Are clients’ perceptions of the goals of their therapy always the same as our own? As a newly published study suggests, lack of proper alignment and regular review of goals may have unintended consequences, and we can’t afford to make assumptions that we’re always on the same page.
How does lack of clarity over the goals of therapy, as perceived by the client, impact on the process and outcomes of therapy?
A recently published study by Naline Geurtzen and colleagues in the Netherlands set out to establish the impact of client perceived lack of goal clarity on a range of unfavourable therapy factors such as higher levels of clients’ symptoms, poorer therapeutic alliances, higher levels of care dependency, and expectations about treatment lengths and needs.
The study’s findings powerfully underline the importance of initial goal setting and collaboration, and regular review as therapy unfolds. We provide some highlights here, but the full paper is well worth a read. By way of a refreshing change, it’s available in full here.
What do we already know?
As we’ve previously written, goals are one of the three critical elements that together form the therapeutic alliance first articulated by Edward Bordin. Goals, together with the tasks of therapy and the bond between client and therapist, account for perhaps seven times more of the variance in therapy outcomes than the therapy model itself.
We also know that goal consensus between client and therapist has a significant bearing on outcomes. The meta-analysis by Tryon & Winograd published in 2011 yielded a goal consensus – outcome effect size (d= 0.72) similar to the effect size for the alliance – outcome relationship. Their conclusion, quite simply, was that “….better outcomes can be expected when patient and therapist agree on therapeutic goals and the processes to achieve these goals.”
Despite the importance of goal consensus, however, some studies suggest that we’re not always on the same page as clients as far as goals are concerned. A study by Oddli and colleagues, for example, used a modified constructivist grounded theory methodology to examine the strategies used by highly experienced therapists to explore client goals for therapy during the first three sessions. They concluded that:
The transcripts revealed few therapist behaviours directed toward agreeing upon explicitly defined goals.……….the client–therapist dialogs examined in this study were characterized by processes regarding hope, motivation, and engagement rather than by explicit goal agreement.
The study in question
Our current study set out to develop a short and reliable self-report measure to detect clients’ perceived lack of goal clarity in therapy settings. In addition, to examine the relationships between goal clarity and a range of unfavourable treatment factors: higher clients’ symptom levels, poorer therapeutic alliance, higher levels of care dependency in clients, and treatment length expectations and needs. The measures employed are outlined briefly below.
Goal Clarity Scale: An 11-item version of a scale designed to test clients’ perceptions of goal clarity in their therapy, rated on a 7-point Likert scale. Examples of questions include “It is clear to me what the focus of my treatment is”; “I find it difficult to indicate what the desired result of my treatment is”; or “The goal of the treatment tends to change from time to time.”
Goal setting and evaluation: The degree to which clients perceived that goals were set at the outset of therapy and monitored during it was tested with four questions: (1) “At the start of the treatment, were one or more treatment goals set?” (yes/no); if yes, (2) “Did you set this treatment goal or these treatment goals together with your therapist?” (yes/ no); (3) “Are your treatment goal(s) discussed during the therapy sessions?” (Yes, at [almost] each session/often/sometimes/ [almost] never); and (4) “Is your progress measured during the treatment? (Yes, at [almost] each session/often/sometimes/[almost] never).
742 clients in adult outpatients in short- and longer-term treatment settings in the Netherlands
On average, patients had received 174 treatment sessions at the moment that they participated in the current study
* Goal Clarity Scale
* Goal setting and evaluation in treatment (4 questions)
* Working Alliance Inventory for patients (WAI-12)
* Outcome Questionnaire (OQ-45.2)
* Care Dependency Questionnaire (CDQ)
* Expected and needed number of future treatment sessions (2 questions)
Therapeutic alliance: The therapeutic alliance was measured with the client completed Working Alliance Inventory (WAI-12), which measures the degree of agreement between client and therapist on treatment tasks and the treatment goals (i.e., goal consensus), and the strength of the bond between them.
Psychological symptoms and functioning: Clients’ symptoms and functioning were measured with the Outcome Questionnaire (OQ-45.2), a 45-item scale measuring symptomatic distress, difficulties in interpersonal relationships, and problems regarding functioning in a social role.
Care dependency: Clients’ levels of care dependency were measured using the Care Dependency Questionnaire (CDQ). This contains 18 items covering three dimensions of care dependency; patients’ submissive stance in treatment (e.g., “I present all my decisions to my therapist”), patients’ need for contact with the therapist (e.g., “I dread ending the contact with my therapist at the end of the treatment”), and the lack of perceived alternatives (e.g., “In my opinion, this treatment is the only way of ridding myself of my complaints”).
Expected and needed number of future treatment sessions: Clients were asked about their expected number of future treatment sessions: “How long do you think that your current treatment will continue? Please report a number reflecting the number of future sessions.” In addition, they were asked about their perceived need for future treatment sessions: “How many treatment sessions do you think you still need in order to be able to function independently after treatment?”
What did the study find?
Two of the 11 items from the Goal Clarity Scale were eventually dropped to produce a nine-item scale with good internal consistency, measuring clients’ lack of goal clarity in treatment. Subsequent analysis produced a range of findings which clearly illustrate the impact of a perceived lack of goal clarity on factors known to related to therapeutic outcomes, such as the alliance. In summary:
Almost one in four clients (23%) reported that their therapy lacked goal setting.
Of the 77% of clients who indicated that goals for their therapy were set, 30% reported that those goals were then addressed only sometimes during therapy, and 8.7% that they were (almost) never revisited.
Across all clients in the study, more than four in ten reported that their progress was monitored only sometimes (32%) or (almost) never (9.6%).
As measured by the Goal Clarity Scale, perceived lack of goal clarity was significantly lower for those clients who reported that goals were established at the outset of their therapy.
Of this group, goal clarity was significantly higher among clients who established their goals together with their therapist.
Lack of goal clarity was significantly higher when initial treatment goals were discussed less frequently during therapy, and higher also when treatment progress was not evaluated on a regular basis.
Lack of goal clarity was strongly linked to clients’ views on the quality of the therapeutic alliance. In particular, greater lack of goal clarity was related to lower levels of client/therapist agreement on the treatment goals and task dimensions of the Working Alliance Inventory, as well as a lower level of bond with the therapist.
Higher levels of perceived lack of goal clarity were related to higher levels psychological symptoms and problems in interpersonal relationships and functioning
Perhaps counter-intuitively, a higher lack of goal clarity was linked to lower levels of care dependency. These clients were characterised by a less submissive stance toward the therapist and were less likely to perceive a lack of alternative options.
Lack of goal clarity was modestly correlated to clients perceiving a need for a larger number of future treatment sessions.
This study points to a clear link between clients’ perceptions of a lack of goal clarity, and initial goal setting and the degree to which goals (if set) were revisited and progress monitored. Clients who established goals collaboratively with their therapist at the outset, and whose goals were then regularly reviewed and monitored during therapy, were likely to have a significantly greater likelihood of knowing what they were working toward.
In the absence of shared clarity over goals, we may be in danger of therapeutic ‘drift’. I know I’ve been guilty of this at times and I’ve seen it in many therapists’ data – that sense that the client is ‘flatlining’ in terms of their progress. We would do well to see such data as an opportunity to go back to basics and collaboratively revisit goals with our client.
It is also clear that clients who showed greater lack of clarify over goals also scored lower on each of the three dimensions (goals, tasks, and bond) of the therapeutic alliance. Given the clear and strong relationship between alliance and outcome mentioned earlier, this is worrying.
Clients with a greater lack of clarity over goals also had higher levels of psychological distress and more problems in interpersonal relationships and functioning. This seems unsurprising – it is hard to imagine how not knowing quite where your therapy is headed and where you are in the process can be anything but unsettling for a client.
None of these findings should really come as surprise, but perhaps they serve as a timely reminder to us that even if we think we know precisely where we and our clients are in the process of working towards their goals, we cannot assume the same of them. It seems clear that collaborating with our clients in the process of keeping their goals current, and keeping them clearly in mind as we move through our work, will serve us both well.
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