Goals and Psychotherapy Research

Abstract

This chapter, ‘Goals and psychotherapy research’, examines goals in psychotherapy as they relate to clinical outcomes by surveying the extant research. Following a brief discussion of the importance of goals for personal development, the chapter focuses on research concerning the collaborative relationship between client and psychotherapist in goal-setting and effecting psychotherapy tasks to meet therapy goals, with particular emphasis on the client-therapist collaborative-outcome relationship. Next, the chapter reviews goal-psychotherapy outcome research for both adult and child/adolescent clients. The research presented is interpreted using clinical examples. The chapter closes with conclusions gleaned from the research reviewed followed by suggestions for practitioners.

Full text

Chapter 5
Goals and psychotherapy
research
Georgiana ShickTryon
e overarching goal of this chapter is to examine goals in psychotherapy as
they relate to clinical outcomes by critically surveying the extant research. More
specically, the goals of this chapter are to discuss:
◆ the collaborative relationship between clients and psychotherapists,
◆ collaborative goal- setting with adult and youth clients,
◆ the relationship of goal consensus and progress monitoring to psychother-
apy outcome,
◆ moderators of the goal- outcome relationship,
◆ implications of the research reviewed for clinical practice.
Goal- based life planning enjoys widespread popularity, as attested by an art-
icle in the New York Times (Parker- Pope, 2016)in which the author details
how her life changed for the better when she began applying design thinking,
advocated by Bernard Roth (2015), to identify obstacles in her life that kept
her from reframing and achieving her goals. Indeed, most individuals have
personal goals concerning what they want to achieve or avoid, and accord-
ing to Emmons (2003), ‘without goals, life would lack structure and purpose’
(p.106). Research results have shown that strong goal commitment, coupled
with life circumstances that are favourable for goal achievement, is associated
with goal attainment, which is in turn associated with increased emotional
wellbeing (see Brunstein, Schultheiss, & Maier, 1999; Emmons, 2003; Freund
& Riediger,2006).
Client- therapist collaboration and
psychotherapygoals
Like other individuals, psychotherapy clients have personal goals, but clients’
psychotherapy goals sometimes dier from personal goals of non- clients. For
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GOALS AND PSYCHOTHERAPY RESEARCH88
instance, psychotherapy clients’ goals tend to be more concrete and explicit,
such as overcoming a specic fear, with denite endpoints rather than abstract
motivational goals, such as becoming independent or being kind to others
(Grosse Holtforth & Grawe, 2002). Jansson, an, and Ramnerö (2015) exam-
ined the goals of adult psychotherapy clients and individuals who were not
in psychotherapy. ey found that clients tended to have more goals ‘related
to depressive symptoms, substance abuse, and coping with somatic prob-
lems. . .compared to the non- client group’ (p.187), and clients also endorsed
fewer interpersonal goals and goals related to past, present, and future events
than did non- clients. Clients were more likely to believe that they were further
from reaching their goals than were non- clients. ese results indicate that cli-
ents choose goals that concentrate on their symptoms/ problems, and perhaps
because they have been struggling with their problems for some time, they do
not see these goals as being resolved in the near future.
Relative to non- clients, psychotherapy clients tend to have more avoid-
ance goals concerning situations or emotions that they want to avoid (Grosse
Holtforth, Bents, Mauler, & Grawe, 2006). Several studies have associated cli-
ents’ avoidance goals, such as not stressing about work, not being afraid, and
not being self- destructive, with greater symptomatology (Dickson & MacLeod,
2004; Elliot & Church, 2002; Grosse Holtforth, Grawe, Egger, & Berking, 2005).
But what is perhaps most unique about psychotherapy goals is that their formu-
lation generally results from a collaboration between client and psychothera-
pist, and there is research evidence that this collaboration is related to client
outcomes.
Collaboration inpsychotherapy
It is dicult to imagine how clients and psychotherapists would nd consensus
on psychotherapy goals and how to reach them without collaborating with each
other. Collaboration is an active process whereby client and therapist engage
in a discussion about what goals to work toward in psychotherapy and how to
work toward them. Clients generally come to therapy with problems that have
made their lives dicult and that they have tried, but failed, to solve. erapists
bring skills gleaned from their training and experience that can be used to help
clients address their problems successfully. Collaboration between therapist
and client entails a mutual discussion that begins with the therapist asking the
client what brought him or her to therapy and what the client hopes to achieve
in therapy. Some clients have concise, specic goals, such as to be able to y
on a plane without experiencing anxiety. Others have more general goals that
need to be claried, such as a desire to be happier. To facilitate a clearly dened
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CLIENT-THERAPIST COLLABORATION AND PSYCHOTHERAPYGOALS 89
goal, the therapist must ask for specic examples of what ‘being happier’ would
entail.
Collaboration is the process of client reection on and communication of
what he or she would like from psychotherapy coupled with the therapist listen-
ing to and clarifying what the client wants to achieve and suggesting how the
therapy process will proceed to enable goal achievement. e collaborative pro-
cess continues throughout therapy as goals and the methods to achieve them
are modied depending on what occurs. In short, client- therapist collaboration
to achieve a consensus on psychotherapy goals appears necessary; otherwise,
therapy will have no agreed direction.
at said, there is no consensus in the research literature about what consti-
tutes a good collaboration or how to measure it. Bachelor, Laverdière, Gamache,
and Bordeleau (2007) asked adult clients to describe their psychotherapy col-
laboration experiences and found that clients’ perceptions of what constitutes a
good collaboration varied according to the emphasis they placed on their own
contribution to the work of psychotherapy, which includes goal formulation, on
a continuum from very active to very therapist- dependent. Although all clients
emphasized psychotherapists’ active involvement in the psychotherapy process,
the greater the emphasis that clients placed on their own responsibility for pro-
ductive therapy work, the less responsibility they placed on their therapists.
In our meta- analysis (i.e. statistical integration of the results of several inde-
pendent studies), Greta Winograd and I(Tryon & Winograd, 2011)examined
the collaboration- outcome relationship in 19 studies with a total of 2260 adult
psychotherapy clients that used a variety of measures of collaboration, includ-
ing instruments looking at clients’ role involvement and cooperation as well as
client and therapist mutual involvement in the psychotherapy process. Clients’
collaboration was oen assessed by the quantity and quality of homework com-
pleted, by clients’ ratings of their commitment to therapy, and by therapists’
ratings of how involved the clients were in activities such as self- disclosure and
working productively with therapists’ suggestions. erapists’ collaboration
was assessed by clients’ ratings of therapists’ understanding and helpfulness.
e meta- analysis yielded an average correlation of .33 between client- therapist
collaboration and psychotherapy outcome. Acorrelation of this magnitude rep-
resents a medium eect, which Cohen (1992) describes as ‘an eect likely to be
visible to the naked eye of a careful observer’ (p.156). us, one would expect
that an individual who observes a course of psychotherapy would be able to see
from the behaviour of client and psychotherapist that there is a relationship
between the degree of their collaboration and the outcome the client achieves,
such that greater collaboration is associated with a better outcome.
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Collaboration in psychotherapy with children and adolescents usually
includes the youth, his or her parents/ caregivers, and the psychotherapist, and
is further complicated by younger children possibly not having sucient cogni-
tive development to understand the process whereby psychotherapy goals and
the tasks to achieve them are developed (Shirk, Karver, & Brown, 2011). Similar
to adult psychotherapy, there is no consensus on how to measure collaboration
in psychotherapy with youths. Results of a meta- analysis of 49 studies by Karver,
Handelsman, Fields, and Bickman (2006), however, provide some indication of
the collaboration- outcome relationship in child and adolescent psychotherapy
by investigating the relationship between psychotherapy outcome and parent
and youth participation in therapy, which they dened as ‘the client’s (parent
or youth) eort, involvement, collaboration, cooperation, and engagement in
therapy or therapy homework tasks’ (p.53). e eect size (i.e. average correl-
ation) for youth participation- outcome was .27 (a medium eect), and for par-
ent participation- outcome was .261 (also a medium eect). us, there is reason
to believe that collaboration assessed by participation of both parent and youth
clients with their psychotherapists is related to better child/ adolescent psycho-
therapy outcomes.
Collaborative goal- setting
Several authors emphasize the importance of client- psychotherapist collabo-
rative goal- setting in psychotherapy (Cooper & McLeod, 2007; Duncan &
Reese, 2015; DeFife & Hilsenroth, 2011; Ryan & Deci, 2008), and stress that
the inclusion of clients in goal- setting enhances their motivation to partici-
pate in treatment (Ryan, Lynch, Vansteenkiste, & Deci, 2011). Not all clients
are motivated to engage fully in the psychotherapy process. Some begin treat-
ment with scepticism or hopelessness about its eectiveness. Others come
to therapy because of outside pressures rather than of their own volition.
When clients are not fully motivated, therapy may not be eective, and clients
may not even stay in therapy. Collaboration engages the client to participate
actively in choosing the goals of psychotherapy, which mobilizes the client to
work toward what he or she has chosen, thereby increasing the client’s moti-
vation for treatment. Goldman, Hilsenroth, Owen, and Gold (2013) found
that when therapists collaborate with their clients in setting therapy goals
and dening the course of treatment, clients are likely to agree with and have
condence in the treatment process. Research results indicate, however, that
1 is eect size does not include results of one study of frequent reporting of abuse that
Karver etal. (2006) indicated represented a treatment that was atypical.
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CLIENT-THERAPIST COLLABORATION AND PSYCHOTHERAPYGOALS 91
achieving collaborative goal consensus is not an easy task, nor is it always
successful.
Withadults
Although some adult clients and psychotherapists readily come to agreement
on treatment goals, others do not. For example, Swi and Callahan (2009)
asked clients and clinical psychology trainee psychotherapists to specify the
two most important goals that they were working on aer the third therapy
session. Client and psychotherapist identied the same two goals only 31.1%
of the time; they agreed on one of the two goals 56.3% of the time; and they
did not match on either target goal 12.6% of the time. Lest readers think that
the lack of goal agreement in this study is solely the result of psychotherapist
inexperience, results of a study by Zane etal. (2005) indicated that expe-
rienced psychotherapists sometimes do not agree with their clients about
treatment goals. In this study, client- psychotherapist goal match predicted
client- rated session depth and smoothness as well as session positivity. In
other words, client- therapist goal consensus is associated with deeper, more
meaningful, smoother, and more positive psychotherapy sessions. If, on
the other hand, there is disagreement between client and therapist about
goals, they will nd it dicult to work toward an agreeable session outcome,
because there is doubt on the part of the client, the therapist, or both about
the direction that the session should take. So, for one or both members of
the therapeutic dyad, the session will seem supercial and without much
value. Because client and therapist are ‘not on the same page’, the session will
not go smoothly. e client may argue with the therapist or contribute little
information; the therapist may express frustration with the client’s behav-
iour. Neither will evaluate the session positively, and one can imagine that if
goal consensus is not achieved, future sessions, if they occur at all, will also
have little positive eect.
Results of one study suggest that adult clients sometimes place more empha-
sis on collaborative goal consensus than do their psychotherapists. Bachelor
(2013) examined clients’ and psychotherapists’ perceptions of their work
together. Both emphasized a collaborative working relationship, but only clients
stressed the importance of non- disagreement on goals. Notably, it was clients’
view of the relationship that better predicted psychotherapy outcome. Bachelor
indicated that the results suggest that therapists should not conclude that clients
share their views about their work together, but should regularly check with
clients to get their feedback on how therapy is progressing. ‘erapists should
ensure that goals and therapeutic tasks are discussed together and mutually
determined and remain vigilant for signs of tension in the relationship that
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GOALS AND PSYCHOTHERAPY RESEARCH92
could reect a perceived lack of shared views, adjusting their responses accord-
ingly’ (Bachelor, p.133).
Several authors (Cooper & McLeod, 2007; Michalak & Grosse Holtforth,
2006) have emphasized the importance of continued collaborative goal
review throughout psychotherapy. Evidence suggests that when psychothera-
pists change goals during the course of psychotherapy without agreement of
their clients, treatment outcome is adversely aected (Schulte- Bahrenberg &
Schulte,1993).
To assist practitioners to foster better collaboration with clients, researchers
have developed procedures that facilitate systematic client feedback on psycho-
therapy goals and the tasks to achieve them throughout the process of psycho-
therapy (Duncan, 2012; Duncan & Reese, 2015; Goldman etal., 2013; Lambert,
2010; Lambert & Shimokawa, 2011). Areview of 32 studies (Gondek, Edbrooke-
Childs, Fink, Deighton, & Wolpert, 2016)that used feedback found that, relative
to no- feedback or other experimental conditions, treatments that incorporated
feedback had better outcomes on at least one measure and were particularly
eective when feedback was provided to both clients and psychotherapists.
Another review by Davidson, Perry, and Bell (2015), however, indicated that
many feedback studies were done with mildly disturbed college student clients,
and that results may be less positive when clients have more severe disturbances.
In that vein, a recent study by Lucock and colleagues (2015) with clients from
the UK National Health Service (NHS) found that clients treated at two UK
NHS centres that use patient monitoring and feedback improved with treat-
ment, but they did not show signicantly greater improvement than did clients
at another UK NHS site that did not use feedback. us, feedback to clients
about treatment progress (i.e. progress toward their goals) may be more helpful
for clients with milder disturbances than for clients with more severe problems.
Withyouths
Youth, particularly children, usually do not decide to enter therapy on their
own. Many do not believe that their behaviour presents a problem, nor do they
necessarily know why parents/ caregivers bring them for help. Afew days aer
intake, Yeh and Weisz (2001) asked 381 parents and their children to list the
children’s target problems independently. Almost two- thirds (63%) of parent-
child pairs failed to agree on even one problem. When the authors grouped
parents’ and children’s responses into broader categories, over a third of the
parent- child responses did not fall into the same broad problem area, such as
withdrawn or aggressive behaviour.
Parents may have goals for youth with problems that are not shared by their
children or, for that matter, by their psychotherapists. us, it is not surprising
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GOALS AND PSYCHOTHERAPY OUTCOMES 93
that in a study of 315 children, parents, and psychotherapists, Hawley and Weisz
(2003) found that only 23.2% of the members of the triad agreed on any target
problem, or put another way, ‘when asked to report the main problems in need
of treatment, 76.8% did not agree on a single target problem’ (p.65). Garland,
Lewczyk- Boxmeyer, Gabayan, and Hawley (2004) reported similar ndings for
adolescent clients.
In a more recent study, Staord, Hutchby, Karim, and O’Reilly (2016) found
that half of their sample of clinicians did not bother to ask child clients why they
came for psychotherapy and what they expected to occur. is does not seem
a good way to initiate goal collaboration. In contrast, results of another study
(Diamond, Liddle, Hogue, & Dakof, 1999)found that psychotherapist behav-
iours associated with good treatment alliances involved telling adolescents
that their stated problems are important, asking what concerns adolescents
want help with, and indicating that they will advocate for the youth. In cases
with poorer client- therapist relationships, psychotherapists did not engage in
these collaborative goal- setting behaviours. Others (Coatsworth, Santisteban,
McBride, & Szapocznik, 2001; Faw, Hogue, Johnson, Diamond, & Liddle,
2005)have reported the eectiveness of psychotherapists’ engagement in simi-
lar behaviours with youth and family members to negotiate goals that include
each family member’s concerns.
Garland, Hawley, Brookman- Frazee, and Hurlburt (2008) reviewed the
manuals of eight treatments for children with disruptive disorders and found
that collaborative agreement on psychotherapy goals, which includes periodic
reviews of goals and progress toward them, is a core element of evidence- based
treatments. Collaboration, described as ‘therapist building togetherness with
the child client’, associated with goal- setting has also been related to a positive
child- therapist working relationship using manualized treatment for anxiety
disorders (Creed & Kendall, 2005, p.503). In the UK, shared decision making
(SDM) has been implemented in Child and Adolescent Mental Health Services
(CAMHS) in recognition of the importance of including children and adoles-
cents as well as parents/ caregivers and other stakeholders in continuing col-
laborative goal- setting and treatment evaluations (Abrines- Jaume etal., 2016;
Hoong, Heatheld, Fitzpatrick, & Benson, 2014; Law & Jacob, 2013; Law &
Wolpert,2014).
Goals and psychotherapy outcomes
One of the main reasons to engage in collaborative goal- setting is to establish an
endpoint for clients and their psychotherapists to work toward. Hopefully, during
psychotherapy, the goals will be reached, and clients will be better o as a result.
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GOALS AND PSYCHOTHERAPY RESEARCH94
Goal consensus and goal progress monitoring and their
relationships withoutcome inadult clients
Greta Winograd and I (Tryon & Winograd, 2011) examined the relation-
ship of client- psychotherapist goal consensus and psychotherapy outcome via
a meta- analysis of 15 studies with a total of 1302 adult clients. Goal consensus
measures included assessments of client- psychotherapist goal agreement, client-
psychotherapist congruence on the origin of clients’ problems, and client- therapist
agreement on the expectations of psychotherapy. Some of the goal measures were
subscales of working alliance measures, such as the Working Alliance Inventory
(WAI; Horvath & Greenberg, 1989)and the California Psychotherapy Alliance
Scale (CALPAS; Marmar, Horowitz, Weiss, & Marziali, 1989), whereas others
were constructed by the authors of each particular study. Psychotherapy outcome
was assessed by examining post- therapy improvement on several standard meas-
ures of symptoms (most studies used more than one outcome measures), such
as the Beck Depression Inventory (BDI), the Brief Symptoms Inventory (BSI),
the Symptom Checklist- 90 (SCL- 90), the Hamilton Rating Scale for Depression
(HAMD), and Yale- Brown Obsessive Compulsive Scale (Y- BOCS), as well as by
treatment dropout, behavioural avoidance tests, and therapist and client ratings
of improvement. e majority of outcome ratings were made by clients.
We found a positive, medium eect size of .33 between client- therapist
goal consensus and psychotherapy outcome. is nding suggests that client-
psychotherapist agreement on goals is related to better client outcomes. Readers
should note that the studies in the meta- analysis usually measured goal consen-
sus at just one point during psychotherapy, and usually this assessment happened
early in treatment. is suggests that practitioners who establish goal consensus
with their clients early in psychotherapy are likely to achieve better outcomes.
Another meta- analysis examined the relationship between goal progress
monitoring and outcome in 138 studies with a total of 19951 adult participants
(Harkin etal., 2016). All of the studies randomly assigned adults to a treatment
that monitored goal progress or to a control condition (i.e. a comparative treat-
ment that may have included some monitoring, but of a dierent type or to a lesser
degree or to a no- treatment control). e studies monitored a variety of outcomes
including mood, depressive symptoms, physical activity, medication compliance,
weight, diet, and time management. Harkin and colleagues found an average cor-
relation of .202 between goal monitoring and outcome, which represents a small
2 Harkin etal. (2016) reported this eect size as d=.40. To ensure consistent reporting of
eect sizes, Iconverted this eect and the other eects from articles reported in this chapter
to correlations (r) using soware on the Psychometrica webpage at http:// ww w.psychomet-
rica.de/ eect_ size.html.
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GOALS AND PSYCHOTHERAPY OUTCOMES 95
to medium eect size. is result suggests that treatments that include goal moni-
toring are associated with better outcomes for a variety of concerns.
Taken together, the results of these two meta- analytic publications (Harkin
etal., 2016; Tryon & Winograd, 2011)suggest that therapists who work collabo-
ratively with clients at the beginning of treatment to determine why they came
to psychotherapy and what they want to achieve and then monitor progress
toward these agreed goals are more likely to have better outcomes than thera-
pists who do not engage in these activities.
Moderators ofthe goal- outcome relationship
e results of the meta- analyses reported above indicate that goals and out-
comes are positively related, but that the relationship between psychotherapy
goals and outcomes is not always the same. Other variables, called moderators,
can inuence the strength of the relationship between goals and outcomes. In
the Harkin etal. (2016) study, one moderator of the goal monitoring- outcome
relationship was problem type. us, the relationship between goal monitoring
and outcome represented a medium eect of .31 when the clients’ problems
dealt with depression, and a small eect of .15 when the clients’ problems dealt
with dieting. So, if you observed psychotherapy for each of these two types of
problems, you might notice more improvement when clients had monitored
goals related to depression than when clients had monitored goals related to
weight loss. In similar manner, if a client’s goal was to increase his or her physi-
cal activity (eect size r=.28), monitoring might be associated with greater
gains than if a client’s goal was to follow a diet (r=.11).
e relationship between goal monitoring and outcome was also stronger
when participants’ monitoring was physically recorded by clients on a form
or in a diary (r=.21, a small to medium eect) and publicized (monitored in
public, such as weighing oneself in front of another, or sharing with others in
written form) (r= .26, a small to medium eect) than when the monitoring
was not recorded (r=.14, a small eect) and the information was kept private
(r=.09, a small eect). When clients make a record of their goal progress, they
can refer to it both with their therapists and between sessions. Physical record-
ings that clients make and retain can prompt clients to continue toward their
goals by allowing concrete examination of where they have started, where they
are now, and how far they have to go to achieve their goals. When clients share
self- monitoring records with therapists, and perhaps with others as well, they
may feel a greater commitment to progress toward goals because of a belief that
therapists will hold them accountable. us, goals that are monitored by clients
themselves, recorded, and publicized are associated with better outcomes than
are goals that are monitored but not recorded and not publicized.
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GOALS AND PSYCHOTHERAPY RESEARCH96
Other types of goals have also been found to moderate, or change the
strength of, the goal- outcome relationship. For instance, avoidance goals (i.e.
things that clients are motivated to avoid, see Chapter3, this volume) have
been associated with greater client symptomatology (e.g. clients who have
more avoidance goals tend to have greater psychopathology), and studies
also show that they are related to more negative psychotherapy outcomes.
For example, a client may have an avoidance goal to stop being so self- critical.
To achieve this goal, the client may criticize herself whenever she nds her-
self being self- critical. is behaviour might lead to a feeling of hopelessness
about ever being able to reach her goal and an increase in her cycle of self-
criticism. If, on the other hand, the client frames her goal as being kinder
to herself (an approach goal), she will look for ways to reward herself for
the behaviours she likes. Readers should note that clients’ avoidance goals
can oen be reframed as approach goals that are more attainable than avoid-
ance goals but still address the clients’ problems, such as in the example just
presented.
Elliot and Church (2002) found that adult clients who had more avoidance
goals were less satised with their psychotherapists, and tended to have smaller
increases in subjective wellbeing over the course of psychotherapy than did
clients who had fewer avoidance goals. Avoidance goals were also negatively
related to perceived problem improvement at termination. Grosse Holtforth
etal. (2005) found that avoidance goal motivation of 76 outpatients decreased
over the course of psychotherapy. e decline in intensity of all types of avoid-
ance goals combined related to improvement in interpersonal problems and
optimism, as well as attainment of other treatment goals. Declines in avoidance
goals associated with vulnerability (e.g. to stop being emotionally overwhelmed,
to stop showing weakness) were more strongly related to interpersonal, symp-
tom, and optimism improvement than were other avoidance goals, such as to
stop being lonely or embarrassed.
In a further study, Grosse Holtforth etal. (2006) examined interpersonal
problems of 284 clinic clients relative to their approach and avoidance goals.
ey found that both avoidance goals and interpersonal distress were nega-
tively related to achievement of approach goals. Moreover, interpersonal dis-
tress moderated (i.e. changed the strength of) the relationship of avoidance
goals to achievement of approach goals such that lesser interpersonal distress
was associated with a less intense negative relationship between avoidance
goals and approach goal attainment. us, clients with fewer interpersonal
concerns were more likely to achieve therapy approach goals even though
they had some avoidance goals than were clients with more interpersonal
concerns. Another study (Wollburg & Braukhaus, 2010)found that, although
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GOALS AND PSYCHOTHERAPY OUTCOMES 97
having avoidance goals did not aect goal attainment, clients who had avoid-
ance goals achieved less symptom improvement than did clients who had
only approachgoals.
Intrinsic goals (i.e. goals that are rewarding in themselves, such as learning
something for the pleasure gained from that knowledge, see Chapter3, this
volume) are also associated with better psychological outcomes (i.e. stronger
goal- outcome relationships) than are extrinsic goals (i.e. goals that are external
to the client, such as learning something because it is required to obtain a grade
or satisfy some other requirement). Michalak, Klapphack, and Kosfelder (2004)
found that clients who had more intrinsically oriented personal goals and who
were more optimistic about attaining those goals had better session outcomes
and less psychopathology (i.e. the study showed that people who set intrin-
sic goals are less disturbed) than did clients whose goals were more extrinsic
and who were less optimistic about attaining them. e intrinsic goals in this
study were general life goals, such as being a good person, husband, or parent,
and did not necessarily focus on symptom relief. In another study (Ryan, Plant,
& O’Malley, 1995), 109 adults with alcohol problems who were in treatment
because of external pressures from family or legal authorities (i.e. had extrinsi-
cally motivated goals) were less involved in their treatment and more likely
to drop out than were clients who chose to participate on their own (i.e. had
intrinsically motivated goals).
Other types of goals besides approach/ avoidance goals and intrinsic/ extrin-
sic goals also may moderate the goal- outcome relationship. Using the Bern
Inventory of Treatment Goals (BIT- T; Grosse Holtforth & Grawe, 2002),
Berking, Grosse Holtforth, Jacobi, and Kröner- Herwig (2005) examined the
treatment goals of 2770 adult inpatients to determine if some types of goals
are easier to attain (i.e. yielded better goal- outcome relationships) than others.
ey found that, of the ve general BIT- T goal categories, wellbeing- related
goals (such as learning to relax, increasing calmness, improving leisure activi-
ties) were most oen attained, followed in order by interpersonal, personal
growth, symptom- related, and existential goals (such as coming to terms with
one’s past or reecting on the future). e most attained specic goals dealt
with panic attacks and self- acceptance, and the least attained specic goals
dealt with chronic pain and sleep problems. e authors suggested that psy-
chotherapists motivate clients to choose attainable goals based on the results
of their research by explaining that the goals that the clients want may be more
dicult to attain than a similar, but related, goal. Berking etal. provide the
following example:‘If a patient wants to work on a sleep disorder problem,
the goal ‘to learn how to cope with my sleeping problems’ is more appropriate
than the goal ‘to get rid of my sleeping problems’’ (p.322). e authors stress,
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GOALS AND PSYCHOTHERAPY RESEARCH98
however, that clients must be fully accepting of any reformulation of goals;
otherwise, it may be best to stick with the original goal formulation because
clients may not have the motivation to do otherwise.
Goals aspsychotherapy outcomes
Most studies of goals use measures of general functioning or standardized
symptom inventories to assess psychotherapy outcomes. But, because clients
and their psychotherapists have treatment goals, it makes sense to assess those
goals specically at termination. us, degree of goal attainment can be used as a
measure of outcome with both adults and children (see Chapter6, this volume).
Sheer, Canetti, and Wiseman (2001) used trained judges to construct individ-
ual Goal Attainment Scales (GAS) for 33 clients in short- term psychotherapy
based on intake transcripts. e scales addressed ve content areas (symptoms,
self- esteem, romantic relations, same- sex friendships, and work performance).
Termination and six- month follow- up GAS scores were signicantly related to
scores on standard measures of outcome such as the Brief Symptom Inventory
and the Rosenberg Self- Esteem Scale. us, results supported the use of GAS as
a measure of outcome.
Grosse Holtforth, Reubi, Ruckstuhl, Berking, and Grawe (2004) asked 675
inpatients to list three individual treatment goals at their admission to hospital.
At the end of hospitalization, patients rated their goals on a 6- point scale where
higher numbers indicated greater goal attainment. e ratings showed sub-
stantial improvement across most goal categories, especially those that tapped
symptoms and wellness.
In a study by Proctor and Hargate (2013), 477 outpatient adults completed
the Goal Attainment Form (GAF), which asked them to identify at the begin-
ning of psychotherapy as many as four diculties they hoped to address and
to rate the degree to which they were helped with the diculties at termina-
tion from psychotherapy. Clients also completed the Clinical Outcomes for
Routine Evaluation- Outcome Measure (CORE- OM) at both the beginning
and the end of psychotherapy. In the UK, the CORE- OM is a widely used
and researched measure of psychological distress (Barkham, Mellor- Clark,
Connell, & Cahill, 2006). e relationship between clients’ GAF and change
in CORE- OM scores at termination was a - .27 (a medium eect), which sug-
gests that improvements in clients’ goal concerns were associated with less
psychological distress. e authors concluded that this correlation ‘suggests
that the GAF is measuring something dierent from the CORE- OM and jus-
ties its use as a separate measure, perhaps providing a clearer client perspec-
tive on what they consider to be improvement and how much this is due to
therapy’ (p.240).
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GOALS AND PSYCHOTHERAPY OUTCOMES 99
The goal- outcome relationship withchild
and adolescent clients
Unfortunately, there are no large meta- analyses of research on the goal- outcome
relationship with youth3, but that does not mean that goals are unimportant
in psychotherapy with youth. Indeed, one study (Grossoehme & Gerbetz,
2004)found that, at discharge from hospital for mental health problems, former
adolescent inpatients (aged 11- 18) rated goal- setting work along with peer goal
contacts as one of their most meaningful experiences.
Goal consensus and outcome
Similar to ndings with adult clients, youth goal consensus with psychothera-
pists appears related to outcome. Auerbach, May, Stevens, and Kiesler (2008)
studied 39 inner- city adolescent substance- abusing clients who received three
months of intensive treatment. ey and their psychotherapists rated their goal
consensus on the goal subscale of the WAI during the second week of treat-
ment. e relationship between client- therapist goal consensus represented
only a very small eect (r=.07); furthermore, the dierence between client-
therapist goal ratings predicted client illegal activities at outcome (r= .38, a
medium eect), indicating that larger disparities in goal consensus were related
to poorer adolescent outcomes.
Pereira, Lock, and Oggins (2006) examined goal consensus ratings of 41
adolescent girls and parents with their psychotherapists during manualized
family- based therapy to empower parents to take responsibility for changing
adolescents’ eating behaviours and gradually return responsibility of eating to
the adolescents themselves. ree clinical psychology graduate students rated
adolescent- therapist and parent- therapist goal consensus early (aer approxi-
mately one to two months) and later (aer approximately eight to nine months)
in treatment using the goal subscale of the observer form of the WAI. Adolescent
weight gain was associated with greater early therapy client- therapist goal con-
sensus (r=.33, medium eect). us, as with adult clients, it seems important
to establish client- therapist goal consensus to achieve better therapy outcomes.
Goals and treatment continuation
Treatment continuation, or lack thereof, is akin to psychotherapy outcome
because clients are more likely to have better outcomes if they remain until
3 Although there have been meta- analyses (McLeod, 2011; Shirk, Karver, & Brown, 2011)of
youth- therapist working alliance- outcome studies that included measures of the working
alliance such as the WAI, which has a goal subscale, the studies did not examine subscales
in their alliance- outcome analyses.
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GOALS AND PSYCHOTHERAPY RESEARCH100
psychotherapy is completed. Citing studies that showed that approximately half
of families terminate psychotherapy prematurely, Brookman- Frazee, Haine,
Gabayan, and Garland (2008) examined the goal agreement of 169 youth (aged
11–18), their parents/ caregivers, and their therapists in community- based psy-
chotherapy. When parents and youth agreed on at least one goal at intake, the
youth attended greater numbers of sessions than when there was no parent-
child goal consensus. Youth- therapist consensus and parent- therapist consen-
sus on at least one goal at intake was unrelated to number of sessions attended.
is result suggested that therapists should facilitate initial parent- youth goal
consensus to keep youth in treatment longer.
Others have found that parent/ caregiver goal consensus is important in youth
treatment continuation; however, the person with whom parents have consensus
oen diers. For example, Pereira etal. (2006) found that early parent- therapist
goal consensus was signicantly related to continuation in therapy (r=.35,
medium eect) for adolescents with eating disorders. Adolescent- therapist goal
consensus, although in the positive direction, was not signicantly related to
continuation in psychotherapy (r=.21, small to medium eect).
Finally, others have emphasized the importance of goal consensus among
youth, parents, and psychotherapists for psychotherapy continuation without
providing consensus data for participant pairings. For example, Coatsworth
etal. (2001) cited low rates of engagement (i.e. client return for psychother-
apy aer intake assessment) and treatment retention of families who seek help
for youth behaviour problems. ey compared engagement and retention of
families who received Brief Strategic Family erapy (BSFT) and those who
received community- based treatment as usual. BSFT emphasizes collabora-
tive agreement on treatment goals among therapy participants. Families who
participated in this goal- directed psychotherapy were more likely to engage in
treatment initially (r=.22, small to medium eect) and to stay in treatment
(r=.30, medium eect) than were families receiving treatment asusual.
Goals asoutcome
Similar to studies with adult clients, researchers have used idiographic (indi-
vidually customized) measures to examine goal achievement in psychother-
apy with youth (see Chapter6, this volume). Weisz etal. (2011) incorporated
the pretreatment perspectives of 178 children (aged 7- 13) and their parents
who independently identied three top problems and rated their severity
weekly on a 10- point scale. Youth and caregivers also completed standardized
outcome measurements. e top problems information complemented the
results obtained from the standardized measures by providing very specic
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GOALS AND PSYCHOTHERAPY OUTCOMES 101
information about problems that were high- priority treatment targets for youth
and their parents that were not covered by items in standardized narrow band
clinical scales. ‘For example, for 41% of caregivers and 79% of youths, the iden-
tied top problems did not correspond to any items of any narrowband scales
in the clinical range’ (p.369). Top problems scores were reliable and showed
sensitivity to change.
Several studies conducted in the UK have used idiographic Goal Based
Outcome (GBO) assessments (Law & Wolpert, 2014)to both guide and evaluate
psychotherapy with youth. Wolpert etal. (2012) used GBO wherein therapist,
youth, and caregiver identied collaboratively up to three goals within the rst
three sessions that were rated on a 10- point scale, where higher values mean
greater goal achievement, at the beginning and end of treatment. Caregivers
and youth also completed the standardized measure Strengths and Diculties
Questionnaire (SDQ) at the rst session and aer six months. Practitioners
completed two standardized measures:aer rst meeting and aer six months.
GBO scores showed statistically signicant improvement in goal achievement
at the end relative to the beginning of treatment (r=.69, a large eect). GBO
pre- post dierence scores were related to pre- post scores on standardized
measures completed by both caregivers and psychotherapists with most cor-
relations representing medium eects (range of r=.26 to r=.39). us, the
authors concluded that idiographic collaboratively identied goal attainment
can be used in conjunction with more standardized measures to assess youth
psychotherapy outcome.
In another study, Edbrooke- Childs, Jacob, Law, Deighton, and Wolpert
(2015) compared data, collected over the course of several years, using SDQ
and GBO scores from treatment cases involving 137 children, aged 0– 18,
that were completed early in and aer four to six months of treatment and
compared with psychotherapists’ ratings of youths’ global functioning. GBO
scores showed greater change at outcome (r= .76, large eect) than did the
SDQ ratings of change in psychosocial diculties (r=.22, small to medium
eect) and impact on daily life (r=.41, medium to large eect), and import-
antly, GBO scores were uniquely associated with psychotherapist- reported
change in functioning over treatment (r=.45, medium to large eect). Ameta-
analysis using combined GBO data from three randomized controlled trials of
humanistic school- based counselling for distressed youth (Cooper etal., 2010;
McArthur, Cooper, & Berdondini, 2013; Pybis etal., 2014) found medium
eects for improvements in goal outcomes at six and 12 weeks of treatment
(r=.31, r=30, respectively). Results support the importance of including
goals in outcome evaluations.
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GOALS AND PSYCHOTHERAPY RESEARCH102
Conclusions and causality
e research reviewed in this chapter suggests that client- psychotherapist col-
laboration and goal consensus is related to better psychotherapy outcomes
for both adult and youth clients. For adults, the goal- outcome relationship is
moderated by goal type, problem type, and recording of goal monitoring. Child
goal- outcome research has not yet yielded moderators. Further, collaborative
goal- based treatments with both youth and adult clients are associated with bet-
ter outcomes as measured by both standardized and idiographic assessments.
Does this mean that collaborative goal- setting causes better outcomes?
Causality is dicult to establish because relationships do not always mean that
one thing causes another; for example, both could be caused by other, unmeas-
ured variables. Although newer studies of goal consensus and outcome include
other variables related to outcome in addition to goal consensus, it is impossible
to include, or probably even surmise, all the variables that are important to the
goal consensus- psychotherapy outcome.
Our methods of assessment are less than perfect, and unreliable measures
lack validity. us, studies that use unreliable measures do not add to causal
conclusions concerning psychotherapy goals and outcomes. Some studies have
assessed client- psychotherapist goal consensus using idiographic instruments
constructed by the authors that occasionally consist of just one item. It is not
possible to judge the reliability of single- item ratings of a construct such as goal
consensus. Other measures, however, such as the goal subscale of the WAI and
its shorter version (the WAI- S, Tracey & Kokotovic, 1989), have demonstrated
good to excellent reliability in numerous studies and can be used in practice
as well as research. Readers of studies that employ standard measures such as
the WAI can be more certain of the validity of the conclusions drawn by their
authors.
Samples in published studies may consist of clients who are dierent in
important ways from clients with whom readers practice. For instance, studies
using feedback have oen been done with college students who may not dem-
onstrate the same level of psychopathology as clients in outpatient clinics or
hospitals, and the level of client pathology may relate to the results achieved.
us, results that apply to one type of client may not apply to others.
Much of the research on psychotherapy goals relies on correlational sta-
tistics, which generally do not support causative conclusions. Newer studies
that use more sophisticated designs and statistics, such as structural equation
modelling, permit some assurance of a causal relationship. Meta- analyses, such
as those cited in this chapter, that aggregate data from several studies across
many clients and psychotherapists allow for more denitive conclusions. In
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POINTS FOR REFLECTION 103
their inferences based on meta- analyses of several psychotherapy relationship
variables, Norcross and Wampold (2011) indicated that goal consensus and
collaboration between adults and their psychotherapists are ‘probably eect-
ive’ (p.99) in improving client outcomes, but more studies are needed before
these elements are deemed ‘demonstrably eective’. Indeed, more goal- outcome
research with both youth and adult clients is needed to clarify the goal- outcome
relationship.
Summary and suggestions forpractitioners
Suggestions for practitioners are presented throughout this chapter and sum-
marized here. e research literature reviewed indicates that practitioners who
want to achieve better client outcomes should:
◆ ask clients at intake why they come to psychotherapy and what they want to
achieve,
◆ collaborate with clients to determine specic treatment goals and ways to
achievethem,
◆ determine that clients are fully committed to achieving theirgoals,
◆ include parent/ caregiver and youth in goal- setting, making sure to satisfy
the wishes ofboth,
◆ direct clients to set more approach than avoidancegoals,
◆ direct clients to set goals that are intrinsic rather than extrinsic,
◆ direct clients to set goals that are more easily attained,
◆ physically record and regularly review goals and goal progress with clients.
Points forreflection
◆ How do you think the literature reviewed in this chapter will inform your
clinical practice?
◆ Imagine you have an adolescent client and parents who disagree with each
other about treatment goals. How would you address this issue given the lit-
erature reviewed in this chapter?
◆ ink of some client goals that may be dicult to attain. How would you
address them with the client given the research presented in this chapter?
Further reading
Karoly, P., & Anderson, C. W. (2000). e long and short psychological change:Toward
a goal- centered understanding of treatment durability and adaptive success. In C. R.
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GOALS AND PSYCHOTHERAPY RESEARCH104
Snyder & R. E. Ingram (Eds.), Handbook of psychological change (pp. 154– 76). NewYork,
NY:Wiley.
Provides, in the authors’ words, ‘a goal- based motivational alternative to the symptom-
centered, stage change models of human adjustment that have dominated clinical science’.
Martre, P. J., Dahl, K., Jensen, R., & Nordahl, H. M. (2013). Working with goals in
therapy. In E. A. Locke & G. P. Latham (Eds.), New developments in goal setting and task
performance (pp. 474– 94). NewYork, NY:Routledge.
Provides updated literature on psychotherapy goal- setting.
Poulsen, A. A., Ziviani, J., & Cuskelly, M. (Eds.) (2015). Goal setting and motivation in
therapy:Engaging children and parents. London, UK:Jessica Kingsley Publishers.
Excellent chapters addressing methods of collaborative goal- setting with child clients and
their parents.
Winston, A., Rosenthal, R. N., & Pinsker, H. (2004). Introduction to supportive
psychotherapy. Core competencies in psychotherapy. Arlington, VA:American Psychiatric
Publishing.
Research- based guide for novice therapists that provides basic principles of psychotherapy
that include realistic goal- setting with clients. Good case illustrations.
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