Setting SMART goals
The setting of well-defined goals is an important CBT process and key therapist competency. However I rarely succeed in achieving this simply by handing the client a sheet describing and giving examples of how to set SMART goals! So why and how should the client move from a vague wish-list to Specific, Measurable, Achievable, Realistic and Time-framed goals?
Goals have several valuable functions:
• They provide structure and focus to sessions
• They give hope to the client that her future can change for the better
• They prevent therapeutic drift away from the formulation. Goals can easily just become a lifestyle wish-list rather than an articulation of how the client will be able to live her life differently once she can better manage the processes that are maintaining her current problems
• They can signal when therapy may be coming to an end, as the client’s goals have been reached.
I tend to first mention goals during the first treatment session, after the assessment sessions are done. Generating the longitudinal formulation often pushes out a couple of goals, although they are often vague and couched in terms of ‘I won’t be doing X or Y when I’m feeling better.’ This is an example of the wonderfully named ‘dead woman’s solution’ as the goals could be achieved by a dead woman. e.g. ‘I won’t be panicking or over-preparing or getting angry any more’.
It takes time and explicit discussion to get to a tight description of what the client wants to achieve rather than what she wants to avoid. If our discussions to date happen to have touched on distraction as being a double edged sword of ‘moving away from’ or ‘moving towards’, I may refer to this analogy and ask her to reflect on
‘What do you want to ‘move towards’ doing in the future, when you’re no longer exhausting your energy and time on being depressed or anxious?’
Another high yield question for me is:
‘If we meet up six months after your therapy has finished, what would you have to be doing in your life then to be able to say to me, ‘Hey, that therapy was the best thing ever!”?’
Another way of guiding the client is to say
‘I want to focus our attention on what you’ll be DOING in the future if therapy really works out for you, rather than what you will be FEELING or NOT DOING then.’
I find that the goals become SMARTer through re-visiting and refining them every session or two. SMART, of course, means goals that are:
• Specific
• Measurable
• Achievable
• Realistic
• Time-framed
Imagine a highly anxious client with self-critical thinking, a tendency to ruminate and a difficult relationship with her parents. In the first couple of treatment sessions, she may only be capable of defining her goal around the parental relationship as ‘to make our relationship better and get a bit closer to them.’ By the time she has formulated her life experiences, current problems and maintaining factors and learned some CBT skills to deal with self-criticism and rumination, she may be able to better operationalise this goal into something SMARTer like:
‘In six months time, I will be limiting seeing my parents to once a month only, for lunch, with my sister present. I will be controlling what gets discussed by being assertive. I’ll know I’ve achieved this goal because I will be spending the evening before seeing them and the afternoon after seeing them doing what I’d normally do on these days, instead of lots of worrying and ruminating.’
This goal fulfills most of the SMART criteria and is related to her formulation and maintaining processes. It will have taken a while to get there and clearly, she isn’t going to write it down spontaneously on a bit of paper in those words, but we can easily get it up in bullet point on the whiteboard after a few sessions.
An additional benefit to revisiting and refining goals is that the therapeutic alliance may be disturbed if I point out at too early a stage that a particular goal may not be entirely achievable or realistic. It may be better to wait until the client has started to gain new skills and confidence before revisiting and reframing the goal more helpfully.
Summary points
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Goal setting is an iterative process and so review of goals is a helpful standing agenda item
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Most clients start out with ‘dead woman’s solutions’ for goals – the task is to give them life and resonance
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It often takes a small handful of sessions before reaching goals that could be described as being ‘SMART’