Mdule 6: Gal Setting Objectives T understand the cncept f gal setting in Brief CBT T acquire skills t set feasible and apprpriate gals in Brief CBT What is gal setting, and why is it imprtant t set gals in therapy? Gal setting is the prcess f cllabratively identifying specific therapeutic utcmes fr treatment. Gals must be bservable, measurable and achievable and relate t cgnitive r behaviral changes relevant t the patient s presenting prblem. Gals are tied t specific skills t be addressed in treatment. Gals increase the cntinuity f sessins, allw fr directed, fcused treatment, and enable the patient and therapist t assess the prgress f therapy and identify change in an bjective manner. When? (Indicatins/Cntraindicatins) In additin t identifying the prblem and building rapprt, gal setting is ne f the first therapeutic activities t be cmpleted in Brief CBT. Althugh gals can be changed/mdified at any pint during therapy, t maximize applicability and benefit t the patient, a preliminary set f gals shuld be established and agreed upn by the end f the first r secnd sessin. Hw? (Instructins/Handuts) Gal setting begins with the identificatin f brad gals. These are glbal and refer t areas f functining (e.g., family, wrk, scial relatinships, financial cncerns, health, etc). Brad gals are clsely tied t the therapist s case cnceptualizatin and the patient s presenting prblem. Once brad gals are identified cllabratively, the patient and therapist priritize gals. This prcess invlves determining the mst central issues that cause cncern and arranging them frm mst imprtant t least imprtant. Starting with the prblem that has the best chance f being slved can help increase the patient s cmmitment t therapy. If ne skill is prerequisite t a subsequent gal, that gal can als be priritized in treatment (e.g., relaxatin befre expsure, awareness f thughts befre thught challenging). Use a graded apprach t gals, in which yu take small steps in service f the larger gal each week thrugh sessin cntent r hmewrk assignments. Identifying and sequencing actin steps invlves breaking each gal int smaller steps t help the patient knw what t d at every stage f accmplishing the gal withut feeling verwhelmed by a huge task. Once gals have been identified and priritized, they are peratinalized, which invlves defining the gal and all the steps that it will take t achieve it in cncrete, bservable/measurable cgnitive r behaviral terms. Example Gal: Learn tw cgnitive and tw behaviral strategies fr cping with stress. Operatinal Cgnitive Gals Learn and use thught testing and prblem slving t manage anxius thughts/situatins Operatinal Behaviral Gals Plan and cmplete ne pleasant r scial activity per week Page 1 f 5
Assessing Facilitatrs, Barriers, Imprtance and Cnfidence Once a gal r multiple gals have been established, it is critical t assess the patient's situatin and attitudes abut the gals. Fr example, ask whether there are aspects f the patient's life that may facilitate r inhibit the gal. A strng family and scial-supprt system may help a patient t reach his r her gal, but a functinal limitatin may create an bstacle. Explre facilitatrs and barriers and discuss strategies t maximize the chance f gal attainment. Assessments f imprtance and cnfidence are als imprtant. Ask the patient t rate the imprtance f the gal n a scale f 0 t 100 (where 0 is nt imprtant and 100 is very imprtant). Discuss ratings lwer than 60 r s, and refine gals t increase meaning. Similarly, ask the patient t rate his/her cnfidence in btaining the gal. Here, cnfidence ratings culd be a little lwer but wuld hpefully increase as treatment prgresses. Trubleshting Gal Setting Sme clues that gals may need mdificatin are wrsening symptms, n change in symptms, patient failure t cmplete hmewrk (see Mdule 8: Hmewrk), and patient/cllateral reprt that the patient is nt benefitting frm treatment. In these cases, it is imprtant t revisit initial gals with the patient and elicit his/her feedback abut the prgress f therapy ( What d yu find helpful? ). Often, t-ambitius gals need t be mdified. In these cases, it is imprtant t frame the revisin in terms f taking small steps twards lasting change, nrmalize the difficulty f making changes when depressed r anxius, and jin the patient ( I think I may have gtten a little ahead f myself; let s mdify these a little, s that they can be the mst help fr yu ; I may have missed the mark n this ne; what d yu think abut adding/changing/remving a gal? ). Gal revisin shuld nt imply t the patient that he/she has failed in therapy. It is an pprtunity t mdel functinal change in respnse t changing situatins. If the patient is wrsening, discuss any changes in cntext (e.g., relatinship, wrk, sleep, medicatin cmpliance, physical health) the patient is experiencing. Create a new gal pertinent t what the patient believes is wrsening and what might help. At this pint, yu shuld als cnsult a supervisr/clleague r ther prfessinal (e.g., patient s treating physician). If the patient is nt imprving, elicit his/her feedback abut changes he r she is experiencing and his/her perceptins abut why these changes have ccurred. If a patient seems t have truble understanding the assignments, fcus n mre cncrete and behaviral skills. Page 2 f 5
Tips fr Gal Setting Prvide Ratinale fr Setting Gals. This helps the patient understand the directin f treatment and hw he/she will be invlved in the prcess. Elicit Desired Outcmes. Example: If yu can identify what yu want t change abut yur situatin, we can then take steps t crrect the prblem. This invlves the therapist s assisting the patient in defining gals and specifying reasns fr cming t treatment. Example: List a few things yu wuld like t get ut f therapy. Be Specific Abut What the Gal Is. Determine each gal, what the gal is attempting t target, and what the patient s rle is in reference t the gal. Guide the patient twards gals that require change frm him/her (vs. thers). Example: Yu said that yu want yur wife t listen t yu. Since we can t really make smene d what we want, what culd yu d t help yu feel heard r cpe with a situatin when yu dn t feel heard? State Gals in a Psitive Light. This clarifies what the patient wants t d instead f highlighting what he r she desn t want t d. Example: List sme things that yu want, instead f things that yu dn t want. Fr example, instead f I dn t want t be depressed anymre, yu culd list, I want t enjy my favrite hbbies again. Weigh Advantages and Disadvantages f a Gal. This aids in understanding the csts and benefits f the patient s achieving the gal. It may be used t mtivate an ambivalent patient r identify salient gals fr a passive patient r a patient seeking t please the therapist. Example: What wuld be the benefits if yu accmplished this gal? What might be sme f the csts t yu? Page 3 f 5
Define Behavirs Related t Gal. Tips fr Gal Setting (cntinued) This instructs the patient what actins t perfrm in relatin t the gals that have been set. Define a Level f Change. Example: What wuld it lk like if yu were less depressed? If I saw yu and yu were feeling happy, what wuld I see? What d ther peple d when they are happy? What things d yu think have changed in yur life since yu have been depressed? What did yu used t d that yu enjyed that yu dn t d anymre? This determines hw much a patient shuld d a particular behavir. T increase the patient s chance f success, set achievable gals. In ther wrds, it is usually nt reasnable t try t d smething every day, and setting a gal like this will result in failure if the patient misses just 1 day. Alternatively, discuss the gal with the patient; and start small. If the patient succeeds, he/she is mre likely t remain actively engaged. Example: Hw ften d yu think it is reasnable t d smething pleasant? Once a week? Regularly Evaluate Symptms. Track hw effective the gals are in decreasing mental health symptms and increasing functining and quality f life. Fr example, assess the fllwing areas during the intake prcess, during the actual interventin strategy, and a mnth t a year after terminatin f therapy: Patient s level f satisfactin with yur assistance and the results f therapy Amunt f grwth the patient experienced frm the beginning f therapy t the end Benefits btained by the change made by the patient and which treatment was effective in helping t accmplish the gal Self-reprt tls, such as the Beck Depressin Inventry r md-tracking charts, and clinician-administered assessments, such as the Hamiltn Depressin Rating Scale, may be used as bjective measures f change ver the curse f treatment. Example Hmewrk Assignments 1. Make a shrt list f brad gals. What areas f yur life d yu wish t imprve (e.g. wrk, family, scial, recreatinal, financial, health, etc.)? Think abut which gal wuld be mst imprtant. 2. List three issues, in rder f imprtance, that yu want t discuss in the next sessin. 3. Weigh the prs and cns f each gal that we have agreed upn in treatment. Page 4 f 5
Supplemental Readings Beck, J.A. (1995). Cgnitive therapy: Basics and beynd. New Yrk: Guilfrd Press, Chapter 6. Crmier, W.H. & Crmier, L.S. (1991). Interviewing strategies fr helpers: Fundamental skills and cgnitive behaviral interventins, 3rd ed. Pacific Grve, CA: Brks/Cle Publishing Cmpany; Chapter 10. Page 5 f 5