CFN9885 - SECTION 8: COUNSELING AND TREATMENT GOALS
Helping Clients Develop Goals
The research shows that clinician empathy is positively related to client progress - when progress is measured by clients’ estimates of progress. However, when progress is measured by more objective measures, for example by a standardized text or direct observation of client change, clinician empathy is less significant.
Just showing empathy for clients is not enough. (Lieberman & Lester, 2004) Empathy is only one component of successful counseling. Clinicians and clients also need goals. One of the primarily responsibilities of the clinician is to help clients develop goals that are realistic and obtainable.
Goals serve four primary functions:
1) Motivational: Client involvement in the goal setting process can motivate clients to accomplish their goals.
2) Educative: Setting goals helps clients to clarify and target problem behaviors or issues they want to work on in counseling and develop realistic, attainable solutions.
3) Evaluative: Setting goals enables both the client and the clinician to evaluate or gauge the progress toward their goals.
4) Treatment Assessment: Setting goals enables the clinician to evaluate what types of goals and intervention work best with what types of clients. (Hackney & Cormier, 2005)
It is important to realize that gaining insight into one’s problems does not always produce change. Even dysfunctional behavior can have rewards, and trying new behaviors can have risks. When the problems are more recent and less complex - and the client has adequate coping skills and a good support system - gaining insight into the problem may be enough to motivate the client to make meaningful changes.
However, for many types of problems, gaining insight is only the first step toward meaningful change. For these situations, clinicians and clients need to develop specific outcome goals for counseling and use these goals to design an action plan to achieve them. The goals for the action plan should include: 1) strategies for restructuring client self-perceptions, 2) strategies for reducing physiological and emotional distress, and 3) strategies for behavior change. (Brammer, Abrego, & Shostrum, 1993)
Setting realistic, obtainable goals involves identifying what goals the client would like to accomplish; what specific thoughts, behaviors, and situations would have to change or be evident if these goals are to be realized; and the specific tasks the client would have to undertake for these goals to be accomplished.
When thinking about goals it is best to conceptualize them in terms of immediate, intermediate, and ultimate goals. While it is important to identify the counseling goals, these goals are never fixed, rather they can be altered as new information and insights into the problems are identified.
It is important for clinicians to find out what their clients want to work on in therapy and not make assumptions about the goals of counseling. When clients do not want to work on a problem area that we as clinicians feel they should work on, we need to respect their decision because they may be telling us very important things about them, about us, and the counseling process.
While developing meaningful counseling goals is important, sometimes clinicians can be so predisposed to finding a solution to the client’s problems that they forget that it is ultimately the client’s responsibility to solve the problems. By offering premature suggestions to resolve clients’ concerns prior to giving them adequate time and attention so that they feel comfortable that you truly understand them and their concerns, can give clients the impression that it is the clinicians’- and not ultimately the clients’ - responsibility to solve their problems.
Coming up with treatment goals is important because it allows both the client and the clinician to monitor the progress of their work together. Goals represent the results the client wants to achieve in counseling. Goals give direction to the counseling process and help both the clinician and the client to move in a focused direction. Goal setting is an extension of the diagnosis or assessment process.
During the assessment process, the goal is to determine what problems or concerns the client wants to work on in counseling. In goal setting, the clinician and client identify specific areas they want to work on in the counseling process. While setting specific goals is very important to the success of counseling, some clients and some clinicians can be hesitant about implementing this step. Setting specific goals involves making a commitment to a course of action and an outcome.
We need to be careful not to conclude that we are necessarily more insightful or clever than our clients. I learned this lesson with two of my earliest clients.
A woman in her mid-30s came to therapy wanting help in a difficult marriage. In the course of therapy, she revealed that she was molested by a cousin when she was five, raped by a former boyfriend when she was 17, and got pregnant and had an abortion. All of the red flags from my training went up and I immediately wanted to address these areas. However, she assured me that with the help of some friends and over time she had worked through these issues earlier in her life and they were no longer significant issues.
With more experience, I later realized that she was not in denial. I needed to trust her when she said they were no longer significant issues in her life and she was in therapy to get help for her marriage. We focused counseling on her marriage and after about 8 sessions we were satisfied that she was making good progress in the areas she came to counseling to work on, and we both decided to terminate therapy at that time.
In another case, a couple in their mid-30s came to therapy for help with their marriage. During the course of therapy, they identified a number of problem areas including their sexual relationship. During our six months of therapy they made significant progress in a number of areas, but despite my prodding, they refused to discuss or work on their sexual problems.
Later, I came to see that they were telling me they were not ready to look at this very personal and difficult issue in their marriage and I needed to respect their decision and to acknowledge the improvements they did make in many other areas of their marriage.
Goal Setting and the Clinician/Client Relationship
The type of relationship clinicians have with their clients will influence the types of goals that can be developed and worked on. If clients are in a visitor relationship there is no joint definition of the problems, so it is difficult to agree upon the goals or how to accomplish them.
At that moment, there appears to be nothing that the client wants to work on with the clinician. These clients might be seeing a clinician because they are being pressured by family or friends or forced by a person or agency with the authority to do so (courts, schools, social welfare agencies, employer. etc.). If clients are being pressured to come to counseling, then the challenge might simply be to get them to come back for another session. For clients who are forced, the challenge is to understand why they are reluctant or resistant and find ways to address their concerns.
One way to do this would be to thank clients for coming to the first session and sharing their thoughts. The clinician might say that the two of you have discussed a number of interesting things during the session. You then ask if the client would be willing to come back for another session to continue the discussion. If clients are unwilling to schedule another appointment, you should thank them for coming and offer your services at any time in the future if the need arises or offer the client some referrals.
If clients are in a complainant relationship, the problems have been jointly identified, but clients do not see anything they might do to solve meaningfully address the problems. Often these clients have little sense of what they might want to be different, except they want others to somehow be different. The challenge with these clients is to help them develop goals for their own thoughts and behavior that are not dependent upon other people’s thoughts and behaviors.
With clients in a customer relationship, there is a jointly developed definition of the problem, clients accept their role in addressing the problems, they appears to be motivated to work on the problems, and they are willing to begin to try some different things.
Goal Setting Tools
One of the most difficult challenges a clinician can face in working with some clients is helping them to change their most dysfunctional, deeply held beliefs about themselves. These core beliefs often originated in childhood and are part of the cognitive make-up of clients. Beliefs such as “I am unlovable,” “I am not good enough,” or “I am helpless” are difficult to modify because in many cases they have become part of the client’s identity.
The Core Belief Worksheet helps clients to monitor their progress in changing their negative core beliefs. (Beck, 1998) The worksheet can be used during a counseling session or it can be used by the client during the week when they become aware that one of their negative core beliefs has been activated, that is, when they start to feel bad, unlovable, helpless, inadequate, etc.
Core Belief Worksheet
Name: ____________________________ Date: ___________________
Old Core Belief: I feel like a failure.
How much do you believe the old core belief right now? (1 to 10) 7
New Belief: I’m ok. I have strengths and I have weaknesses.
Evidence that Contradicts the Old Core Belief and Supports the New Beliefs: I am a good mother and my children are doing well in school. I have some good friends who like me. My supervisor recently wrote me a positive evaluation of my work.
Solution talk is very useful to counter the sense of powerlessness that many clients are experiencing when they first come for counseling. Most clients when they first come to see a clinician focus on their problems and how these problems are making their life difficult.
The challenge is to gradually shift the conversation to invite clients to talk in detail about what they want to be different in their lives and how this might happen. When this happens, most clients feel empowered in that they become more hopeful and even confident that they can make meaningful changes in the life. The goal is to help clients become experts about their own world.
When I say that you want your clients to become experts about their own world this does not mean that you as the clinician do not have responsibilities. You lead best when you follow the client's lead.
Using the Solution-Focused Approach to Develop Treatment Goals
The solution-focused approach can be very useful in setting counseling goals. The solution-focus approach can be conceptualized in terms of the following stages:
Stage I: Describing the Problem: Clients are asked to describe the problems that have brought them to counseling with the goal of thinking about ways to turn the conversation toward the next step which initiates solution talk.
Stage II: Developing Well-Formed Goals: Clinicians work with clients to elicit descriptions of what will be different in their lives when their problems are solved.
Stage III: Exploring for Exceptions: Clients are asked about those times in their lives when their problems are not happening or are less severe and who did what to make the exceptions happen.
Stage IV: End of Session Feedback: The client is complemented for what they are already doing that is useful in solving their problems and the client is given feedback based upon information that clients have revealed in the conversations about well-formed goals and exceptions.
Stage V: Evaluating Client Progress: Clients are regularly evaluated on how they are doing in reaching solutions satisfactory to them and what needs to be done before they feel their problems have been adequately solved and they are ready to terminate services. (DeJong & Berg, 2002)
The solution-focus approach assumes that clients, sometimes with the help of clinicians and other people, are competent to figure out what they want and need and how to go about getting it. The clinician's responsibility is to assist clients in uncovering these competencies and help them to create more satisfying life situations. (de Shazer, 1985)
When clients begin to talk about what they might want to be different they often state their goals in abstract, vague ways such as: “I want to be happy. I want to feel loved and appreciated. I want to stop feeling depressed”.
Clinicians can then help clients to begin to form concrete, well-defined, achievable goals and solutions to accomplish their specific hopes and dreams. Additionally, these concrete goals enable both the clinician and the client to evaluate if they are making progress toward satisfactory solutions.
Using supportive nonverbal responses, paraphrases, and affirmation of clients’ perceptions can all convey a sense of empathy without amplifying the situation. Clinicians should pay particular attention to anything that clients say that might suggest they want something different in their life, they have had past success in an area of their life, or they have already tried to improve their situation.
You want to shift the focus from problems to past successes and future possibilities. For example, you could say: “I can see that your marriage is not what you would like it to be.” You can then explore what the client might want different in the relationship or what the client is doing to use her strengths to get through this difficult time. This can change the client’s focus from problem talk to solution talk. (de Shazer, 1994)
Solution-focused therapy tries to help clients remember times in their lives when they were able to successfully deal with their presenting or other related problems. These are called exceptions, and they are those past experiences in a client’s life when the problem might reasonably expected to occur, but somehow did not.
You can do this by asking such questions as: “Have there been times in your life when the problem has not happened or it has been less serious? Have there been times when your life was a little like the miracle picture you described? How did this happen?
For example, a mother may come for counseling and she describes how she feels she has no control over her daughter both at home and what she does outside the home. By questioning her in a solution-focused manner and listening to, and seeking clarification of her answers, the same mother is able to figure out that her daughter is not out of control all the time, that most of the time the mother has some degree of control and her daughter does obey her rules and expectations.
Understanding the when and how of those times when the daughter is cooperative and complaint, helps the mother and the clinician to see the mother in a different light, and to work on finding ways to improve the problem situations.
Using scaling questions can help clients to express their observations about their past experiences and estimates of their future possibilities. For example, the clinician might say to the client: “Let’s say that 0 equals how bad your marriage was at the time you made the appointment to see me and 10 is the miracle you described to me earlier. Where are you on that scale today?”
You then ask a series of follow-up questions to expand their response. You should pay particular attention to the ways in which these exceptions time were different from the problem times. You should inquire about who did what to make the exception happen.
Clinicians often assume that clients begin to change when the clinician starts working with them. To the contrary, change is regularly happening in most clients’ lives. Two-thirds of clients report positive change between the time they made the appointment and their first meeting with clinicians. (Weiner-Davis, de Shazer, & Gingerick, 1987)
You can also ask a scaling question that asks how confident or motivated the client is to work on building solutions. For example, you could ask the client: “Let’s say that 10 means you are willing to do anything to find a solution, and 0 means that you are willing to do nothing. How hard, from 0 to 10, are you willing to work?” You then ask a series of follow-up questions based upon the client’s response.
With each client you need to develop a treatment plan with specific goals that are consistently being examined, evaluated, and modified if necessary. What goals you develop with your client will depend upon your assessment of types of relation you have with your client and the degree to which the client has developed well-formed goals. (de Shazer, 1988)