would develop goals for the new problem. Often as therapy progresses, goals change.
I encourage my clients to write down their goals. It makes their goals more concrete, and it gives us a written document to refer back to. Most importantly, research indicates that setting goals early in therapy significantly increases client satisfaction and the likelihood of a positive outcome (Safran & Wallner, 1991).
Below are some suggestions for how to introduce goal setting with new clients as well as current clients with whom you have been working for some time but had never set goals. You can download a handout with these prompts (Explain Goal Setting) at http://www.newharbinger.com/38501.
When explaining setting goals to a new client, you might start with the following:
What I would like to do next is spend some time exploring your goals for therapy. I find that having clear goals gives therapy a sense of direction. I would like to start with identifying goals for the first problem you said you would like to work on.
The explanation would start off differently for a current client with whom you had not set goals at the beginning of therapy:
I have been thinking about our sessions. At this point, I think it would be helpful for us to spend some time thinking about your goals, and what you would like our future sessions to focus on. Setting goals can be helpful in giving therapy a sense of direction.
But from that point on, the explanation would be the same with both clients:
I also want to spend some time making your goals as specific as we can, as I find the more specific the goal, the more helpful it is. Specific goals can also help us measure whether therapy is working for you. As we talk about each goal, I would like to write it down. Would that be okay with you?
I am going to ask you to imagine explaining goal setting first with a new client and then with a current client. Before you start this exercise, rate from 1 to 10 how comfortable you feel introducing setting goals with your clients, with 1 being very comfortable and 10 being very uncomfortable. At the end of the exercise, rate your level of comfort again to see whether it changed. Now, let’s try the exercise.
Once you have introduced goal setting, you need to help your client develop more specific goals. The more specific and clear the goal, the more helpful it is. However, what do we mean by specific, measurable goals?
Clients often start with very general goals, such as “I would like to be less depressed [or less anxious],” “I would like to have better self-esteem,” or “I would like to have a better relationship with my partner.” The problem with these general goals is that you don’t have a specific idea of how your client wants his life to be different, nor does your client have any way of knowing whether he is on his way to achieving his goals. Goals that are specific and measurable give therapy a direction and provide a yardstick for measuring whether therapy is on the right track. The easiest way to understand the difference between general and specific goals is to look at some examples.
| Examples of Goals | |
|---|---|
| General Goals | Specific, Measurable Goals |
|
Be more assertive. |
Talk to my partner about some of my concerns about our relationship. Set more limits with my boss (e.g., tell my boss that I can’t take on new clients; ask my boss not to regularly call me on weekends or evenings). Express my opinion when I am out with friends. |
|
Be less anxious. |
Give a presentation at work. Don’t check on my kids as much (e.g., don’t phone them on their cells if they are 10 minutes late, but wait until they are half an hour late; only ask once a night whether their homework is done). Don’t blow up over little things, like my husband forgetting to pack the children’s lunch. |
YOUR TURN! Identify Specify, Measureable Goals
At first the difference between a general goal and a specific, measurable goal can be hard to identify. Look at the goals below and decide how you would rate them. You can find my answers in the appendix.
Let’s look at two of the above goals in detail. The goal “talk to my boss about getting paid for working overtime” is a specific goal. We know exactly what behavior the client wants to do and we can measure whether he was able to do the behavior. The goal “be less demanding of my friends” is a general goal. Since we don’t know what specific thoughts, feelings, physical reactions, or behaviors the client would like to increase or decrease, we will have no way of knowing whether the client was successful in working toward this goal.
It can be challenging to move your client from general goals to more specific goals. Below are some questions that can help. You can download them in handout form (Questions to Develop Helpful Goals) at http://www.newharbinger.com/38501. You can substitute one of your client’s general goals for “less depressed.”
A client of mine, Barbara, came to therapy because of low self-esteem and “wanting to like myself more.” When I asked, “If you liked yourself more, what would you do differently?” she paused and responded, “I have never thought about that.” She was able to list a number of specific issues, including applying for a promotion, not saying yes to her girlfriends in situations where she thought they were taking advantage of her, and standing up to her mother. We explored each goal. At the end she turned to me and commented, “You really heard me. I feel that we have something specific to work toward.”
When developing specific goals, you don’t want to be rigid. If your client wants to keep a general goal that is meaningful to him, I would keep it, but try to add some more specific goals to guide therapy.
One of Raoul’s initial goals was to be less anxious. This is a good general goal. Let’s see how Raoul’s therapist uses Questions to Develop Helpful Goals.
Therapist: Being less anxious is a good general goal, and a good place to start. I think it would be helpful if you could be a bit more specific or concrete.
Raoul: What do you mean?
Take a moment and think about how you could you use Question 1 to make Raoul’s goals more specific.
Therapist: I think it would be helpful to think of some specific ways that we could know you were on your way to achieving your goal. For example, are there any particular situations where you would like to be less anxious? (Question 1)
Raoul: I guess at work, I am just really stressed.
Raoul’s goals are starting to be more focused, but we still do not have specific, measurable goals. How could you use Question 2 to make Raoul’s goals more specific?
Therapist: If you were less anxious about work, I am wondering what you would be doing differently? (Question 2)
Raoul: Mainly I wouldn’t procrastinate over my big projects.
Raoul is starting to be more specific. Take a moment to think about how you could use what he just said and turn it into a goal.
Therapist: Might one goal be to stop procrastinating on your big projects?
Because Raoul did not explicitly state this as a goal, his therapist used the term “might” when she turned Raoul’s words into a goal. Using “might” permits Raoul to disagree with his therapist.
Raoul: Definitely.
Raoul has made the goal more specific, but it would still be hard to measure. How could you use Question 2 to make Raoul’s goals more measurable?
Therapist: If you stopped procrastinating, what would you like to do differently? (Question 2)
Raoul: I would stop avoiding my colleagues on the project, get down to work, and talk to my boss about the project.
Therapist: It sounds like some of your goals might be to stop avoiding your colleagues, talk to your boss about the project, and get down to work.
Raoul: Yeah, those would be good goals. I am not sure that I want to talk to my boss, but it would be good to start the project.
Therapist: It seems that a first goal might be to contact your colleagues and start work on the project, and then a longer-term goal might be to talk to your boss. Does that sound right?
The therapist realized that talking to the boss might not be Raoul’s goal at the moment. The therapist wondered whether breaking the goals down into immediate and longer-term goals was more in line with what Raoul wanted.
Raoul: (looking a bit more energetic) Yes, I think that would be very helpful.
Therapist: Those are good goals. Let’s write down the goals we have talked about so far and then see whether there are any other ones. When you think about what we just talked about—how would you write out the goals?
Notice that the therapist gives Raoul positive reinforcement for developing good goals.
The therapist and Raoul continue to explore his general goal “be less anxious at work.” They develop the following list of specific goals:
You will notice that some of Raoul’s goals are very specific and measurable, for example, “get my projects done on time.” Some of the goals are still fairly general, for example, “start to like work again.” The therapist thought they had made a good start and did not want to push developing specific goals too much, as they were just forming a relationship. The specific goals could be used immediately to give direction to therapy, and the more general goals could be worked on later in therapy.
YOUR TURN! Help Suzanne Make Her Goals More Specific
Imagine that you have just introduced goal setting to Suzanne. Try to help Suzanne set specific goals that can be measured.
Look at the three possible responses below and pick the one that will help Suzanne develop a more specific goal:
Response #3 is the most likely to help Suzanne develop a specific goal and to start thinking about what she would like to be different in her life. Response #1 starts to problem solve. This is too early in therapy. Response #2 is a supportive comment, but it does not help Suzanne become more specific.
Ask yourself whether “go out more and not want to stay home all the time” is specific enough. Look at the three possible responses below and pick the one you think will help Suzanne be more specific.
Response #2 is most likely to focus the client on identifying specific activities she would be doing. Response #1 starts a problem-solving process without being clear what “going out more” refers to. Response #3 is too vague. You might get helpful information, but Suzanne may also talk about being depressed in a general manner.
Suzanne and her therapist continue to explore her goals and what might be some good indicators that she is on the path to feeling less depressed. Here are the goals that Suzanne and her therapist developed:
When you look at Suzanne’s goals, you will see that some are still very vague, such as “have more energy”; however, some are concrete and specific. You’ll also notice that some of the goals are stated in the negative and involve what Suzanne wants to stop doing, for example, not be angry all of the time, and some are positive goals, or what she wants to do. If your client has a negative goal, it is important to balance it with a positive goal.
The third stage in goal setting involves choosing where to begin. The therapist can simply say, “Let’s look over your goals and pick one to start with.” Frequently a client’s goals are interrelated, in which case it will be possible to work on more than one goal during a therapy session. For example, many of Raoul’s goals are related to work. You want to start with goals that are doable and where there is a good chance of success. When therapy helps clients make changes in their lives, clients become more committed to therapy and more hopeful that their lives can improve.
When Suzanne and her therapist looked at her goals, Suzanne’s first priority was to fit into her new school and try to make some friends among the other teachers. Her second goal was to do some fun things with her children and husband. Suzanne’s therapist thought these were good places to start and that it might be possible to address both goals early on in therapy.
Before moving on to the next chapter, take some time to try the homework.
Complete the following exercise.
Before practicing this week’s skills with your clients, let’s start with focusing on your own goals.
Homework Assignment #1 Set Goals for Yourself
| Your Goals | |||
|---|---|---|---|
| Your General Goal(s) | Specific and Measurable Goal | What Was It Like to Set Specific Goals? | What Did You Learn That Is Relevant to Your Therapy with Clients? |
Choose both a new client and a current client who you think would be open to setting goals for therapy. If you don’t have a new client this coming week, choose two current clients.
Homework Assignment #2 Set Specific Goals with Your Clients
Complete these steps with each client you selected.
| Help Your Client Set Specific Goals | |||
|---|---|---|---|
| Client’s General Goal | Specific and Measurable Goal | How Did the Client React to Setting Specific Goals? | What Did You Learn? |
|
Client #1 |
|||
|
Client #2 |
|||
Answer the questions under the agenda items.