9: Goal Setting and Care Planning

The service works with service users’ goals using care planning. There are regular reviews that clarify the service user’s preferences and choices. This starts in the first contact / the initial Choice appointment and continues throughout the whole contact with the service. May involve frequent routine outcome monitoring.

What do they want?

Being clear with people about what they want help with and monitoring progress is key in CAPA. Sometimes this can feel very difficult – service users can have many problems and there is always more that can be done! It can also be hard to define accurately. As people, especially children, grow and develop, and move through their life cycle, new problems emerge. Some mental health problems are recurrent or persistent so the work may never be ‘done’. In these circum- stances our interventions may involve a burst of intense contact during crises followed by infrequent ‘booster’ contact.

We need to be clear with clients about how we can help and how we cannot. And help them engage effectively with other agencies that can complement what we do.

Achievable Goals

It is worth spending some time working out goals that are achievable and measurable. Doing this improves therapeutic and task alliance and the effectiveness of the experience for the service user. Read the Philosophy article in the Choice chapter for more information. Goals need to include how the client is going to manage the issues themselves. What resources have they got? Can extended family help?

How will the client know when things have improved? Sometimes this is straightforward e.g. return of normal body weight and menstruation in anorexia nervosa; return to school regularly in school phobia. For others it will be a reduction in frequency and severity of behaviours e.g. aggressive outbursts or cutting.

Writing down goals and plans helps with focus and continues to strengthen the task alliance. You may choose to do this as a structured Care Plan or letter. It needs to include a written description of the main issues, interventions, goals and which professionals and agencies are involved. Decide on review dates and stick to them. Go through what has changed since the last review.

Outcome measures appropriate to your client group (for CAMHS these could be those recommended by the CAMHS Outcomes Research Consortium (CORC) or CYP-IAPT in England) can also help both you and the client review how things are going. CORC has a goal focused out- come measure that can be used. Clinical Global Assessment Scale (CGAS), Strengths and Difficulties Questionnaire and the Experience of Service Questionnaire (ESQ) add further evidence of how things are changing and their experience.

What happens if you don’t set goals and use Care Plans?

Work becomes unfocussed; clients and clinicians are not clear about what they are both working towards. Things drift. People may be seen for longer than needed. Flow through the whole system for all service users is impeded.