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Reference–aneditedversionhasbeenpublishedasabookchapter:Elliott,A.,Butler,J.&Kearns,T.(2017)FormulatingGoalStatements.InS.Trenoweth&N.Moone(Eds.)PsychosocialAssessmentin

MentalHealth(Chap14,p211-227).London:SagePublicationsLtd(ISBN978-1-4739-1284-7)

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FormulatingGoalStatementsAlisonElliottMSc,PGCert,BSc(Hons),DipHE,RMNSeniorLecturerinMentalHealth,UniversityofCentralLancashireJohnButlerMSc,PGDipHE,BSc(JtHons),CertCBT,RMN,RNT,FHEASeniorLecturerinMentalHealth,UniversityofCentralLancashireTraceyRogersMSc,BSc(Hons),RMNLecturerinMentalHealth,UniversityofCentralLancashire

ChapterObjectivesThroughtheconsiderationofshortcasestudiesandreflectiveactivities,thischapter:o providesanunderstandingofgoalformulation;o considerspracticalmethods forengaging the individual / family-member in identifying

andprioritisingmeaningfulpersonalgoalsasakeystageofthepsychosocialapproach;o considershelpfulwaysofreviewingandmonitoringtheachievementofgoals;o promotes an awareness of strategies and resources that are helpful in overcoming

difficulties/obstaclestogoalformulation,thussupportinggoalattainment;and,o offerssomeresourcestosupportthepracticeofgoalformulationandreview.IntroductionThis chapter introduces the concept of goals and collaborative goal formulation as a keyfeature of psychosocial assessment and intervention. It offers practitioners a practicalapproach to working alongside individuals to formulate meaningful short and long-termgoals, exploring how this can be achieved, and highlighting useful tips in the event ofdifficultiesandobstacles.Goalsettingisanessentialcomponentofapsychosocialapproachand goals should be agreed from the outset, otherwise it can be unclear as to theprogression of interventions and whether they have had any impact on the distress /problemsexperiencedbytheindividual(Laidlaw2015).GoalSetting:afeatureofPsychosocialApproachesAgoalmayberegardedasadesiredoutcome,assomethingthatyouwishtoachieve,suchas living independently, getting a jobor gettingmarried (Wright et al 2014, p.52). Settingandworkingtowardspersonalandmeaningfulgoalsisaneffectivewayoffocusingyourlife,achieving a sense of value andmanaging stress, which enhances the individual’s morale,motivation, senseof achievement and self-confidence, reducesdistress and their senseofdemoralisationandhopelessness,andthuspromoteshopeandrecovery(Meyeretal2010;Powell2009;Westbrooketal2007;Wrightetal2014).



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Workingwiththeservice-userandtheircarerstonegotiateandenabletheirachievementofrealistic goals forms one of the Ten Essential Shared Capabilities (DH 2004), providingservice-user centred care. Supporting the individual to set and reach recovery-focused,strengthsbased,personal lifegoalsprovidesmeaning for the individual (Slade2009,p.10-16):anapproachthathasconsistentlybeenemphasisedwithinprioritiesformentalhealthcare(DH2006).Therearemanydifferentapproachestoestablishingclearandmeaningfulgoals,asmaybeevidencedthroughthepracticeofgoalsettingasakeyfeatureofboththenursingprocess(Barrett et al 2012) and several psychosocial approaches and strategies – consider thefollowingexamples.Goalsettingformsakeycomponentoftheplanningstageoftheproblemsolvingapproachtonursingcaredelivery,withgoalsofferingshortdirectivestatementsof theoutcomesofcare(Barrettetal2012).Meyeretal (2010)recommendhelping individualswhohaveaseveremental illnesstosetand achieve goals, as an essential component of their IllnessManagement and Recoveryprogram,emphasisingaperson-centred,individualisedandrecoveryfocusedapproach.Asacomponent of a standardised intervention, which involves a combination of educational,motivational and cognitive behavioural strategies, this program enables the individual todefine personally meaningful goals, supporting them to manage their illness through theachievementoftheirgoals(p.23-5).WithinCognitiveBehaviourTherapy,collaborativegoalsettingformsanimportantphaseofthe intervention process, helpful in maintaining the structure and focus of sessions.Expressedinspecificterms,goalsfocusuponissueshighlyrelevanttotheindividual,andareuseful in testing predictions, promoting positive behavioural change andworking towardsagreedoutcomes(Westbrooketal2007;Wrightetal2009).AfeatureofBehaviouralFamilyIntervention(Falloonetal2004),individualfamilymembergoals and collective goals for the family are agreed over a series of individual and familysessions. Goal setting with the family is facilitated as part of the assessment phase andreviewed within educational sessions, which involves providing a rationale together withspecificexamples,assistingthefamilytoagreeandworktowardsoneormoremeaningfulgoals.Importantly,practitionersand teams thatare trained ingoal settingaremore likely to setgoalsthatservice-users/family-memberswillmeet,whichislikelytohaveapositiveimpactuponrecovery.Asanotableexample,Clarkeetal(2009)demonstratedimprovementsinthepractice of goal setting following training, in areas such as: recovery focus; levels of goalattainment;and,problemsolvingthebarrierstogoalattainment.



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WorkingtowardsasharedunderstandingSettinggoalscanbedifficult,asmanypeoplelackagoalorientation,areunsureabouthowbest to set goals, may fear or have experienced failure or disappointment, or have feltpressured to pursue the goals of others (Meyer et al 2010; Powell 2009). Furthermore,negotiating and agreeing goalswith a couple or family canprove challenging, as differentandperhapsconflictingprioritiesmayarisepriortoreachingagreement.Establishingagoodrapportandworkingrelationshipwiththeindividual/familyisthereforea pre-requisite to collaborative andmeaningful goal setting, strengthening and facilitatingdecision-making. Engaging the individual / family within collaborative formulation willenhance their understanding of their experiences and needs, lead to a focus upon highpriorityissues,andthedevelopmentofgoalsandrelatedplansforintervention/action.Theplace of goal setting within the care process is thus a key part of the care process, asrepresentedwithinFig.1.

Fig.1:goalsettingasakeystageofthepsychosocialapproach

Aswiththedevelopmentofproblemstatements,theroleofthepractitioneristofacilitateandguidethisprocess.Forgoalsetting tobemeaningful, thepractitionerclearlyneedstoadopt a style and approach consistent with some important principles for practice– forexample:• collaboratingorworkingtogetherwiththeperson,assistingthemtoagreegoalswhich

arepersonalandhighlyrelevanttotheirpriorityissues;• helpingtofocustheindividualuponadesiredoutcomethatisachievable,andsobeing

outcome-orientated;• enablingthepersontoestablishgoalsthatareclearandspecific.Thiscanbeadifficultprocess– forexample,considerthepersonwhosimplystatesthat ‘Iwantmyvoicestogo’. Ifgoalstaketheformofvague,generalandunfocusedstatements,theymayneverbeachievedandmaycontributetofeelingsoffailureandhopelessness.Itisthereforemorehelpfultosetspecificgoals.



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Of course, encouraging and assisting the individual to write down their goals can betherapeutic,expressingacommitmenttoact/dosomething,andpromotesownershipandresponsibility(Powell2009,p.131).Adequate time needs to be allocated for setting goals, being mindful of the potentialdifficultiesthatmayarise.Negotiationiskeyduringthisprocess,ensuringtheagreementofspecificattainablegoals,andprovidingtheindividualandpractitionerwiththeopportunitytoexplorepotentialbarriersandchallengestoachievingthegoals.When facilitating goal setting, it can be really helpful to use strategies such as openquestions, positive reframing / rephrasing, reflecting upon previous positive experiences,considering the availability of supports, andmaintaining a focus upon small steps. Thesestrategieswillenhancethechancesofachievement/successandreducetheriskoffailure,demoralisationandblame.Forexample,considertheindividualwhostrugglestobelieveintheirabilitytoachievetheirgoal,perhapssaying,‘Iwanttogototheshop,butIcan’t.’S/hecouldbeencouraged to consider:Whathashelped in thepast?’; ‘Whatwouldhelpme inachievingthisgoalofgoingtotheshops?’.IdentifyingandPrioritisingPersonalGoalsGoalsettingisameaningfulinterventionthatmaybestructuredasaseriesofsteps(Meyeretal2010,p.39-40;Powell2009;Wrightetal2014,p.52-53),asshowninTable1.

Table1:theStepsofGoalSettingStep1 explore your interests and goals before you became unwell, thinking creatively about

different areas of your life (e.g. family, home, work, study, leisure) in beginning toidentifyvaluedgoals,orwhatyou’d liketoachieve/ improveoverthenext fewyears;asacriticalfirststepinenhancingmotivationtochange,clarifywhatisimportant

Step2 review your emerging list, modifying or dropping those potential goals that areincompatibleorunattainable(Powell2009)

Step3 identifyalong-termrecovery-focusedpersonalgoal,focusinguponthedesiredoutcome,andconsiderthebenefitsofchangee.g.howwouldthingsbebetterifyouachievedthisgoal(Meyeretal2010;Treasure2004;Wrightetal2014)

Step4 identifytwoorthreerelatedshort-term,orsmallermanageablegoals,andselectoneasyourinitialfocus(Meyeretal2010;Wrightetal2014)

Step5 createspecificstepsorcommittedactionsformakingchangesandachievingeachshort-termgoal(Meyeretal2010;Wrightetal2014)

Step6 identifyandplanfortheobstaclesorchallengesthatmayneedtobeovercome(Powell2009)

Step7 steadilytakestepstowardsthegoal,gainingsupportandassistanceasneeded(Meyeretal2010)

Step8 recogniseandcelebrateeffortandsuccess,andovercomingobstacles(Meyeretal2010;Powell2009)



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Asarecommendedstageinmeaningfulgoalsetting(steps3&4),itisthereforeimportanttohelpthe individualtoconsiderboth longandshort-termgoals,whichmaybedescribedasfollows:• short-term goals tend to relate to the stages or steps that are necessary in achieving

long-term goals, often being the first steps towards recovery, which are possible toachieve in the short term (e.g. a few weeks) – they may thus be viewed as processorientated;

• long-termgoalsfocusuponwhattheindividualwouldliketoachieveinthelongerterm(e.g. 3 – 6 months), providing overall direction and hope, and usually focus upondeveloping meaningful activities e.g. a job, independent living, confiding / intimaterelationships (Wright et al 2009, p.261-2) – they may thus be viewed as desiredoutcomes(beingoutcomeorientated),andareideallyrecoveryfocused.

ConsideringCaseStudiesAsafocusfordiscussionandinprovidingillustration/examples,considerthefollowingtwocasestudies,asshowninBoxes1&2.

Box1:CaseStudy1–JulieJulie isa49-yearoldwomanwho liveswithhermother. Shedoesn’thaveany childrenandhasnever beenmarried. Julie used towork as a photographer and has travelled the world but forapproximately10years shehasnot felt able towork.Although Julie liveswithhermotheranddescribes having a close relationship with her, she remains isolative and does not discuss hersymptomswithhermother.Julie first began to hear derogatory voices in her early 20’s, and although the voices weredistressing she was able to continue with her work. Julie has a history of alcohol use but hasremained abstinent for over fivemonths now. Julie continues to experience both positive andnegativevoices,thelatterbeingthemostprominentanddistressing.Asaresultofherdistressingsymptoms,Julieonlygoesoutwhensheneedsto.Sheavoidsbusyandunfamiliarplaces,andavoidsmakingeyecontactwithothersbecauseshebelieves thatshecan read people’s minds and they are being negative towards her. Julie is low in mood anddistressedforlargeperiodsoftheday.Shefeelsthatthevoicesareverypowerfulandshehasnocontroloverthem.Despitethevoicescausingherdistress,Juliedoesnotwanttolosethevoices,stating that she would feel lonely without them and sometimes feels that they are trying toprotectherandkeepherfromharm.TheABCmethodwasusedtohelpindevelopinganunderstandingofherdistressingexperienceofthevoices:

Aactivatingevent

Bbeliefs/thoughts

Cconsequences

hearingthevoiceswhengettingreadytogoouttothe

shop

As the voices tell me, I amuseless, stupid, worthless, Ishould kill myself, I’m notworthanything,they’regoingtogetmeIbelievethevoicesIfeelworthless

distressedagitated&pacingaroundstayingin/notgoingout



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Box2:CaseStudy2–theSmithfamilyMelanieisa42-yearoldwomanwholivesonherown,andhasdailycontactwithherparents,JimandGill.Havingadiagnosisofschizophrenia,Melaniehasbeenreceivingcarefromlocalmentalhealth services for over 10 years now, though she depends on her parents for practical andemotional support, and particularly her Dad. Her parents feel that they have little quality timetogetherandthatmuchoftheirtimeistakenupwithMelanie.Thefollowingfamilygenogramoftheimmediatefamilywasdeveloped:Prior to becoming unwell,Melanie worked in a local supermarket, although found this difficultduetobelievingthat:‘I’mbeingwatched/followed;theygoingtogetme;theywanttohurtme;they’regoingtokidnapme.’Melanierecognisesthatsheisdependentonherparentsforsupport,inparticularspendinglongperiodsoftimewithherfather.Melaniefindsitdifficulttotalktohermotherandfeelsthatsheis‘gettingather’.This results indifficulties intheir relationship,argumentsandhostility. Jimfeelsoverwhelmedbyhiscaring role,butfeelsheneedstohelptokeepMelaniewell.Gill feelsthatMelanieismoreableandshedemonstratesthiswhensheiswithher.

Jim69-yearsold

retiredseesMelaniedaily&feelsoverwhelmed

Gill67-yearsold

retiredfeelsthatshehaslittlequalitytimewithJim

Liam45-yearsold

worksfulltimefortheRoyalNavylivesaway

Melanie42-yearsoldunemployed

livesindependentlyseesparentsonadailybasis

difficulttotalktomum

ReflectiveActivity1:Considerthetwocasestudiesandtryto identifysomeexamplesofshortandlong-termgoalsbothforJulieandformembersoftheSmithfamily.



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Inclarifyingthedifferencebetweenlongandshort-termgoals,considertheexamplesshowninTable2.

Table2:ExamplesofShort&LongtermGoalsShortterm Longterm

Juliewantstogetupat9ameachmorning

Juliewouldliketoreturntowork(photography)

Juliewouldliketobeabletolistentothevoicesfor10minuteseachday

Juliewouldliketobeabletogototheshopsonherown

Jimwantstore-startplayinggolfonceeachweek

Jimwouldliketoimprovehisphysicalhealth

Gillwouldliketogoforamealwithherhusbandonceeverytwoweeks

Gillwouldliketohavemorequalitytimewithherhusband(Jim)

Thoughitishelpfultodevelopbothshortandlongtermgoals,itisimportanttorealisethatshort-term goals are likely to be more helpful in the first instance, as these will have agreaterchanceofearlysuccess,andwillthereforeassistinfurtherenhancingtheindividual’shope,morale,motivationandcommitmenttochange(Morrisonetal2004).Whennegotiatinggoals,itisessentialtoclearlydefineandprioritisegoalswiththeperson.The risk of failure to achieve the agreed goals will increase if you are not clear, specific,realistic and time-orientated (Meyer et al 2010).Negotiation and collaboration are key toreducing any potential conflict, clarifying the rationale andmeaning of the goals that areagreed, and in agreeing priorities. When prioritising, it is important to consider risk /urgency, the importanceof thevariousgoals, the individual’s levelofdistress,orwhetheronegoalneedstotakeprecedence(Westbrooketal2007,p.156).

FormingMeaningfulGoalStatementsWhendevelopingmeaningfulgoalsitisimportanttobepersonalised,clearandspecific.Toassist this process, consider the following two well-known methods for writing goalstatements.Method1:consideringbehaviour,conditions,frequency&durationAs described by Fox and Gamble (2006), the initial stage to forming a meaningful goalstatement involves asking the individual to describe what they would like to achieve,encouraging them to describe something they would be doing (a positive change oralternativebehaviour)thatwouldindicatethattheproblem/issueislesssevereorhasbeenresolved.

KeyMessage:toenhanceasenseofownership,hopeandrecovery,itispivotalthattheidentifiedgoalsaregeneratedbytheindividual



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Westbrooketal (2007,p.155)andWrightetal (2014,p.181-2)recommendfacilitatingthisprocessofidentifyingameaningfulgoalbyaskingafewopenquestions–forexample:Whatwouldbeameaningfulchangeforyou?,Whatwouldyoulikethingstobelike?,Whatwouldgiveyouasenseofpurpose?,Whatwouldyouliketobedifferent?Thenextstagewouldinvolveenablingtheindividualtophraseagoalstatement,usingtheirown words. Facilitating this process would involve reflecting back what s/he wishes toachieve,inclarifying,refiningandfine-tuningthegoalstatement.FoxandGamble(2006)proposetheuseofaveryhelpfulstructureinformulatingaclearandmeaningfulgoalstatement:behaviour;conditions;frequency;and,duration.So,when forming a clear goal statement, always succinctly define the positive behaviour,and,asrelevant,captureanyrequiredconditions,thefrequencyandtheduration.Thelatterelements are helpful in providing clarity, measurement and sustainability. To illustrate,considerthecasestudies,andthegoalsforJulieandforGill(MrsSmith),asshowninTable3.

Table3:GoalStatements–behaviour,conditions,frequency&durationalwaysinclude andasrelevant…Behaviour Conditions Frequency DurationJulie:Iwouldliketobeabletoshopinthelocalsupermarket

onmyown atleasttwiceeachweek

foratleast90minuteseachtime

Gillian:Iwouldliketogooutforamealinarestaurant

withmyhusband onceeachweek foratleast2hours

Method2:who,what,where/how&whenInconsideringtheformulationofmeaningfulgoalstatementsfocusinguponaddressingriskissues, Hart (2014, p.147-151) describes an alternative helpful structure: the concernedperson(orwhowilltakeresponsibilityfortheaction/solution);theobjective;thecontext/setting;and,thetime-frame.Similarly,Barrettetal(2012)recommendconsiderationofthefollowingwhendevelopingagoal:• Whowillachieveit?• Whatwilltheyachieve?• Howwilltheyachieveit?(alternatively:where/thesetting)• Whenwilltheyachieveitby?

Soforexample:Julie(whoby)willkeepherselfsafe(what)whilstathome(thesetting)overthenext2weeks(when).



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TestingGoalStatementsIndevelopingmeaningfulgoals,itishighlyrecommendedthateachgoalisclearlyexpressed,tofacilitateameaningfulreviewatkeypoints.Itisthereforeimportanttoensurethateachgoalisconsistentwithaseriesofkeycriteriaorprinciples,whichhavebeensummarisedbyseveral authors in the form of ‘aide memoire’ style acronyms, as shown in Fig. 2 anddescribedbelow.

Fig.2:TestingGoals

Thesecommonacronymsreferto:• SMART = Specific, Measurable, Achievable, Relevant / Realistic & Time-limited (for

example:Wrightetal2014)• SMARTEN = Specific, Measurable, Achievable, Realistic, Time-orientated, Explicit &

Negotiated(Padmore&Roberts2013)• RUMBA=Relevant,Understandable,Measurable,Behavioural&Achievable• SPORT=Specific,Person-centred,Observable,Realistic&Time-bound• MACROS=Measurable,Achievable,Client-centred,Realistic,Outcome-written&Short

(Barrettetal2012)• PRODUCT = Patient-centred, Recordable, Observable & measurable, Directive,

Understandable&clear,Credible,Time-related(Barrettetal2012)These variations of well-known acronyms clearly share and reinforce the importance ofsomecommonprinciples:

ReflectiveActivity2:Remindyourselfaboutcasestudy2andpracticewritingagoalstatementforMelanieandforJim,usingoneoftheabovemethods.



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• Realistic: it is important to ensure that each goal is realistic, not too limited or over-

ambitious,whichmayrequiresomedelicatenegotiationwiththeindividual(Westbrooket al 2007: 156), thus increasing the likelihood of completion – so, can you make ithappen?

• Understandable:eachgoalneedstobewritteninasimpleway,suchthatthemeaningisclear–so,isitclearandeasytounderstand?

• Measurable: clarifyinghow the goalwill bemeasured allows for frequent and specificreviewsofprogress–so,howwouldyouknowthatyou’vecompletedyourgoal?

• Behavioural:describing something that thepersonwouldbedoing–so,does it clarifytheactionthatwillbetaken?

• Achievable:negotiatingwhatwillbeachievablegiventheindividual’sownresourcesandabilities(e.g.skills,time,supportsfromothers,money,transport),focusinguponwhatiswithin the person’s control, rather than relying upon the actions of others – so, is itpossibleforyoutodo?

• Specific: ensuring that the goal is very clear to the individual and is tailored to need,clearlyidentifyingwhatwillbedone–so,isyourgoalspecificenough?

• Time-bound: agreeing the time frame for completion allows for a focus uponprogression, though some flexibility is helpful – so,whenwill you have achieved yourgoal?

It is helpful to select and apply one of these aide memoires in ensuring that you havenegotiatedameaningfulgoal, thuspromotingthe individual’ssuccess inactuallyachievingthegoal.Thismay lead tomodifyingandstrengthening thegoal statementand/or furtherbreakingdownagoalintoaseriesofsub-goals.Inpractice,asyoucollaborativelyformulateagoalstatement,explainthepreferredaidememoiretotheindividualasaguidetotestingandagreeingameaningfulgoal.Reviewing&MonitoringAchievementItisveryimportanttoensureopportunitiesforthefrequentreviewofprogressinachievingagreedgoals,forwhichseveraloptionsmaybeconsidered.Asexamples,Meyeretal(2010,p.41), Powell (2009, p.134) andWright et al (2014, p.181-2) offer goal setting / planningrecord forms which may be useful in explicitly recording and reviewing the setting andcompletionofgoals.InadditiontowritingoutaSMARTgoal,theseproformasalsoinvolvespecifyingaseriesofrelatedactionsteps.Asafurtherresource,considerourexamplebelow(Fig.3).Toillustrate,thisconsidersJulie’sgoals,withafocusuponshort-termgoal2.AblankcopyofthisproformaisprovidedforyourownuseinAppendix1.Asshownintheexample,theindividualisinvolvedinmonitoringandratinghowclosetheyaretoachievingtheirgoal,usingasimplescalingmethod.



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Fig.3:ExampleGoalMonitoringRecord

Long-term goal – write down the goal you’d like to achieve over the next 3 – 6monthsconsideringhowyou’dlikethingstobedifferentintermsofyourfeelingsandbehaviour.I’dliketojoinashortcourseonphotographyatthelocalcollegewithinthenextsixmonths.

Short-term goals – now break down your long-term goal into two or three smaller,manageable, short-term goals that you like to achieve over the next few weeks; thenhighlighttheshort-termgoalthatyou’dfirstliketoworkon,bycircling/underliningit.Goal1 I want to better structuremy day, getting up by 9am eachmorning –within 2

weeks.Goal2 I would like to be able tomanage the voices, feeling less distressed by them –

within4weeks.Goal3 Iwant tobeable togo to the local supermarketonmyown,onceeachweek–

within6weeks.Steps–youmayalsofindithelpfultowritedownaseriesofsteps/actionsthatyouneedtotakeinachievingyourchosenshort-termgoal.Step1 Tostartmonitoringmyvoiceswithinavoicesdiary.Step2 Tomakealistofpotentiallyhelpfulwaysofcopingandmanagingthevoices.Step3 Toselecttwowaysofcopingandtotrytheseout.Step4 Tomonitorhowwellthesecopingstrategiesworkthroughmydiary.Monitoringyourprogress(usinga0–10scale)write in dates forreview

ratehowcloseyouaretoachievingyourgoal,byplacingamarkontothescale(0=noprogress;5=partiallyachieved;10=fullyachieved)

2ndJuly 0 1 2 3 4 5 6 7 8 9 10

12thJuly 0 1 2 3 4 5 6 7 8 9 10

22ndJuly 0 1 2 3 4 5 6 7 8 9 10

As amore sophisticatedmethodofmonitoringand review,Bovend’Eerdtet al (2009) andClarkeetal(2006)describetheuseofgoalattainmentscaling:amethodforevaluatingtheattainmentofgoals,whichinvolvesratingattainmentonadefined3or5-pointscale,wherethemidpoint refers to theexpected level (or indicator)ofperformance,andthehighandlowcategoriesof thescalerefertomuchbetterormuch lessthanexpectedperformance.Appliedwithintherehabilitationsetting,thismethodreliesupondefiningclearmeasurablegoalsandindicators,andcanincludetheweightingofgoalsforimportanceanddifficulty.Monitoring performance and providing feedback has the potential to further enhancemotivationandprogress,allowingthepersontoconsiderwhattheyhopedtoachieveversuswhattheyactuallyachieved(Clarkeetal2006).

ReflectiveActivity3:TakealookatthegoalsinFig.3–towhatextentarethesegoalsSMART?TryproposingsomestepsthatJuliecouldtaketoachieveshort-termgoals1&3.



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SupportingGoalAttainment:identifyingresourcesPsychological well-being and goal attainment are closely associated and, according toSchindlerandSauerwald(2013),thesupportoffriendsandfamilyisaninfluentialfactorinrelation togoalattainment. It’s important therefore toconsiderhowgoalattainmentmaybe effectively supportedby family / friends: onemethod is by theuseof the red / greenpeople exercise, wherein the service user is asked to consider those peoplewhomay besupportiveofgoalattainment(greenpeople),andthosewhomaynotbesupportiveormaysabotage goal attainment (red people), with the aim of increasing contacts with ‘greenpeople’,thusmakingattainmentmorelikely.ThisSocraticapproachenablesexplorationanddiscussionofhelpfulandunhelpfulrelationshipsinrelationtothedesiredgoal,andpotentialdifficultieswithregardtoachieving it.Thered/green‘people’can includethe individual’s‘voices’andtheirrelationshipwiththem(seeFig.4),andtheexercisecanbeusedinrelationto a variety of goals e.g. Julie’s goal of going to the supermarket, or can be applied toreducingalcohol/drugconsumption.

Fig.4:Example–usingtheRed/GreenPersonExercisewithJulie

ForJulie,itwouldappearthathermumandthe‘angel’voicesshehearsarehelpfultoher,thereforeintermsofsupportinggoalattainment,itwouldbeimportanttoenlisthermum’ssupport(withJulie’sconsent),andtofocusonreducingthe impactofthedevil’svoiceshehears.



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Inadditiontoenlistingthesupportoffamilyandfriends, it’salsohelpfultorecordsuccessand failure (aidedby theuseof activity scheduling / diary recording etc…), and to ensurethat progress towards the desired goal is monitored regularly (through care planning).However,buildinginanawarenessoftimeswhenattainmentmaybemoredifficultorlesslikelycanbehelpfule.g.stresscanadverselyaffectmotivationandimpactuponsymptoms,so an awareness of and realistic contingency plans in relation to this can be helpful insupportinggoalattainment.Other strategies can include the provision of information as to local and online resourceswhereserviceusersandfamilies/carersmaybeabletoaccesssupport,examplesofwhichareshownbelow.WebResourcesForserviceusers/familieswww.selfhelpservices.org.uka NorthWest based, user led mental health charity, which provides a range of support,servicesandopportunities forpeople livingwithcommonmentalhealthproblemssuchasanxiety,depression,phobiasandpanicattacks;atleast60%ofthestaffhavehadpersonalorlivedexperienceofacommonmentalhealthproblemwww.moodjuice.scot.nhs.ukaScotland-basedwebsitedesignedtohelppeoplethinkaboutemotionalproblemsandworktowardssolvingthem;providesinformationandlinkstolocalresourcesforarangeofissuese.g.benefitanddebtadvice,health related information,organisations / services, selfhelpguidesetc…www.healthtalk.org/peoples-experiences/mental-health/experiences-psychosis/topicshasusefulinformationaboutpsychosis,causes,treatments,andcopingstrategiesetc…www.nhs.uk/Conditions/stress-anxiety-depression/Pages/low-mood-stress-anxiety.aspx‘MoodZone’hasinformationaboutcommonmentalhealthproblems,andtipsonimprovingmentalwellbeingaswellaslinkstootherpotentiallyusefulinformationhttp://www.mentalhealth.org.ukthe Mental Health Foundation provides information about a range of mental healthproblems,aswellasbeinginvolvedinresearchandpolicydevelopmenthttp://www.mind.org.ukMIND provides information about a range of mental health problems, information aboutrights,andwheresupportcanbeaccessed



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www.rethink.orgRethinkprovidesinformationandadviceinrelationtolivingwithmentalillness,hasarangeof services and support groups nationally, and campaigns to improve policy in relation tomentalhealthwww.turning-point.co.ukTurning Point is a social enterprise, providing services which focus on improving lives forpeople, especially those with complex needs, across mental health, learning disability,substancemisuse,primarycare,thecriminaljusticesystemandemploymentwww.self-help.org.ukafreesearchabledatabaseofover1,000selfhelporganisations,patientsupportgroupsandcharities across theUK that provide support, guidance and advice to patients, carers andtheir relatives; thegroupsandorganisations covera rangeofmedical conditions,diseasesandtreatmentshttp://self-help.toolsprovidesfreedownloadableselfhelptools,informationaboutCBT,andadviceabouthowtofindanappropriatetherapistForpractitionerswww.getselfhelp.co.ukhasfreedownloadableinformationleaflets,handoutsandtoolsetc…www.therapistaid.comhasfreedownloadableresourcessuchasworksheets,videos,guidesetc…http://psychology.tools/hasfreedownloadableinformationaboutarangeoftherapeuticapproaches/techniquestoarangeofproblems,inarangeofdifferentlanguageshttp://healthypsych.com/psychology-tools-series20free,downloadablepracticalpsychologytoolsbasedincognitivebehaviouralscienceandmindfulness-basedtheoryhttp://www.cci.health.wa.gov.au/resources/index.cfmfreedownloadableresourcestoassistinprovidinginterventionsformentalhealthproblems;theresourcesaimtoprovidegeneralinformationaboutvariousmentalhealthproblems,aswellastechniquesthatfocusonacognitivebehaviouralapproachtomanagingdifficulties



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IdentifyingandOvercomingDifficulties&ObstaclesTheremaybeoccasionswhenthepractitionerandindividualdonotagreeongoalse.g.anindividualdetainedunder theMentalHealthActmaywant tobe immediatelydischarged,which reinforces the need for sound therapeutic engagement and negotiation skills forpractitioners,butalso thatgoals shouldbeachievableand relate to thingsoverwhich thepersonhassomecontrol. It isalso importanttoconsiderwhethertheserviceuserhastheresourcestheyneedinordertoachievetheirgoals.Motivation occurs when there is a discrepancy between how people currently seethemselves / their situation, and how they want things to be e.g. wanting / achievingpersonal goals, and it diminishes if (see: Boudreaux & Ozer 2013;Westbrook et al 2007;p.154-156;Wrightetal2009,p.260-264):• findingitdifficulttoidentifyspecificgoalsduetofeelingdistressed;• agreed goals are set too low or too high e.g. short-term goals seeming too simple or

beinginconsequentialfortheperson,orbeingunabletoprogresslong-termgoals;• beingoverlypressuredtoachievethesetgoals;• tryingtoworktowardsmultipleorconflictinggoalsatthesametime;• goalsarepoorlydefined.Bullard and Slade (2014) emphasise the importance of collaboration and the earlyidentification of goals,which is supportedbyMcKeown,McCann and Forster (2002),whosuggest that practitioners should ensure that when working collaboratively with serviceusers,goalstatementsarekeptassimpleaspossible,usingbehavioural(measurable),clearandunambiguouswording.However,sometimesactivitiesandgoalscanbeoverwhelming,andso itcanbeusefultobreakgoalsdownintospecificandsmallersteps,workingattheperson’sownindividualpace.Being specific when setting goals also assists in identifying barriers or difficulties theindividualmayhaveinachievingthem,howeveritisalsoimportanttoavoidframinggoalsintermsofhowtheserviceuserwouldpreferNOTtobee.g.notdrinking,notfeelingafraidorstaying inall the time,whichWestbrooketal (2007) refer toas the ‘deadmanssolution’.Instead,serviceusersshouldbeaskedtoconsiderhowtheywouldlikethingstobe,orwhattheydowanttodo.Usingthe‘MiracleQuestion’(seeWestbrooketal2007:155-6)canhelpthisprocess,asfollows:

‘I’mgoingtoaskyouaquestionthatsoundsreallystrange,butit’dbereallyhelpfulifyoucouldtryandansweritashonestlyaspossible,isthatOK?’‘Imaginethatyougotobedtonightandwhileyouwereasleepamiraclehappens,whichmeansthattheproblemyou’vecomeherewith,completelydisappears.’‘Whenyougetupinthemorning,howwouldyouknowthattheproblemhadbeensolved? What sorts of things would be happening? What would you see? Whatwouldyoubedoing?’



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When following this up, it’s important to ask for positive behavioural (measurable)descriptions e.g. ‘if you felt happier, whatwould you be doing?’, and to reinforce this byasking further questions such as ‘what else?’ questions, and ‘relationship questions’ e.g.‘whatelsewouldbehappening?’, ‘whatwouldotherpeople sayordo?’, ‘whatwould theythink?’, ‘howwouldotherpeoplenoticethatthismiraclehadhappenedandthatyouweredifferent?’,‘whatwouldtheysay?’Itisimportanttoappreciatethatthisprocessmaybedifficultforserviceusers,togivethemtime, and to accept their concerns. However, the process can allow practitioners to raiseserviceusers’awarenessofexceptionsintheirlives,asfollows:

‘Iknowthatthismiraclehasn’thappened,butarethereany,evenreallysmallthingsthathavealreadyhappened/arehappeningalready?’‘Tellmeaboutatimewhenthisproblemwasn’tsobad,whatthingswerehappeningthen?’‘Whatwashappeningwhenyoudealtwiththismore/mostsuccessfully?’‘Aretheretimeswhenthisproblemisnotasapparent?Whatdidyoudotoinfluencethis?’

Another potentially useful strategy is that of ‘chaining’ which, according to Grist (2015),‘allowsforthemotivationmuscletobestretched’bylinkingsmalleractivitiestoanultimategoal–considertheexampleforJulie,inrelationtogoingtothesupermarket(seeFig.5).

Fig.5:Example–usingChainingwithJulie

Remember: one of the key barriers to service users achieving their goals, and thereforemakingdisengagementmorelikely,isthatgoalshavebeenpoorlyarticulatedandwritten.



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RecognisingthechallengesofwritinggoalstatementsAs discussed, when setting goals it is recommended where possible to ensure that goalstatementsaretestedagainstkeycriteria,assummarisedthroughtheuseofacronymssuchasSMART.ReflectiveActivity4:testingandenhancinggoalstatementsTaking time to review this chapter, critically review the following goal statements,consideringtheextenttowhicheachgoalisSMARTand,ifappropriate,proposeanexampleofabetterphrasedandSMARTergoalstatement.Youmayfindithelpfultorelatethesegoalstatements to particular individualswithin the case studies, or to draw from your clinicalexperience.1. ForGilliantosleepbetteratnight2. ForJulietoremainstableinmood

3. Juliewillbesymptomfree4. Jimwouldliketohavequalitytimewithhiswife5. ForMelanietocomplywithhermedicationOnceyouhaveproposedyourownalternativegoals,considertheexamplesprovidedwithinAppendix2.FormulatingGoalStatements:10keypoints• Agoalmayberegardedasadesiredoutcome,assomethingthatyouwishtoachieve.• Goalsettingisameaningfulinterventionwhichmaybestructuredasaseriesofsteps.• Establishingagoodrapportandworkingrelationshipwiththeindividual/familyisapre-

requisitetocollaborativeandmeaningfulgoalsetting.• The practitioner is recommended to adopt a collaborative approach in facilitating the

developmentofspecific,highlyrelevantandpersonalised,longandshort-termgoals.• Workingtowardsshort-termgoalsislikelytobemorehelpful,offeringagreaterchance

ofearlysuccess,andfurtherenhancingmotivationandcommitmenttochange.• When formulating goal statements, succinctly define the positive behaviour and, as

relevant,captureanyrequiredconditions,thefrequencyandtheduration.• Testandfine-tunegoalstatementsbyusinganaidememoire,suchasSMART.• Ensureopportunitiesforthefrequentreviewofprogressinachievingagreedgoals.• Consider accessing the support of friends, family and other resources in progressing

agreedgoals.



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• Considertheuseofhelpfulpracticalstrategiesinovercomingdifficulties,challengesand

obstacles–forexample:breakinggoalsdownintosmallermanageablegoals;useoftheMiracleQuestion;chainingtechniques.

ChapterSummaryIn this chapter, we have considered the place of collaborative goal setting within thecontemporarypracticeofpsychosocialandmentalhealthassessment.Wehavepresentedaseries of practical methods for the negotiation of personalised, recovery-focused,meaningful goals, and considered the importance of frequent monitoring and review. Indiscussingaseriesofpotentialdifficultiesandchallenges,wehavehighlightedanumberofhelpfulpracticalstrategiesandsign-postedsomepotentiallyhelpfulresources.Inensuringapositiveexperiencefortheindividual,werecommendthatpractitionersadoptahighlycollaborative,flexibleandcreativeapproachinactivelyengagingtheindividualandtheirfamilymembersinidentifyingandachievingtheirpersonalgoals,asacentralaspectoftherapeuticassessmentandintervention.RecommendedFurtherReadingGamble,C.&Brennan,G.(2006)WorkingwithSeriousMentalIllness:AManualforClinical

Practice(2ndEdition).Edinburgh:Elsevier.A popular text among mental health practitioners who are working with those whoexperienceaseriousmental illness,JayneFox&CatherineGambleexplaintheirmethodofformulatingproblemandgoalstatementsinChapter9(p139-144).Powell, T. (2009) The Mental Health Handbook: a cognitive-behavioural approach (3rd

Edition).MiltonKeynes:SpeechmarkPublishingLimited.Areallyhelpfulresource,thisprovidesasetofpracticalresourcesandhandoutstosupporttherapeutic assessment and intervention, primarily based upon the cognitive behaviouralapproach.ACD-ROMresourceisprovidedwiththehandbook,whichincludesmaterialsongoalplanning.Westbrook, D., Kennerley, H., & Kirk, J. (2007) An Introduction to Cognitive Behaviour

Therapy:skillsandapplications.London:Sage.Apopulartextamongmentalhealthpractitioners interestedintheapplicationofcognitivebehaviouralintervention,ahelpfulsectionisincludedontheuseoftheMiracleQuestionasastrategytofacilitatinggoalsettinginChapter11(p155).



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Wright,N.P.,Turkington,D.,Kelly,O.P.,Davies,D,.Jacobs,A.M.,Hopton,J.(2014)Treating

Psychosis:AClinician’sGuide to IntegratingAcceptanceandCommitmentTherapy,Compassion Focused Therapy and Mindfulness Approaches within the CognitiveBehaviourTherapyTradition.Oaklands,California:NewHarbingerPublicationsInc.

Focusing upon the use of an integrative approach for working with service users withpsychosis, this clinical guide sets out practical interventions and exercises, supported bysampleresourcesanddownloadabletools,whichincludesgoalsetting(p.181-2).ChapterReferencesBarrett,D.,Wilson,B.&Woollands,A.(2012)CarePlanning:aguidefornurses(seeChapter

2(p19-44):ASPIRE–theproblem-solvingapproachtocaredelivery.).Harlow,Essex:PearsonEducationLtd.

Boudreaux,M.J.,Ozer,D.J. (2013)Goalconflict,goalstriving,andpsychologicalwell-being.MotivationandEmotion37,433–443.

Bovend’Eerdt,T.J.H.,Botell,R.E.,Wade,D.T.(2009)WritingSMARTrehabilitationgoalsandachievinggoalattainmentscaling:apracticalguide.ClinicalRehabilitation23,352-361.

Clarke,S.,Oades,L.G.,Crowe,T.P.,Deane,F.P.(2006)Collaborativegoaltechnology:theoryandpractice.PsychiatricRehabilitationJournal30(2),129-136.

Clarke, S.P., Crowe, T.P., Oades, L.G., Deane, F.P. (2009) Do goal setting interventionsimprove the quality of goals in mental health services? Psychiatric RehabilitationJournal32(4),292-299.

Department of Health (2004) The Ten Essential Shared Capabilities: a framework for thewholeofthementalhealthworkforce.London:DH

Department ofHealth (2006)FromValues toAction: the ChiefNursingOfficer’s ReviewofMentalHealthNursing.London:DH

Falloon,I.R.H.,Fadden,G.,Mueser,K.,Gingerich,S.,Rappaport,S.,McGill,C.,Graham-Hole,V.&Gair,F.(2004)FamilyWorkManual.Birmingham:MeridenNetwork

Fox, J. & Gamble, C. (2006) Consolidating the Assessment Process: the semi-structuredinterview. InC.Gamble&G.Brennan (Eds)WorkingwithSeriousMental Illness:amanualforclinicalpractice(2ndEdn)(Chap9,p133-144).London,UK:Elsevier

Grist, S. (2015)Why should I get fit?Physical activity asan intervention. In S.Walker (Ed)PsychosocialInterventionsinMentalHealthNursing.London:SagePublications

Harris, N., Williams, S., Bradshaw, T. (2002) Psychosocial Interventions for People withSchizophrenia;APracticalGuideforMentalHealthWorkers.PalgraveMcMillan.

Hart,C.(2014)APocketGuidetoRiskAssessment&ManagementinMentalHealth.London:Routledge

Laidlaw,K.(2015)CBTforOlderPeople:AnIntroduction.London:SageMcKeown, M., McCann, G., Forster, J. (2002) Psychosocial Interventions in Institutional

Settings.InN.Harris,S.Williams&T.Bradshaw(Eds)PsychosocialInterventionsforPeoplewithSchizophrenia:apracticalguideformentalhealthworkers(p211–235).Basingstoke:PalgraveMacMillan



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Meyer, P.S., Gingerich, S., Mueser, K.T. (2010) A Guide to Implementation and Clinical

Practiceof IllnessManagement andRecovery for Peoplewith Schizophrenia. InA.Rubin,D.W. Springer, K. Trawver (Eds)Psychosocial Treatment of Schizophrenia: aclinician’sguidetoevidencebasedpractice(Chap2,p23-87).Hoboken,NewJersey:JohnWiley&Sons

Morrison,A.P.,Renton,J.C.,Dunn,H.,Williams,S.&Bentall,R.P. (2004)CognitiveTherapyforPsychosis:aformulation-basedapproach.Hove&NewYork:Brunner-Routledge

Padmore, J. & Roberts, C. (2013) Care Planning. In I. Norman & I. Ryrie (Eds) The Art &ScienceofMentalHealthNursing:principlesandpractice (3rdEdn) (Chap15,p220-232).Maidenhead,Berkshire:OpenUniversityPress

Powell, T. (2009) The Mental Health Handbook: a cognitive-behavioural approach (3rdEdition).MiltonKeynes:SpeechmarkPublishingLimited.

Schindler,V.P.&Sauerwald,C.(2013)Outcomesofa4-yearprogramwithhighereducationandemploymentgoalsforindividualsdiagnosedwithmentalillness.Work46,325–336.

Slade, M. (2009) 100 ways to support recovery: a guide for mental health professionals.London:Rethink

Treasure,J.(2004)MotivationalInterviewing.AdvancesinPsychiatricTreatment10(5),331-337.DOI:10.1192/apt.10.5.331

Westbrook, D., Kennerley, H. & Kirk, J. (2007) An Introduction to Cognitive BehaviourTherapy:skillsandapplications.London:SagePublications

Wright, J.H., Turkington, D., Kingdon, D., Ramirez Basco, M. (2009) Cognitive-BehaviourTherapyforSevereMentalIllness.London:AmericanPsychiatricPublishingInc.

Wright,N.P.,Turkington,D.,Kelly,O.P.,Davies,D,.Jacobs,A.M.,Hopton,J.(2014)TreatingPsychosis:AClinician’sGuide to IntegratingAcceptanceandCommitmentTherapy,Compassion Focused Therapy and Mindfulness Approaches within the CognitiveBehaviourTherapyTradition.Oaklands,California:NewHarbingerPublicationsInc.



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GlossaryofKeyTermsChaining:amethodoflinkingsmalleractivitiestoanultimategoalFormulation:awayof integrating informationgathered through theassessmentphase, in

reaching a shared understanding of the themes and issues concerning theindividual’sand/orfamily’spresenting issues,needsandstrengths,whichbecomesthefocusandguideforintervention

Genogram:abriefwayofrepresentingrelevantfamilyhistoryintheformofafamilytree,

thathighlightsmajoreventsexperiencedbythefamilye.g.healthconditions,lossesof family members, where they live(d), occupations, relationships, patterns ofcommunicationetc…(foranexample,seecasestudy2)

Goal:adesiredoutcome,orsomethingthatyouwishtoachieveGoalAttainment Scaling: amethod for evaluatingprogress towards goals,which involves

useofapersonalratingtool/scalingtechniqueLong-term Goal: a recovery-focused desired outcome that can be achieved in the longer

term, within 3 – 6 months or sometimes longer, such as gaining employment orindependentliving

MiracleQuestion: a specificgoalorientatedstrategy fromBriefSolutionFocusedTherapy,

which involves considering indicators of positive change following the imaginedexperienceofa‘miracle’thatresultedinthepresentingproblemdisappearing

Short-termGoal: a process orientated stageor step towards a longer termgoal, that can

typicallybeachievedwithinafewweeksandisoftenthefirststeptowardsrecoverySMART Goal: referring to the use of the well-known ‘SMART’ (specific, measurable,

achievable/attainable,relevant/realisticandtimebound)acronymfortestingthequality and value of a personal goal statement; alternative acronyms includeRUMBA,SPORTetc…

SocraticApproach:amethodnamedaftertheGreekPhilosopher,Socrates,thisisaformof

conversation / dialogue (whether internal orwith another person)which involvestheuseofopenquestionsandreflectingstatementstosupporttheindividual’sownrealisationsandenhanceawarenessoftheirownsolutions

TenEssentialSharedCapabilities:aframeworkofsharedcapabilitiesthatallstaffworking

withinmentalhealthservicesshouldachieveanddemonstrateasbestpractice(seeDH2004)



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Appendix1

GoalMonitoringRecord

Long-term goal – write down the goal you’d like to achieve over the next 3 – 6monthsconsideringhowyou’dlikethingstobedifferentintermsofyourfeelingsandbehaviour.

Short-term goals – now break down your long-term goal into two or three smaller,manageable, short-term goals that you like to achieve over the next few weeks; thenhighlighttheshort-termgoalthatyou’dfirstliketoworkon,bycircling/underliningit.Goal1

Goal2

Goal3

Steps–youmayalsofindithelpfultowritedownaseriesofsteps/actionsthatyouneedtotakeinachievingyourchosenshort-termgoal.Step1

Step2

Step3

Step4

Monitoringyourprogress(usinga0–10scale)write in dates forreview

ratehowcloseyouaretoachievingyourgoal,byplacingamarkontothescale(0=noprogress;5=partiallyachieved;10=fullyachieved)

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10



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Appendix2

ReflectiveActivityonTesting&EnhancingGoalStatements:somealternativegoalstatements

As more meaningful alternatives to the stated goals in reflective activity 4, consider thefollowingexamples:1. Gillianwouldliketogainsevenhourssleepeachnight,duringthemajorityofnightsover

thenexttwoweeks.2. Juliewould liketobeabletorecogniseandmanagethechanges inhermood–within

threeweeks.3. Juliewouldliketolearnwaysofcopingwiththevoices–withinfourweeks;Juliewould

likethevoicestobelessfrequent,intenseanddistressing–withinfourweeks.4. JimwouldliketogooutwithGillianforamealinarestaurantinthenexttwoweeks;Jim

wouldliketogotothecinemawithGillianinthenext7days.5. Melaniewould like to understandmore about her prescribedmedication, within two

weeks;Melaniewouldlikeanysideeffectsofhermedicationtoberesolvedormanagedwithin6weeks.

Howdotheseexamplescomparewithyourownsuggestions?



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Appendix3

FurtherReflectiveActivity:CaseStudy–Luke

Reviewingthepracticerecommendationsthathavebeenmadewithinthischapter,considerthe following short case study and identify some precipitating (trigger) factors andpresentingissuesforLukeandhiswife.Then,proposeoneortwomeaningfulgoalsforLukeandforhiswife.

Lukeisa29-yearoldmanwhoismarriedwithayoungdaughter.Heisunemployedafter being made redundant, is experiencing financial difficulties and smokescannabis on a regular basis. Prior to Luke’s relapse, his father died suddenly. Lukespendsthemajorityoftimeinhishouse.Hefindsitdifficulttotrustothersbecausehebelievesthatsomeoneisgoingtoharmhimorhisfamily.AsaresultofthisLukehas stopped socialisingwithhis friends, althoughhedoes communicatewith themviasocialmediaashebelievesnoharmcancometohimthisway.Lukeoccasionallygoesoutwithhiswifeanddaughtershopping,buthefindsthisverydifficultandhashadtoleaveduetosevereanxietyandparanoia.As a consequence of Luke’swithdrawal, hiswife’s social activity has also reduced.Theyoftenusedtohavemealswithfriendsinthehouseandhaveregulargatheringswiththefamily.

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