Goal alignment is the health bar of therapy.
Winnie-the-Pooh *shifty eyes*
Before I start, here is what I have written so far of my top 10 tips for Deliberate Practice in therapy:
I’m going to start with a potentially controversial belief. I’ve come to believe that goal alignment is more important than therapeutic connection with a client, when it comes to therapy outcomes. This idea started to form as I noticed that a lot of clients seem to have an increased tolerance in therapy when what they want to achieve in therapy and the action plan for getting there is clear. I’m also considering the hypothesis that the stronger this goal and action plan alignment is between therapist and client – the more tolerance the client will have in therapy.
What do I mean by tolerance? I mean the client’s bandwidth or threshold to put up with things that are missing the mark and challenging content in therapy. For instance, I’ve noticed that if my reflection statements are missing the mark, I’m intellectualising too much or I my empathetic tone is a bit off; clients seem more likely to stay engaged and maintain their buy in if my goal alignment with them is strong. In these cases, clients seem to care less about what I’m acting like because their spotlight of attention is fixated like Sauron’s eye on getting better and working towards the steps that will help them get there – how they interact with me is a side priority or even a distraction to that focus. In their eyes helping them with their goals is what they are paying me for, so that’s where they want to really get their moneys worth.
There is an inverse effect at play as well. If on the other hand my goal alignment is off or non-existent – clients will be fair less patient with other aspects of therapy missing the mark, such as therapeutic connection or challenging content. Lack of goal alignment seems to exacerbate any other issues with the therapy and make such issues more glaring. Does this mean that goal alignment has the power to decide whether clients are looking at therapy through a positive or negative lens?
Goal alignment is the health bar of therapy. The stronger the goal alignment, the stronger that health bar is.
This is why I think goal alignment is of vital importance if a therapeutic relationship Is not only to survive, but also thrive.
Even after engaging in Deliberate Practice for all this time, a recent review of my outcome data revealed that goal misalignment, but more often goals not being established in the first place, is responsible for most of my therapy drop outs. I have made efforts in the past to improve how I was goal-setting, but what I didn’t do is ensure I reliably bring up goal-setting. I can have a great goal-setting system, but if I don’t bring up goal-setting in the first place then that system becomes effectively useless.
As I believe in following the data, I’ll be putting my efforts to tackling how I over-explain/try too hard in therapy largely on pause. If I’m serious about improving my goal-setting further, I know I’ll need to give it as much attention as possible. I don’t want to split my attention across two things.
Increasing the Effectiveness of Goal-Setting
Always bring up goal-setting and be direct with clients when asking them about their goals– Always overtly ask clients about their therapy goals, don’t allow the goals to be implied. I try and keep it simple by asking “what would you like to get out of therapy?”, while assuring clients if they don’t know I’ll help them figure it out. I don’t mean to force the client to have a clear goal, but make sure to overtly ask clients about their therapy goals. Lead the process and don’t passively hope the goals will just reveal themselves. New clients with past therapy experience have often said their previous therapists expected them to lead the goal-setting process. I think that’s unfair pressure on clients, goal-setting is too vital to leave the client alone to deal with and they are paying us for our help and expertise in this space.
Be mindful of the clients current goal setting stance – Understanding how your client views their goals is integral to the process. As an early part of the goal setting process I think about if the client fits into one of the the following categories, which I think of as their goal setting stance:
Concrete = The client knows what they want out of therapy and they may also know how they want to get there – they are clear about their goals.
Uncertain = These clients have no idea what they want from therapy, this is more common with clients who are new to therapy.
Overwhelmed = These clients feel overwhelmed by the sheer amount of things they want to address in therapy. These situations can also include overwhelming emotional distress – where clients are just looking for relief. For me, these are amongst the most challenging goal-setting situations.
Experientially Avoidant = Clients who wish to simply get rid of their unwanted thoughts or feelings. They want to stay in a place where they are comfortable, happy, care free and maximising their potential. Common with perfectionism. I consider this one a bonus stance because it tends to piggyback with one of the previous stances.
Thank you to Jordan Harris, who I first read about the idea of these goal-setting stances, you can read his fantastic blog post, which includes the idea here.
I find thinking of these types really helpful because it helps simplify the goal setting process – it becomes an if, then approach:
If a client is concrete, then I help the client pursue that goal, even if I disagree with it. I don’t challenge concrete goals until I have the clients trust and it’s obvious their concrete goal isn’t working.
If a client is uncertain, then I list out their main presenting challenges and ask which one is impacting them most? Which challenge they pick becomes the first steps of the therapy action plan. If a client can’t pick a challenge to start on, then I help by suggesting one based on my interpretation of what is going on.
If a client is overwhelmed, then I ask if therapy needs to start with coping skills to lower distress and bring initial relief. If the client is ok to start without distress coping skills, then I follow the same process as uncertain clients in helping the client choose a presenting challenge to start on.
Remember that there are two phases of goal-setting – the what and the how.
The What = the outcome goal, it’s where the client wants to end up after therapy is successful – the end point. I often formulate this as the clients ideal self.
The how = the process goals, it’s the steps along the way to ideal self. These are things like coping skills, reflection skills or psychoeducation etc. I think of this as the action plan of therapy.
Unless a client is adamant they have no interest in goal-setting, I believe it’s really important to talk to the client about their what/ideal self goals and how/process goals. It would be natural to just focus on the how (action plan), but without understanding the clients ideal self it can be too easy for therapy to overstretch into too many goals because the end point was not defined. It’s harder to stay on track if you’re not sure where you want to go. I often think that if ideal self was the north of a compass, we want to make sure that the action plan is helping us head north.
Remember to stay in contact with the goal, don’t set and forget – It’s really easy to set therapy goals and then just assume that the sessions that follow will stay on target, but this risks drifting off track. Early in each session, I ascertain from the client if we are continuing from the goal of the previous session – “are we continuing our conversation from last time?”. This is also my way of asking if the client has another focus in mind for the session.
In Conclusion
As you can see, goal setting can start simple, but also become incredibly nuanced – so it deserves a lot of work, love and attention. Too often effective goal setting and alignment is taken for granted and not something we practice deeply or deliberately (we also don’t really get taught how in or training). It’s also not the most exciting skill, which makes it easier to want to move on from. I’m determined to ensure I don’t make that mistake and to put in the work until goal setting becomes a strength of my game. Is it worth you considering doing the same?
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Deliberate practice at its core is a very simple system to follow. The challenge is that DP can become incredibly nuanced if you endeavour to deepen and strengthen your DP efforts. I believe a lot of people get put off by the nuances when they try to pick up DP. In order for DP to be successful, we first need to understand and concentrate on the foundations. The simpler those foundations can be presented, the easier it will be to engage with them; helping people to feel confident to give DP a go. DP is like mathematics, you can’t do complex maths unless you feel confident in the basics – which is why I suck at maths and avoid it. However the foundations of DP make sense to me and this is what has allowed me to create my own system of DP with increasing complexity over time.
A final note on why I’m writing these tips
Deliberate Practice Psych 