Goal formulation

Summary

Helping the patient to identify goals for therapy is essential to every cognitive behavioral therapy. There are two different, mutually reinforcing ways of working with goals in CBT; focusing on specific and achievable goals on the one hand, and focusing on more value-based goals on the other hand. All goal formulation should be based in what the patient wants to change in his or her life, in terms of what he or she would like to be able to _do_ differently.

Principles and practice

CBT is a goal-oriented therapy. This is an important principle for many reasons. One of the reasons why it is so important to make goals explicit is for ethical reasons: The therapist should only help the patient with concerns that are important to him or her – the therapist shall never impose something upon the patient, related to the therapist’s moral principles or his or her ideas of how to live a fulfilling life.

During the initial sessions of CBT, the therapist wants to help the patient find goals for the therapy, that is, what the patient would like to be different at the end of a successful therapy. In CBT there are basically two different kinds of goals: “SMART” goals and value-based goals.

SMART goals

“SMART” is an acronym for “Specific, Measurable, Achievable, (within a) Realistic, Time-frame”. This is the traditional way to help the patient define goals in CBT: From all the different, often very broad things in life that the patient would like to change, the therapist will help the patient to break these down into more specific goals, that the therapy could focus on within the time-frame of the therapy. One example could be the patient that says “I would like to find a partner, to engage in a relationship and eventually start a family”. It is then helpful to break this “big” life goal down into smaller, more specific, realistic goals within the time-frame of the therapy; of which an example could be (for the heterosexual patient): “To be able to engage in conversation with someone of the opposite sex in a social setting”, “To be able to be attentive to this person during a date even if I am very anxious”. These goals would be “SMART”-goals than one could work on in therapy.

Value-based goals

The notion of value-based goals comes from the so-called “third-wave of CBT” (see separate article) and specifically from ACT (Acceptance and Commitment Therapy; see separate article). They are, by definition, not “SMART” – but often very useful in therapy. One example could be, following the same example of the patient above that would like to find a partner: “I would like to be an empathic person, attuned to the needs of those close to me”. This goal reflects more of a value; it is not “specific” or “achievable” in the sense that one could say “OK, now it’s done!” – it is an “eternal” goal, something to strive for but to never fully “achieve”. It works by changing the inner context of doing something – or as ACT would say: by changing the “relational framing” of doing something in one’s everyday life. Put differently: It introduces positive reinforcement (“I’m an empathetic person now”) where other reinforcers may be scarce.

One common challenge in goal formulation is that the patient often, to the question “What would you like to be different”, answers something like “I would like to not be so anxious” (or “depressed”, or “tired” etc). That is, he or she answers with a goal about no longer _feeling_ the way they do. This is completely understandable, given that the patient suffers from emotional problems. However, the challenge in CBT is that such a goal (“I don’t want to feel so anxious/so depressed”), however understandable, doesn’t really help in guiding therapy. The cognitive behavioral therapist needs to help the patient identify what he or she needs to _do_ differently, in able to eventually feel differently.

The Miracle Question

A very effective way to help the patient identify such behavioral goals is by way of the so-called “Miracle Question”, which is actually a technique that CBT has “borrowed” from another type of therapy within the systemic tradition, namely Solution-Focused Brief Therapy (SFBT). There are many different ways to phrase this question, but in CBT its function is help the patient go from emotional goals or goals in terms of the absence of something (“I don’t want to…”) to behavioral goals, in terms of the presence of something (“I would like to be able to…”). One way to phrase “Miracle Question” is like this:

Therapist: “Imagine I had a magic pill, that I could give to you now, and that you would swallow with a glass of water before you go to sleep this evening. During the night, during your sleep, the pill has its miraculous effect: that all the difficult sensations and emotions you have described to me would magically disappear! So here comes the question: When you wake up tomorrow morning, what would you _do_ that made you realise that the miracle really had occurred? What would your family notice that you would _do_ differently? What would your colleagues notice? Your friends? Your neighbour?”

This miracle question, adapted to CBT goal formulation, with its focus on behavioral change, thus asks what the patient would notice that he or she would _do_. It is very common that the patient still answers something like “I wouldn’t be so tired”, “I wouldn’t be so anxious”, but then the therapist just continues in the same vein: “OK, interesting, what would you _do_ if you weren’t so tired? Remember, the miracle has taken all that tiredness away”.

At the end of the session during which the “Miracle Question” was introduced, a common homework (see separate article) is for the patient to, until the next session, reflect upon it and write down as many answers to it that he or she can imagine. It is often also very helpful to also include in that homework that the patient should explain the “Miracle Question” to his partner or family and specifically them “What do you think you would notice that I would do differently?”

Our clinical experience tells us that this is a very effective way to help the patient find goals. In a CBT for anxiety, OCD, or related disorders, the list of things that the patient finds that he or she would do (following the miracle question), often directly become material for the exposure hierarchy (see separate article). Examples: for the socially anxious person to “speak to someone they don’t know”, for the OCD contamination-patient to “use a public bathroom”, etc.