Goal measures for psychotherapy: A systematic review of self‐report, idiographic instruments

Abstract

Routine outcome monitoring can support client progress in psychotherapy and provide evidence on population‐level outcomes. However, measures have been almost exclusively nomothetic. Idiographic tools provide a complementary approach, combining individually set outcomes with standardized progress ratings. Evidence suggests that goal‐focused idiographic measures may particularly facilitate client progress, and this systematic review aimed to identify and critically evaluate such measures, as used in psychotherapy. In total, 104 texts were eligible for inclusion in the review, with nine measures identified. These took the form of multidimensional tools, brief rating forms, and goal attainment scaling. Psychometric and clinical evidence suggests that these measures may be appropriate tools for supporting client progress, but there is insufficient evidence to validate their use for population‐level evaluation.

Full text

Clin Psychol Sci Pract. 2019;e12281.
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https://doi.org/10.1111/cpsp.12281
wileyonlinelibrary.com/journal/cpsp
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INTRODUCTION
Over the last two decades, the use of routine outcome moni-
toring (ROM) in psychotherapy has become a major area of
research activity and has had a “substantial impact on national
and international policy decisions” (Lutz, De Jong, & Rubel,
2015, p. 625). The session‐by‐session use of outcome mea-
sures, for instance, is integral to NHS England's Improving
Access to Psychological Therapies program (IAPT; Clark,
2011). Routine outcome monitoring has the potential to serve
two key functions: first, at the population level, it can provide
evidence on the outcomes of different services and treatment,
thereby informing service commissioning and policy guide-
lines; second, at the individual level, it has the potential to
enhance therapy progress. Here, meta‐analyses indicate that
providing therapists with feedback on client progress using
specific measures brings about positive improvements in
outcomes, particularly for “not on track” clients (Bickman,
Kelley, Breda, de Andrade, & Riemer, 2011; Lambert,
Whipple, & Kleinstäuber, 2018).
To date, systems for monitoring client progress have al-
most exclusively used nomothetic measures, with predefined
and predetermined items that are consistent across clients
(Sales & Alves, 2016). However, nomothetic measures may
not capture the specific problems, or goals, that are of great-
est importance to individual clients. They may also neglect
differences in the meanings that clients give to the same
item. Hence, at a population level, nomothetic measures may
not capture changes that are of most relevance to particular
groups of clients. Equally, at an individual level, they may
fail to track—or feedback on—changes that are of greatest
importance to the specific client.
Idiographic, or patient‐generated, measures provide an
alternative to nomothetic approaches (Sales & Alves, 2016),
Received: 20 July 2018
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Revised: 30 January 2019
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Accepted: 31 January 2019
DOI: 10.1111/cpsp.12281
LITERATURE REVIEW
Goal measures for psychotherapy: A systematic review of
self‐report, idiographic instruments
Christopher E. M.Lloyd1
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CharlieDuncan2
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MickCooper3
© 2019 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association.
All rights reserved. For permissions, please email: permissions@wiley.com
1School of Social Sciences,London
Metropolitan University, London, UK
2British Association for Counselling and
Psychotherapy (BACP), Lutterworth, UK
3Department of Psychology,University of
Roehampton, London, UK
Correspondence
Christopher E. M. Lloyd, School of Social
Sciences, London Metropolitan University,
London, UK.
Email: CEL0088@my.londonmet.ac.uk
Abstract
Routine outcome monitoring can support client progress in psychotherapy and pro-
vide evidence on population‐level outcomes. However, measures have been almost
exclusively nomothetic. Idiographic tools provide a complementary approach, com-
bining individually set outcomes with standardized progress ratings. Evidence sug-
gests that goal‐focused idiographic measures may particularly facilitate client
progress, and this systematic review aimed to identify and critically evaluate such
measures, as used in psychotherapy. In total, 104 texts were eligible for inclusion in
the review, with nine measures identified. These took the form of multidimensional
tools, brief rating forms, and goal attainment scaling. Psychometric and clinical evi-
dence suggests that these measures may be appropriate tools for supporting client
progress, but there is insufficient evidence to validate their use for population‐level
evaluation.
KEYWORDS
goals, idiographic, outcome and process assessment, patient‐generated measures, patient‐reported
outcome measures, routine outcome monitoring

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and have “grown in popularity over the last two decades”
(Elliott et al., 2016, p. 263). Here, clients construct—and
rate progress against—their own items, within a standardized
questionnaire format. Such individualized measures allow
clients to establish, for themselves, their psychotherapy foci;
enabling the broadest possible array of value systems and
conceptualization of treatment success (Jacob et al., 2018;
Kiresuk, 1994b). This “client‐centered” approach to outcome
measurement has been hypothesized to capture complex
change processes that are of greatest relevance to individ-
ual clients, and to be most consistent with the clinical reality
of psychotherapeutic work (Edbrooke‐Childs, Jacob, Law,
Deighton, & Wolpert, 2015; Sales & Alves, 2016). This may
be important as research indicates that clients with similar di-
agnoses may want very different things from psychotherapy
(Holtforth & Grawe, 2002; Rajkarnikar, 2009). In addition, in
terms of supporting client progress, it has been hypothesized
to empower clients (Kiresuk, 1994a) and to promote individ-
ual rather than normative identity (Smith, 1994), sending “a
clear message to clients that their individuality and unique-
ness are highly valued, and that their distinct perspective is
considered an important contribution to the therapy process”
(p. 252).
Idiographic outcome measures take one of two forms:
problem‐focused and goal‐focused. Problem‐focused mea-
sures invite clients to identify the issues, difficulties, or
concerns that they are wanting to overcome, and then to
rate the magnitude of these problems. By contrast, goal‐
focused measures invite clients to identify the objectives
that they would like to strive toward, and then the degree
to which they have achieved them. Sales and Alves (2016),
in their systematic review of individualized assessment
tools used in psychotherapeutic practice and research,
identified two problem‐focused outcome measures: the
Simplified Personal Questionnaire (PQ; Elliott et al., 2016;
Shapiro, 1961) and the Psychological Outcome Profiles
(PSYCHLOPS; Ashworth et al., 2005). They identified one
goal‐focused outcome measure, Goal Attainment Scaling
(Kiresuk & Sherman, 1968; Kiresuk, Smith, & Cardillo,
1994).
Emerging evidence supports the reliability, validity, and
clinical utility of both problem‐focused and goal‐focused
outcome measures (e.g., Ashworth et al., 2005; Elliott et al.,
2016; Kiresuk, Smith, et al., 1994; Sales & Alves, 2016).
However, the potential for goal‐focused measures to contrib-
ute toward client progress is supported by several additional
lines of research. First, as initially summarized by Locke
(1968), there is an extensive body of psychological evidence
to indicate that goal‐setting and goal‐monitoring procedures
enhance task performance (Locke, 1968; Locke & Latham,
2002; Locke, Shaw, Saari, & Latham, 1981). Indeed, Locke
et al. (1981) described this as, “one of the most robust and
replicable findings in the psychological literature” (p. 145).
Recent meta‐analyses indicate an effect size (d) of 0.34 for
goal setting (Epton, Currie, & Armitage, 2017), and 0.40 for
the monitoring of goal progress (Harkin et al., 2016) across
a range of behavioral outcomes. In addition, of relevance to
routine goal monitoring in psychotherapy, these effects were
larger when the outcomes were reported or made public, and
when they were physically recorded (Harkin et al., 2016).
Second, research indicates that agreement between clients
and psychotherapists on the goals of therapy—which is likely
to be enhanced by goal‐setting and goal‐monitoring proce-
dures—is associated with positive outcomes, with a mean
correlation of 0.24 (Tryon, Birch, & Verkuilen, 2018). Third,
there is evidence that goal setting is desired by a majority of
clients, with approximately 60% of laypeople expressing a
preference for it, 20% not wanting it, and 20% not having a
preference (Cooper & Norcross, 2015). This means that the
use of goal measures may lead to greater clinical improve-
ment, because matching therapeutic activities with client
preferences is associated with reduced drop out and improved
outcomes (Swift, Callahan, Cooper, & Parkin, 2018). Finally,
in contrast to problem‐focused measures, goal‐focused mea-
sures allow for the setting of “approach,” as well as “avoid-
ance,” objectives; and there is evidence that the former may
be more effective regulatory devices (Elliot & Church, 2002).
For instance, clients who are oriented toward approach goals
show better psychotherapeutic outcomes than those oriented
to avoidance goals (Elliot & Church, 2002; Wollburg &
Braukhaus, 2010).
A systematic review of goal setting as an outcome
measure within physical and neurological rehabilitation
environments was conducted over a decade ago by Hurn,
Kneebone, and Cropley (2006). The authors identified
15 eligible articles, 11 of which utilized Goal Attainment
Scaling. They concluded that there was “strong evidence
for the reliability, validity and sensitivity of this approach,”
though “further work needs to be carried out with goal set-
ting to establish its reliability and sensitivity as a measure-
ment tool” (p. 756).
Despite the value that goal‐based idiographic measures
may have for psychotherapy, no systematic information is
available for clinicians or researchers on the types of mea-
sures that have been used in this field, their psychometric
properties, or their distinguishing features. Hence, the pur-
pose of this study was to conduct the first systematic review
of goal measures in psychotherapy. Our aims were to iden-
tify (a) What goal measures, with at least some evidence of
psychometric quality, have been used in the psychotherapy
field? (b) What evidence is there for the reliability, validity,
and clinical utility of these measures? (c) What are the rela-
tive strengths and limitations of the measures identified, with
respect to their potential use in routine outcome monitoring?
Through these lines of inquiry, we hoped to generate recom-
mendations for the use of such measures in psychotherapy, as

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well as identifying key areas for further research. In contrast
to Sales and Alves (2016) we focused, in depth, on just goal‐
focused idiographic measures; and, in contrast to Hurn et al.
(2006) we focused on just the use of these measures within a
psychotherapeutic context.
2
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METHOD
Our systematic review was conducted based on the Preferred
Reporting Items for Systematic Reviews and Meta‐analy-
ses (PRISMA; Moher, Liberati, Tetzlaff, & Altman, 2009)
guidelines.
2.1
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Protocol
A draft protocol for the systematic review was prepared by
the first author and subsequently refined by the third author.
Subsequent modifications were made to the protocol dur-
ing the process of the review to maintain a clear focus (see
below).
2.2
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Eligibility criteria
Inclusion and exclusion criteria for the review are detailed in
Table 1. Our study inclusion criteria meant that we focused
on all forms of psychological treatment, including psycho-
therapy, counseling, and other forms of talk therapy.
2.3
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Information sources
The following computerized bibliographic databases were
searched for the review from August 2016 to February
2017: PsycINFO, PsycARTICLES, PsycTESTS and Web
of Science Core Collection. The search terms employed for
PsychINFO, PsycARTICLES, and PsycTESTS (and modi-
fied, as applicable, for further search engine) were as follows
(restricted to academic journal papers and dissertations):
• goal* or *goals or GBOM* or GBO* or plan* or project*
or striving* or want* or life task* or purpose* or *personal
or attainment* or hope* or aim* or aspiration* or self* or
interest* or pursuit* or progress* or ambition* or inten-
tion* or objective* or target* or ideal* or destination* in
title (TI) AND
• mental* or psychology* or counseling* or therapy* or psy-
chotherapy* in abstract (AB) AND
• measure* or test or invent* or question* or survey* or out-
come or effect* or efficacy* or trial or evaluation or goal
attainment or scaling or goals form in abstract (AB) AND
• personal* or personalize* or individual* or individualize*
or idiographic* or customize* or client generated* or cli-
ent focused* or patient generated or patient focused* or
patient customized* or patient rated* or patient valued* or
client valued* or client rated* in abstract (AB)
• Publication Year (PY) = (1968–February 2017).
Requests for information about published and prospective
relevant studies were also made via email to known academ-
ics and clinicians in the field (n = 9) who had created existing
goal‐based measures, however, no extra papers were identified.
A wider recruitment call for relevant papers was also made via
social media, and through a large professional counseling body
in the UK.
2.4
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Study selection
The first author undertook a preliminary search on PsycINFO
and refined the specified search terms, utilizing a trial and
error approach, until given results were agreed by the first and
last author to be both sensitive and inclusive of the research
area. The revised search terms were then run on PsycINFO,
which also included PsycARTICLES and PsycTESTS, in
addition to Web of Science Core Collection (amended as
appropriate). All records were downloaded onto a single
bibliographic management file (Endnote), with duplicate
records discarded. The first author carried out a first‐stage
screening process based on title relevance. This selection was
then sent to the third author for verification. The abstracts
TABLE 1 Eligibility criteria
Inclusion criteria: Measure
Self‐completed by client
Idiographic: clients construct their own items
Focuses on goals or goal‐like phenomena: for example, “personal
projects” (Little, Salmela‐Aro, & Phillips, 2007), “personal
strivings” (e.g., Emmons, 1986), “current concerns” (Klinger &
Cox, 2011a)
Allows for quantitative rating of goals
At least one quantitative rating scales assess degree of goal
achievement: for example, “nearness to goal attainment,”
“likelihood of success”
Measure has evidence of at least one of the following: internal
consistency, test–retest reliability, or convergent validity
Inclusion criteria: Study
Measure used as part of a psychological treatment: for example,
psychotherapy, counseling, CBT
Study published between 1968 and 2017
English language publication
Exclusion criteria: Measure
Only allows clients to set negatively framed, “avoidant” goals
(i.e., “problems” or “concerns”): for example, CORE Goal
Attainment Form (see Proctor & Hargate, 2013)
Goals recorded and rated on a nomothetic basis only: for
example, predefined list of goals

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of all remaining papers were screened by the third author,
with a final selection of papers identified for full‐text review.
At this stage, review papers were removed, but scrutinized
for potentially eligible references, as were our included pa-
pers. Any articles identified from expert sources were also
included at this stage, providing they met inclusion criteria,
as assessed by all authors. In order to focus the review, at
the final stage, only those papers that had evidence of use in
psychotherapy were selected for inclusion.
2.5
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Method of analysis
Our write‐up of the measures follows the structure developed
by Sales and Alves (2016). This divides the critical descrip-
tion of each measure into four sections: brief descriptive
overview, evidence of reliability and validity, clinical utility
(defined as any empirical data which assesses the contribution
made by the measure to therapeutic outcomes or processes),
and comments on identified strengths and limitations.
3
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RESULTS
3.1
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Study selection
In total, 8,475 articles were identified through searching
electronic bibliographic databases (Figure 1). Of these, 191
were selected for abstract review following title scrutiny.
Subsequently, 52 studies were excluded: because they were
duplicates (k = 21), because they did not report any goal
measures (k = 14), because they were problem‐focused only
(k = 13), or because they were solely theoretical (k = 4).
Inter‐rater reliability for this stage of the selection process
was substantial (Cohen's κ = 0.53). This resulted in 139 ar-
ticles for inclusion in the review. In addition, scrutiny of the
reference sections of these papers gave 58 additional papers
that potentially met eligibility criteria, giving 197 for full‐text
review. Of these, 104 focused specifically on measures that
have been used within a psychotherapy context. Nine‐goal
measures were identified and are described below in approxi-
mate chronological order of development.
FIGURE 1 Study flow diagram
k = 191 articles identified for abstract review
Excluded for one or more of thefollowing: k =
8,284
Did not report on idiographic measure of goal
change
Theoretical paper
Not written in English
Excluded from title and abstract scrutinization:
k = 52
Did not report any goal measures (k = 14)
Duplicates (k = 21)
Problem based (k = 13)
Theoretical paper (k = 4)
k = 139 articles for full-text review
Articlesidentified
PsychINFO, PsycARTICLES, PsycTests: k = 7,572
Web of Science: k = 903
k = 8,475article titles reviewed
Excluded following full-text review for one or
more of the following: k = 93
Unable to access full-text (k=20)
Theoretical or review paper only (k = 11)
Main text not in English (k = 6)
No evidence validity and/or reliability (k = 5)
Not idiographic (k = 13)
Does not allow quantitative ratings of goal
progress (k =6)
Unable to accommodate positive goals (k =25)
Developed for use in psychology and health
services (k = 7)
Reference section search results added: k = 58
k = 197 articles for full-text review
k = 104 articles met study inclusion criteria

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3.2
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Goal Attainment Scaling (GAS)
Goal Attainment Scaling (Kiresuk & Sherman, 1968; Kiresuk,
Smith, et al., 1994) was developed to evaluate the results of
mental health interventions and has been applied to a wide range
of other domains, such as education, rehabilitation, drug treat-
ment, and correction (Kiresuk & Choate, 1994; Mintz & Kiesler,
1982). It has been used extensively within the psychotherapy
field, such as in motivational interviewing (Lewis, Larson, &
Korcuska, 2017), cognitive behavioral therapy (CBT), and psy-
chodynamic psychotherapy (Bögels, Wijts, Oort, & Sallaerts,
2014), and with both adult and child clients. It is, by far, the most
widely adopted of the idiographic goal measures; with over 700
citations to the original 1968 article (Springer citations) and an
upwards citation trajectory (Google Scholar).
The GAS procedure is unique among goal measures, in
that it involves the setting, and rating, of expected levels of
outcomes. It is estimated to take 20 min, with a similar time
for post‐treatment and follow‐up assessment (Kiresuk & Lund,
1994). The procedure needs to be led by a trained profes-
sional—for instance, therapist, researcher, or intake worker—
but it is recommended that this should be in collaboration
with the client (Cardillo, 1994; Smith, 1994). The procedure
begins with the identification of focal issues for the treatment
(Smith, 1994). At least three goals are then identified, and a
brief title is chosen for each goal (for instance, “decrease hos-
tility”). This is followed by the selection of an indicator for
that goal: the “behavior, affective state, skill, or process that
most clearly represents the goal and can be used to indicate
progress in meeting the goal” (Smith, 1994, p. 8; for instance,
“number of angry outbursts”). The next stage is to set an ex-
pected, post‐treatment outcome for that goal (for instance,
“3–4 angry outbursts per week”). Two outcome levels are then
set on either side of this expected outcome: a “Somewhat more
than expected level” (for instance, “1–2 angry outburst per
week”), and a “Somewhat less than expected level” (for in-
stance, “5–6 angry outburst per week”). Two further outcome
levels—“Much more than expected” and “Much less than
expected”—are then set (for instance, “no angry outbursts”
and “more than six angry outbursts per week,” respectively);
and this whole process is repeated with each of the remaining
goals. In this way, five levels of outcomes are set for each goal,
and given a score of −2 to +2, with higher scores indicating
better than expected outcomes. Progress on each of these goals
can then be scored at post‐treatment or follow‐up (ideally, the
authors recommend, by an independent rater, Cardillo, 1994)
and an average goal attainment score can be calculated. Tables
are also provided to determine summary T‐scores.
3.2.1
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Reliability and validity
In terms of internal consistency, the average scale intercor-
relation has been reported as 0.30 (Cardillo & Smith, 1994b;
Kiresuk & Sherman, 1968), with correlations of 0.25–0.65
between individual GAS scores and the overall GAS score
(Mintz & Kiesler, 1982). Test–retest reliability, from end of
therapy to 8‐week follow‐up, has been reported as accept-
able (r = 0.77, McGaghie & Menges, 1975 cited in Mintz
& Kiesler, 1982). Inter‐rater reliability on goal attainment
scores, where guides are developed, or rated, by independent
sources, are generally high: r = 0.50–0.99 (Cardillo & Smith,
1994c; Mintz & Kiesler, 1982). In terms of convergent va-
lidity, GAS scores have shown significant moderate to high
correlations with other indicators of psychological health,
such as the Target Complaints Scale (r = 0.50) and the Brief
Symptom Inventory (r = 0.38) in time‐limited psychotherapy
(Shefler, Canetti, & Wiseman, 2001). There is good evidence
for the content validity of the GAS, with approximately 85%
of goals rated as relevant by independent monitors (Cardillo
& Smith, 1994a).
3.2.2
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Clinical utility
Several studies within a mental health context suggest that
“the process of setting goals [with GAS] may itself have a
positive effect on treatment outcome” (Smith, 1994, p. 3);
with more success in reaching goals, and greater personal-
ity adjustment (Mintz & Kiesler, 1982). Clients have also
reported being more satisfied with treatment when GAS is
used and saying that they found the process “therapeutic”
(Cardillo, 1994; Mintz & Kiesler, 1982).
3.2.3
|
Comment
Of the goal measures reviewed, GAS has the strongest evi-
dence for its clinical utility. In addition, its implementation
and application are supported by a range of in‐depth written
guides (e.g., Kiresuk, Smith, et al., 1994). By establishing a
range of outcome levels for each goal, the GAS procedure al-
lows for detailed, nuanced, and systematic evaluation of pro-
gress. Clinically, the principal limitation of GAS is that the
goal‐setting process is relatively complex (Mintz & Kiesler,
1982) and mental health workers must go through a fairly
lengthy period of training before they can apply it (estimated
at approximately 14 hr, Kiresuk, Choate, Cardillo, & Larsen,
1994). In addition, given the time required for follow‐up rat-
ings (approximately 20 min), GAS would not lend itself to
session‐by‐session assessment. The complexity of the ini-
tial goal‐setting process also means that it is difficult to add,
modify, or delete goals as the treatment progresses (Mintz &
Kiesler, 1982).
Goal Attainment Scaling generally shows good psycho-
metric properties. However, internal consistency appears low,
suggesting that any total score should be treated with cau-
tion. The assumption of equivalent intervals between GAS
scores, necessary for parametric testing, has been challenged,

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on the grounds that the different levels are determined on an
idiographic, subjective basis. However, Cardillo and Smith
(1994b) argue that this is no more guaranteed than the Likert‐
type scales used by other outcome measures. Scores on GAS
are also limited in that they do not indicate actual levels of
functioning; only the extent to which change is greater or less
than expected (Cardillo & Smith, 1994a).
3.3
|
Personal projects analysis (PPA)
Since its inception, PPA (Little, 1983; Little et al., 2007) has
been used in university counseling services (Salmela‐Aro,
1992), as well as group‐based psychoanalytic and experien-
tial therapies (Salmela‐Aro & Nurmi, 2004). It can be admin-
istered through clinical interview, a self‐report workbook, or
in digital format (Little & Gee, 2007).
In the initial elicitation stage of PPA, clients are in-
vited to list around 15 of their current “projects.” After
elicitation, clients are asked to take around 10 of the most
meaningful projects and to appraise each one individually
on scales ranging from 0–10. The initial appraisal matrix
has 17 scales which relate to cognitive ratings, including
the “likelihood of success” of each personal project, and
10 further additional scales for affective ratings. Goal
progress can be captured specifically with dimensions
of: “likelihood of success,” “time adequacy,” and “prog-
ress.” Scales can be supplemented or removed depending
upon the area of clinical focus. In the final, “cross‐impact”
stage, clients are invited to examine the potential interre-
lationship between each project by using a matrix to rate
the extent to which each project might facilitate or conflict
with other projects (Little & Gee, 2007). Further informa-
tion and free resources (in English) relating to PPA can
be found at http://www.brianrlittle.com/Topics/research/
personal-projects-analysis/.
3.3.1
|
Reliability and validity
The test–retest reliability of PPA, from the same individ-
uals over a minimum of two periods of time (24 hr and
2 weeks), was shown to be moderate (Little & Coulombe,
2015). A moderate alpha coefficient was obtained for
each appraisal dimension across projects (Little, Leccl,
& Watkinson, 1992); with an internal reliability of 0.59
for the “likelihood of success” dimension (Klinger & Cox,
2011b). In terms of convergent validity, independent cor-
relations between each of the PPA factors, and clinical con-
cerns like depression, have been found (Little, 2011). For
instance, in a meta‐analysis examining PPA and depressive
affect, the PPA dimension of progress had a significant
negative association with depression with a mean weighted
effect size (r) of −0.14 (Dowden et al., 2001). Furthermore,
in a cross‐lagged longitudinal study, the standardized
regression coefficient between depressive symptoms and
a combined project appraisal dimension—characterized by
high levels of project accomplishment and progress—was
between −0.50 and −0.59 (Salmela‐Aro & Nurmi, 1996).
3.3.2
|
Clinical utility
No evidence for the clinical utility of PPA could be identified.
3.3.3
|
Comment
Personal Projects Analysis facilitates assessment of goals
along a range of dimensions, as well as the relationships
between goals. This has the potential to support clinicians
in building up an in‐depth understanding of the client's mo-
tivational structure. In addition, PPA is a flexible tool with
the potential to add dimensions that may be of particular
relevance to clients or their contexts. However, for the pur-
poses of outcome monitoring, many of the PPA dimensions
may be superfluous. Hence, as with GAS, PPA may be
time‐consuming to conduct within a psychotherapeutic con-
text, as well as requiring extended training. Furthermore,
due to the complex procedures involved in implementing
PPA in the clinical encounter, it may not be suitable for cli-
ents with cognitive limitations and/or severe mental health
difficulties.
3.4
|
Interview Questionnaire (IntQ)
The IntQ, developed by Klinger (1987), was initially used
therapeutically to predict alcoholics’ responses to treat-
ment and can be used as the basis for “systematic motiva-
tional counseling” (Cox & Klinger, 2011b; Cox, Klinger,
& Blount, 1996). It asks clients to list and describe all
their current concerns on a paper‐based form (e.g., “I feel
lonely”), then to write a sentence on each one involving
an action word before each concern (e.g., “I want to have
more friends”). The form is divided into core life areas to
ensure a broad range of life concerns are generated, with
clients subsequently ranking each action in relation to nine
goal constructs (e.g., “commitment,” “time available”).
The two constructs most closely related to goal progress
are “probability of success,” and “nearness to goal attain-
ment.” “Probability of success” is rated on a 10‐point scale
(0–9), with scores closest to “0” representing the lowest
levels of success and those closest to “9” representing
higher levels of success. “Nearness to goal attainment” is
rated in the anticipated number of days, months or years it
will take to attain the goal. A change score on this dimen-
sion is calculated as the difference in anticipated time to at-
tain the goal between each rating, with progression toward
a goal being reflected in a decrease in the anticipated time
to goal attainment.

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3.4.1
|
Reliability and validity
Forty‐two alcoholic inpatient clients were tested using the
IntQ at one week after intake and again at one month after
intake. The test–retest correlation coefficients of the “prob-
ability of success” and “nearness to goal attainment” vari-
ables were 0.47 and 0.22, respectively. In another reliability
study, 12 clients completed the IntQ twice, with a one‐month
interval. Results showed that around 76% of concerns were
reported at both time points (Church, Klinger, & Langenberg,
1984).
Estimates of validity for the IntQ have assumed that con-
cerns are, at some point, translated into observable behav-
iors and have used diary records to “map” behaviors onto
concerns expressed on the IntQ (Church et al., 1984). It
was found that approximately 81% of activities undertaken
a week after completing the IntQ could be related back to
concerns identified by participants. After one month, approx-
imately 56% of activities undertaken could be related back to
concerns expressed (Church et al., 1984).
3.4.2
|
Clinical utility
No evidence for the clinical utility of the IntQ could be
identified.
3.4.3
|
Comment
Like PPA, the IntQ—and its family of measures (see
below)—allows for assessment of goals on a range of dimen-
sions. However, most of these dimensions are superfluous to
progress, per se. In addition, as with PPA and GAS, these
measures are lengthy to complete—as up to nine dimensions
can be rated for each goal—and may not be appropriate for
session‐by‐session use.
A strength of the IntQ and its family of measure is that
clients are required to formulate goals by employing action
word categories. This has the effect of distinguishing the va-
lence of each goal (e.g., whether it is positive or negative),
which can provide useful distinguishing qualitative informa-
tion around the motivation.
Literature in the systematic motivational counseling field
(e.g., Cox & Klinger, 2011a) suggests that the IntQ has now
largely been superseded by more recent measures (see below).
3.5
|
Motivational Structure Questionnaire
(MSQ)
The MSQ (Cox, Klinger, & Blount, 1991,1996; Klinger &
Cox, 1986) is a methodologically refined, more complex
version of the IntQ (Negru, 2011). Like the IntQ, the MSQ
measures clients’ motivations to change with regards to par-
ticular goals. It has been mainly used in similar contexts to
the IntQ—as the basis for systematic motivational counseling
work with clients struggling with alcohol use—though it
has also been adapted for other environments, such as the
workplace (Roberson & Sluss, 2011). The MSQ has been
therapeutically used with non‐English speaking populations,
including Czech (Man, Stuchlíková, & Klinger, 1998) and
German clients (Grothenrath & Schneider, 1996 as cited in
de Jong‐Meyer, 2004).
The MSQ is completed in a similar manner to the IntQ,
although the “nearness to goal attainment” and “probabil-
ity of success” dimensions from the IntQ are named “goal
distance” and “chances of success,” respectively. In addi-
tion, on the MSQ, clients rate “chances of success” on a 0
(almost no chance – a 0%–9% chance) to 9 (almost certain
– at least 90% sure) scale. Estimates suggest that the MSQ
can take one to two, or more, hours to complete (Klinger
& Cox, 2011b).
In contrast to the IntQ, SPSS (Statistical Package for the
Social Sciences) scoring algorithms are available on Request
for the MSQ (see https://pubs.niaaa.nih.gov/publications/
assessingalcohol/instrumentpdfs/43_msq.pdf for more de-
tails). A motivational profile is created for each client, which
depicts the respondent's motivational structure (the manner
through which they strive for goals to resolve their concerns).
The MSQ is available in five languages: English, German,
Czech, Dutch and Norwegian.
3.5.1
|
Reliability and validity
Internal consistency for the MSQ scales is generally good,
with 0.83 for both “goal distance” and “chances of success”
(Klinger & Cox, 2011b). However, test–retest stability across
a one‐month period was lower: 0.22 and 0.47, respectively,
for “goal distance” and “chances of success” (Klinger & Cox,
2011b). In terms of convergent validity, “goal distance” shows
a correlation of 0.47 with the Beck Depression Inventory,
and 0.39 with the Beck Anxiety Inventory (Baumann, 2011).
Scores on these scales have been found to be independent of
personality dimensions (Klinger & Cox, 2011b). In a test of
construct validity, participants were slower to respond on a
Stroop task (which asks participants to identify the color of
words rather than the words themselves) to words related to
their current concerns, as compared with unrelated, neutral
words (Klinger & Cox, 2011b). This suggests that partici-
pants’ self‐identified concerns on the MSQ did, indeed, re-
flect the issues that were, at a less conscious level, occupying
their attention.
Man et al. (1998) demonstrated how the MSQ was able to
distinguish clinical differences in motivational structure be-
tween 26 patients diagnosed with alcoholism compared to 30
demographically controlled university students. Specifically,
the clinical group listed 40% less goals and showed smaller
than average commitment to their goals.

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3.5.2
|
Clinical utility
Client feedback on the helpfulness, difficulty, and clarity of
the German version of the MSQ suggests that it is feasible
and acceptable to clients, with 61.9% finding the measure
generally helpful and 74.1% finding it feasible (Grothenrath
& Schneider, 1996, cited in de Jong‐Meyer, 2004). Clients’
suggested that the measure provided clarity around goals and
concerns and improved their motivation.
3.5.3
|
Comment
The MSQ can be scored electronically and may require less
practitioner training than the IntQ. In addition, this means
that it can be undertaken as a “take home” exercise, which
may increase the efficiency of the psychotherapy and reduce
the clinicians’ influence on the goals.
3.6
|
Personal Concerns Inventory (PCI)
The PCI (Cox & Klinger, 2000) is a simpler, more user‐
friendly version of the MSQ. The PCI is administered and
completed in a similar manner to the IntQ and MSQ. It takes
approximately one hour to complete as it tends to elicit fewer
concerns than the IntQ and MSQ. All concerns and goals
generated through the PCI are rated on 0–10 scales, rather
than separate multi‐level scoring systems (Cox & Klinger,
2011a). The dimensions most closely related to goal progress
are “How long will it take to attain this goal” (cf. “goal dis-
tance”) and, “How likely am I to attain it, if I do my best” (cf.
“chance of success”).
As with the IntQ and MSQ, the PCI has primarily been
used therapeutically with clients struggling with drug or al-
cohol use, although it has also been used with Finnish adoles-
cents in school‐based group interventions to understand more
about their education‐related personal goals (Salmela‐Aro,
Mutanen, Koivisto, & Vuori, 2009). It has also been adapted
for use with offender populations through the addition of two
life areas (a) concerns they have with their offending behav-
ior; and (b) current living arrangements (the PCI‐OA; Sellen,
McMurran, Cox, Theodosi, & Klinger, 2006; McMurran,
Sellen, & Campbell, 2011). The items relating to drug or al-
cohol use in the PCI have been changed to refer to offending
behavior.
3.6.1
|
Reliability and validity
The internal consistency for “goal distance” and “chances
of success” were 0.48 and 0.04, respectively, in a sample
of heavy alcohol drinkers who were not receiving treatment
(Cox, Pothos, & Hosier, 2007). In a separate study of Iranian
students, the internal consistencies for the same scales were
0.78 and 0.82, respectively (Fadardi, Azad, & Nemati, 2011).
3.6.2
|
Clinical utility
McMurran, Cox, Whitham, and Hedges (2013) found that cli-
ents randomized to PCI interview after initial assessment plus
treatment as usual (TAU) had a median session attendance
of 88.3% over 12 weeks, compared to 66.7% attendance over
the same period for clients receiving TAU only. In the same
study, mean treatment engagement scores—as measured using
the Treatment Engagement Rating scale (TER; Drieschner &
Boomsma, 2008)—were higher in the PCI group compared to
those receiving TAU only (6.64 and 2.94, respectively).
3.6.3
|
Comment
Despite the PCI being a briefer measure than its predeces-
sors, it is still complex and time‐consuming to complete.
There is more evidence for the clinical utility of the PCI, as
compared with the IntQ and MSQ. The more user‐friendly
terms for goal progress on the PCI, compared to the IntQ
and MSQ, may also enhance its utility as a tool for routine
outcome monitoring.
3.7
|
Personal Aspirations and Concerns
Inventory (PACI)
The PACI is a modified version of the PCI, with several
changes that make the measure more explicitly oriented to-
ward positive, “approach” goals (Cox & Klinger, 2011a; Cox,
Klinger, & Fadardi, 2006). At the start of the process, re-
spondents are asked to consider positive aspirations and goals
as well as concerns, to write down “important goals” in each
area of life, and then to specifically rate their “goals” on 14 di-
mensions. This is an expansion from the 10 dimensions of the
PCI, with the items on goal success and goal distance retained.
The PACI has also been adapted for work with offender
populations, the Personal Aspiration and Concerns Inventory
for Offenders (PACI‐O; Campbell, Sellen, & McMurran, 2010;
Nekovarova, 2016), with the adaptations in line with those of
the PCI‐OA (see above). There is little evidence of the use of
the PACI outside of forensic settings and substance abuse work.
3.7.1
|
Reliability and validity
Internal consistency for the probability of success and goal
distance items for the PACI ranged from 0.58 to 0.66, respec-
tively (Cox & Klinger, 2011a). For the same scale, test–retest
stability ranged from 0.52 to 0.67.
3.7.2
|
Clinical utility
Sellen, Gobbett, and Campbell (2013) carried out a pilot ran-
domized controlled trial comparing the use of the PACI‐O
against treatment as usual for 37 adult male sexual offenders

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LLOYD et aL.
participating in a cognitive skills program. The PACI‐O did
not lead to statistically significant improvements in treat-
ment engagement over time, but results were in the pre-
dicted direction, with small to moderate effect sizes on two
separate outcome indicators (ds = 0.16 and 0.36).
3.7.3
|
Comment
Of the four measures developed within systematic motiva-
tional counseling, the PACI is most explicitly oriented to
work with goals. It is also the briefest of these measures, with
emerging evidence of psychometric reliability.
3.8
|
Strivings list and Striving Assessment
Scales (SAS)
Therapeutically, the SAS has been used in both individual
and CBT programs for veterans suffering from Posttraumatic
Stress Disorder (PTSD; Kashdan, Breen, & Julian, 2010), as
well as in motivational interventions for those with co‐morbid
schizophrenia and alcohol use disorders (Carey, Leontieva,
Dimmock, Maisto, & Batki, 2007).
Personal Strivings are captured through Strivings Lists,
whereby up to 15 personal strivings are generated by the cli-
ent. Each striving can then be rated on up to 15 dimensions
using Striving Assessment Scales (SAS; Emmons, 1986).
The dimensions most closely related to goal progress and
outcomes are “probability of success” (“In the future, how
likely is it that you will be successful in the striving?”) and
“probability if no action” (“How likely is it that you will be
successful in the striving if you do not take action?”). Both
dimensions are rated on 10‐point scales ranging from 0 (no
chance of success) to 9 (at least 90% chance of success).
3.8.1
|
Reliability and validity
For “probability of success” and “probability if no action,”
test–retest reliability coefficients after one month were 0.68
and 0.84, respectively. After three months these coefficients
were 0.55 and 0.67, respectively (Emmons, 1986). There is
also some evidence of the stability of the strivings themselves
over time, with 82% of strivings remaining the same (or
closely worded variations) one year later (Emmons, 1986).
3.8.2
|
Clinical utility
No evidence for the clinical utility of the SAS could be
identified.
3.8.3
|
Comment
Unlike the IntQ family of measures, the SAS does not
predefine the areas in which clients are asked to identify
goals. In addition, the SAS makes it explicit that not all
dimensions need to be rated for each striving: practition-
ers can select particular dimensions to rate based on their
clinical judgment, making it a flexible tool for therapeutic
work. This flexibility means that SAS has more poten-
tial to be adapted for use in session‐by‐session outcome
monitoring if a small number of scales are used, or as
a more in‐depth measure of strivings during therapeutic
assessment.
3.9
|
Goal‐Based Outcomes (GBOs) tool
The GBOs tool is an 11‐point scale for rating a client's pro-
gress on their chosen therapeutic goals (Law, 2011). While
it is most often used in therapeutic work with children and
young people, it can also be used therapeutically in adult
settings, and with people with learning disabilities (Law &
Jacob, 2013). In work with children and young people, the
GBOs tool can also capture clinician and parent/carer goals.
The GBOs tool is used across a range of child and adolescent
mental health settings, including school‐based counseling ser-
vices (e.g., Law & Wolpert, 2014; Pender, Tinwell, Marsh, &
Cowell, 2013; Rupani et al., 2014).
Written goal‐based outcomes are usually recorded at the
beginning of therapeutic work in a practitioner‐completed
paper workbook, or using an electronic system, through col-
laborative dialogue with the client. Once goals have been set
and recorded on the GBOs record sheet, their progress is then
rated on a scale of 0 (not met at all) to 10 (fully met), with
a midway anchor point of 5. The GBOs tool can be used to
capture goal progress at two distinct time points: the begin-
ning (T1) and end of therapy (T2), or on a session‐by‐session
basis. Here, goal progress can be monitored using the goal
progress chart. This allows each goal to be rated on up to 12
occasions per sheet and can be used as a visual tool by join-
ing up each subsequent rating with a straight line. A separate
goal progress chart should be completed for each goal (Law
& Jacob, 2013).
The tool has been translated into Japanese, Norwegian,
and Portuguese. More information on GBOs, as a PDF ver-
sion of the tool, can be found at www.goals-in-therapy.com.
3.9.1
|
Reliability and validity
The internal consistency of goal progress, as measured using
the GBOs tool, has been found to be acceptable, with a
Cronbach's α of 0.71 and 0.73 for T1 and T2, respectively
(Edbrooke‐Childs et al., 2015). Research has also found that
progress on goals—as measured using the GBOs tool—is
moderately correlated (r = 0.4) with improvements in emo-
tional symptoms when measured using the practitioner ver-
sion of the Children's Global Assessment Scale (CGAS;
Shaffer et al., 1983; Wolpert et al., 2012).

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3.9.2
|
Clinical utility
Preliminary evidence suggests that children and young people
perceive the GBOs tool positively (Bromley & Westwood,
2013), with 85% of young people agreeing with the statement
“Goal scales helped [me] to show others how [I] was feeling
and where [I] needed help” and 92% saying that they “liked
having the chance to choose their own goals” (Pender et al.,
2013). In the same study, 69% of young people agreed that
“working toward goals helped [me] stay on track.”
3.9.3
|
Comment
The GBOs instrument is a suitable session‐by‐session meas-
ure due to its brevity, easiness to complete, and acceptable
psychometric properties. The progress rating scale is straight-
forward and can easily be interpreted by both clinicians and
clients. An additional benefit of the GBOs instrument, com-
pared to other measures, is the ability to use it as a visual tool,
meaning it may be more engaging for clients. The simplicity
of the goal‐generation procedure, however, may mean that
the goals identified reflect only the most immediate, con-
scious concerns. Further research investigating the reliability
and validity of GBOs would be welcomed.
3.10
|
Goals Form
The Goals Form was developed as a simple, easy to complete
idiographic outcome measure for psychotherapy. It was first
used in a pilot pre‐/postintervention study of “pluralistic ther-
apy”: a collaborative, integrative approach (Cooper, 2014).
The form asks clients, in collaboration with their psychothera-
pist, to identify up to seven goals for therapy—typically at a
first assessment session—and then to rate them on a 1 (not at
all achieved) to 7 (completely achieved) Likert‐type scale. The
agreed goals are then typed onto a digital copy of the form and
printed off, such that clients are able to rate the same goals
at regular intervals, ideally every session. Over the course of
psychotherapy, clients have the opportunity to delete, add or
modify goals; and the electronic copy of the Goals Form is re-
vised accordingly. Change over the course of psychotherapy is
calculated by averaging differences between first to last scores
on each goal, with new or modified goals treated as additional
goals. The form is freely available in English and can be down-
loaded, with instructions for use and scoring, from https://
www.researchgate.net/publication/286928866_Goals_Form.
The Goals Form has been used in a multisite trial of pluralistic
therapy for depression (Cooper et al., 2015).
3.10.1
|
Reliability and validity
At pilot evaluation, between‐client internal consistency at
baseline assessment, using clients’ first three goals, was 0.68
(Cooper, 2014). The median within‐client internal reliability,
using clients’ initial set of goals, was 0.84; with 88.2% of cli-
ents having a Cronbach's alpha of 0.70 or higher. Test–retest
reliability, comparing mean goal scores from assessment to
first session was 0.74 (Cooper, 2014). In terms of conver-
gent validity, mean Goals Form scores showed large correla-
tions with the CORE‐OM at baseline (r = −0.66, p = 0.008;
Cooper, 2014). The Goals Form proved sensitive to change
from baseline to end of therapy, with a Cohen's d of 1.55
(Cooper et al., 2015).
3.10.2
|
Clinical utility
At the end of psychotherapy, clients gave the Goals Form
an average rating of 4.2 (SD = 1.2) on a 1 (very unhelpful)
to 5 (very helpful) scale of clinical utility (n = 17; Cooper et
al., 2015). Qualitative analysis of post‐therapy interview data
indicates that clients found the regular assessment of goals,
through the Goals Form, “acceptable or of positive benefit
for the counseling” (Cooper, 2014). A more recent study of
goal‐oriented practices in a collaborative, integrative psycho-
therapy found that 15 of 22 clients (68.2%) found the use of
the Goals Form helpful (di Malta, Cooper, & Oddli, 2018).
3.10.3
|
Comment
Preliminary evidence indicates that the Goals Form is psy-
chometrically and clinically acceptable and can be used on
a session‐by‐session basis. Further research is needed, how-
ever, on its psychometric properties. As with the GBOs tools,
the simplicity of the goal‐generation procedure may mean
that goals are more superficial, and less comprehensive, as
compared with more sophisticated measures.
4
|
DISCUSSION
Our systematic search identified nine idiographic, self‐report
goal measures that have been used in psychotherapy, four
of which came from the same family of instruments. This
substantially extends the findings of both Sales and Alves
(2016) and Hurn et al. (2006), which identified just one
goal‐based idiographic outcome measure for psychotherapy:
GAS. Our review may have failed to identify measures pub-
lished outside of the English language. In addition, although
we included unpublished materials, we may have overlooked
measures for which there was limited public documentation
or which we failed to identify with our search terms.
The use of these self‐report goal measures in psychother-
apy provides therapists with a means of monitoring outcomes
that are tailored to the individual client, and that may capi-
talize on the benefits associated with goal setting and goal
monitoring. Evidence of clinical utility in our review, where

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LLOYD et aL.
available, generally supported the positive benefits that goal
measures could have in supporting therapeutic progress.
However, an essential area for further research in this field is
to examine, in more detail, whether the benefits of goal set-
ting and goal monitoring, as identified in the psychological
literature do, indeed, transfer to psychotherapy. Controlled
studies, with and without the use of goal measures (such as
scaled‐up versions of Sellen et al.'s (2013) trial), would be
a robust means of assessing this. Controlled studies com-
paring the use of goal‐focused idiographic measures against
nomothetic measures, and also against problem‐focused idio-
graphic measures, could further develop our understanding
of how particular types of measure might contribute to the
process and outcomes of psychotherapy.
In our review, we found three relatively discrete catego-
ries of idiographic goal‐focused measures. In relation to sup-
porting client progress, each of these had particular strengths
and limitations. First were those multidimensional tools that
invited clients to establish goals through relatively structured
procedures, and then to rate them on a range of dimensions
(PPA, IntQ, MSQ, PCI, PACI, and SAS). These instruments
had primarily evolved from the fields of psychological re-
search and assessment. Hence, as well as allowing for the
setting and monitoring of goals, they may provide support for
therapeutic assessment processes: providing clinicians with
an opportunity to develop in‐depth understandings of clients’
motivational structures. This may be particularly helpful in
“motivation‐based therapies”—such as the methods of levels
(Mansell, Carey, & Tai, 2013), and Egan's (2013) problem‐
management approach, as well as systematic motivational
counseling (Cox & Klinger, 2011b)—which are oriented
around an understanding of client's goals and purposes, and
the relationships between them. However, given “real world”
constraints in terms of time and resources, the degree of
training required for the use of these measures, as well as the
time that they take at assessment and follow‐up, may make
them less suited to general psychotherapeutic practice—par-
ticularly on a session‐by‐session basis. In addition, the rela-
tive complexity of the goal generation and rating process may
make them unsutiable for clients with severe cognitive limita-
tions (Hamann et al., 2009; Jacob et al., 2018). Nevertheless,
to some extent, these issues could be mitigated for by using
briefer versions of these measures, such as the PACI, and by
scaling down the dimensions at follow‐up assessment to only
those related to goal progress.
A second set of goal measures were the two brief rating
forms: the Goals Form and the GBOs tools. These had a rel-
atively simple and unsystematic goal‐setting process and just
one dimension for rating goal progress. These measures had
been specifically designed for use in session‐by‐session out-
come monitoring and seemed relatively well‐suited to this
purpose. However, the unsystematic nature of the goal‐set-
ting processes here may mean that the goals identified do not
cover all of clients’ major concerns, or those that are at a
deeper, less conscious, level. Of relevance here is research
which shows that the correlation between “self‐attributed”
motives (as identified through self‐completed questionnaires)
and “implicit” motives (as identified through, for instance,
projective tests) is small (a correlation of 0.09, Spangler,
1992). This suggests that an important priority for further re-
search is to assess the extent to which goals identified through
such brief forms correspond to those identified through the
more systematic goal measures, as well as through tools that
are intended to capture unconscious goals and motivations,
such as the Thematic Apperception Test (Murray, 1943).
The third category of measures, consisting of just one in-
strument, was goal attainment scaling. This combines an in‐
depth goal‐setting process with a specific rating of progress
against that goal and, uniquely, invites clients to consider, and
set, expected levels of outcomes. In terms of clinical assess-
ment, this means that GAS may produce a very well‐speci-
fied understanding of clients’ goals, and the particular criteria
that they, themselves, consider success or failure. As with the
multidimensional measures, however, the time‐consuming
nature of GAS—both in terms of specialist training and its
use in sessions—makes it less suited to session‐by‐session
outcome monitoring in general psychotherapeutic practice.
Several other dimensions of goal measure emerged in our
review. First, some measures could be completed digitally,
while others could not. The capacity to digitally complete
measures is likely to be advantageous as it can enhance effi-
ciency: allowing clients to complete measures before the ses-
sion, and potentially reducing the amount of training needed
for therapists. Second, some measures provided clients with
a predefined list of areas to focus on before generating goals,
while others did not. Although this process may be more
time‐consuming, it may facilitate the development of a more
comprehensive list of goals. Third, some measures allowed
for the revision and resetting of goals, while others did not.
Given evidence that clients like to be able to revisit and re-
vise goals (di Malta et al., 2018), this former process may
be preferable, though it raises important challenges regarding
the rating of goal progress over the course of therapy: par-
ticularly if a “total” score is to be calculated (Sales & Alves,
2016).
Although this review focused exclusively on goal mea-
sures that have been used in psychotherapy, we also came
across a range of additional goal measures used in psycho-
logical research and health services that could be adapted
for this domain. Measures within the former context in-
cluded The Goal Questionnaire (Zaleski, 1987), The Therapy
Goal Assessment Procedure (Elliot & Church, 2002), the
Individualized Outcome Measure (Pesola et al., 2015), and
the Outcomes of Problems of Users of Services (Hunter et al.,
2004). The two measures used within the latter context were
the Patient Goal Priority Questionnaire (Åsenlöf, Denison,

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LLOYD et aL.
& Lindberg, 2004) and the Idiographic Functional Status
Assessment (Rapkin et al., 1994).
Consistent with Hurn et al. (2006), we found evidence
that scores on goal‐focused measures generally, though not
always, showed good temporal stability, and converged with
other measures of psychological wellbeing and distress. This
suggests that, in terms of supporting client progress, they
can function as robust and meaningful feedback instruments.
However, given the limited evidence of internal reliability
across goals, a “total” goal progress score should be treated
with caution. It is also important to note that much of the
psychometric evidence in this review comes from the use of
measures within an assessment context, rather than in routine
outcome monitoring. Hence, findings of psychometric qual-
ity should be treated with caution.
With respect to functioning as population‐level indicator
of outcomes, idiographic measures have been criticized on
the grounds that, as each client has a unique set of indicators,
it is not possible to compare outcomes across clients, treat-
ments, or services (Elliott et al., 2016). In addition, as ther-
apists are usually involved in the goal‐setting process, goal
measures may be more vulnerable to “gaming”: with thera-
pists, for instance, setting easy treatment goals to “evidence”
better outcomes for their service (Law & Jacob, 2013). In our
study, we found some evidence that idiographic goal mea-
sures might be able to function as population‐level indica-
tors of outcomes, in that they tended to converge with more
established, nomothetic measures of wellbeing and distress.
However, more robust evidence of criterion validity is needed
before goal‐based measures could be relied upon to perform
this function. In particular, evidence which shows that vari-
ations in goal attainment, across services or treatment, con-
verge with variations in outcomes on nomothetic measures,
and with diagnostic assessment procedures. This is a priority
for future research.
As with Sales and Alves (2016), therefore, we recom-
mend that, at the present time, goal measures should only
be used in association with one or more well‐established
nomothetic scales—particularly where there is a desire to
evaluate outcomes at the population level. At the individ-
ual level, such combining would also help to offset some
other important current limitations of goal measures: the
absence of clinical cutoffs, the lack of population norms
against which clients’ scores can be compared, and diffi-
culties contextualizing clients’ problems along established
psychological and psychiatric dimensions. Nomothetic
measures would also help to ensure that problems outside
of the clients’ awareness could be identified and, where rel-
evant, addressed. Combining the use of these measures in
this way would also help to build up evidence on the con-
vergent validity of goal measures.
In summary, our review indicates that therapists, and
researchers, have access to a range of goal measures, with
evidence that they are psychometrically acceptable indica-
tors of goal progress. More than this, and consistent with the
psychological research, there is emerging evidence of clini-
cal utility: that they can support the process and outcomes of
therapeutic work. Currently, the evidence cannot substantiate
the use of goal measures alone—particularly where there is a
need for service‐ or treatment‐level outcome evaluation—but
they can be considered an essential complement to nomo-
thetic measures: helping to ensure that the treatment is most
fitted to the individual client. Without the use of idiographic
measures, clinicians, and patients, cannot track whether or
not the treatment is meeting the client's specific, individual
needs. Goal measures can fill that gap and help psychother-
apists “create a new therapy for each patient” (Yalom, 2001,
p. 33).
ACKNOWLEDGMENTS
With thanks to Duncan Law, John McLeod, Hanne Oddli,
and Célia Sales for comments on an earlier draft of this
manuscript.
ORCID
Christopher E. M. Lloyd https://orcid.org/0000-0001-9659-0890
Charlie Duncan https://orcid.org/0000-0002-0634-810X
Mick Cooper https://orcid.org/0000-0003-1492-2260
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