Goals or Wishes?
Goals are a central part of CAPA and any other service model that has collaborative practice and shared decision making at its heart. They are the vehicle by which we don’t impose our views or recommendations on our service users but rather elicit from them the things they want and how we can work with them towards those goals.
Another framework, Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT) in England, suggests that ‘It is important to get things right from the start when working with children, young peoples and their families (A Practical Guide to Using Service User Feedback & Outcome Tools to Inform Clinical Practice in Child & Adolescent Mental Health: CYP-IAPT CO-OP group: Chair Duncan Law). There are three elements to this:
- Understanding the problem (assessment),
- Agreeing how and what to work together on (goals or aims),
- And getting on well enough together (engagement or alliance) to be able to do the agreed work (intervention). These are inter-related and mostly rely on good clinical skills to get right – outcomes tools can help.’
However, even for clinicians who are collaborative in their practice and interested in forming goals with a service user it can be very easy not to go far enough. Quite often we have heard goals described to us which are really only the beginning of a goal process and could really be de- scribed as wishes rather than goals. An example could be the goal of “I want to be happier”. This is, of course, a reasonable thing for someone to wish for but it doesn’t really help the receiving partnership clinician or the service user focus on what they need to do together to actually make them happier.
This is where the usefulness, power and importance of a proper formulation comes into play. But let’s step back for a moment and think about – what is a formulation? It is a set of ideas or thoughts about the current situation which includes salient life events, relationships, internal views and opinions and psychological characteris- tics as well as any relevant diagnoses that together can describe the emotional and psychological predicament that is leading to the distress or challenging behaviour. It may include ideas about what predisposed the situation to arise and what is maintaining it. In other words, it is the “shape” of the problem. It is important to say that any formulation is really only a working formulation, as things change, understandings increase and so on. The formulation that is reached in a Choice appointment may only be the beginning but it is enough to inform the goal making process.
So how do we use the formulation in the development of goals? And how do we turn goal-wishes into goals that can inform a plan or task alliance? We think it is the intersection of the wishes of the person with the shape of their life that adds a level of detail to the goal. It is this that identifies the more specific goals that could be worked on
In the example left the intersection of the primary wish, say “to be happier”, with the formulation tells us that there are a fair number of issues in the family, some at school and a few with themselves.
In the second graphic we can drill down into one of the problem domains in the formulation and see that there is quite a lot to do in the relationship with the mother, some with the father and a little with a sibling
Perhaps we should make up a new term and call it Goal-Forming, so that we don’t forget that goals cannot be described in the absence of the formulation.
Questions to ask…
There might be several questions that we could ask you to help us to “Goal-Form”:
- Have we heard from the client what things they would like to be different in themselves or their lives? (wishes)
- Have we together created a formulation that seems to make sense of the current difficulties? (formulation)
- Have we talked with them about how their wishes intersect with their current difficulties and have we come up with more specific goals and methods? (First order Goal-Forming)
- Have we drilled down into the formulation to get specific goals that lead to action and intervention? (Second order Goal-Forming)