Therapy Goals: Yours, Mine, and Ours

One of the many detriments of a medical model for approaching anxiety and depression, the two most common topics of psychotherapy, is the diminishing art of setting goals. After all, nobody wonders what the goal of treating influenza or infection is; it’s to return to the functioning the patient had prior to getting the virus or bacteria. Doctors have to consider goals for certain kinds of diseases, helping patients choose between survival, productivity, and comfort, for example, but generally, the definition of health is not in dispute in a medical model.

Anxiety and depression are not diseases (excepting the small percentage of each that seem to be biologically-based); they are signs that something is wrong. Therapists and patients must choose between making the signs go away versus changing what is wrong in the first place, a distinction that seems to me to be analogous to turning off a burglar alarm that wakes you up at night versus doing something about the burglar. The difficult work of psychotherapy is made easier when patients can see the relationship between what they are asked to do (whether that is to reveal their inner thoughts, approach unpleasant emotions, or complete homework) and what they hope to get out of the therapy. This relationship between mutual goals and what the patient is asked to do is the essence of what is meant by the working alliance. The articulation of that relationship is called a case formulation.

Many therapists don’t set goals with patients. Some assume the goals are implicit and need not be stated overtly. Freud said the goals of psychoanalysis are love and work. Winnicott added play. Adler added doing something for others. If therapists don’t set goals, it’s often because they and their patients understand that the goal is to find love, work engagingly, enjoy life, or feel their lives have meaning. I prefer to make these goals explicit, even if they never come up again. Some therapists, I’m sorry to say, don’t set goals because they don’t like the idea of subjecting their work to measurable criteria. The latter can signal failure or a time to stop (when goals are achieved), which can be aversive for therapists.

Recent developments in the field of therapy have reacted to the image of the know-it-all doctor pontificating about the patient’s life and psyche. Now you often see therapists who think they can keep from imposing their own values on patients, which leads them to doing it unconsciously. The result is a generation of therapists who think they are not allowed to co-create the goals of the therapy with the patient. Patients want help overcoming their fear of riding the bus, and therapists think they are not allowed to ask where the bus is going, whether to see if they want to help the patient get on it or to see if the fear may be of the destination rather than the ride. This tendency is especially pernicious when the patient wants relief from anxiety or depression and the therapist doesn’t even wonder what the function of the problem may be.

I think it is important to ask patients what they would like to be doing with their time and energy if they weren’t anxious or depressed. This approach allows therapists to decide if they are on board with their patients’ goals, and it articulates an outcome that can inspire the patient. It also sets the stage for psychology to enter the picture when therapists direct attention to patients’ efforts to do these things directly. For example, patients say they would socialize more if they weren’t depressed. Often, it is the case that not socializing is causing the depression rather than the depression causing isolation, but even if that is not the case, it is useful to wonder what step the patient would take if he or she were to socialize. Then, the therapist can focus on what keeps the patient from taking that step. By focusing on a specific moment, the dyad can unearth the psychology of the patient’s behavior, instead of accepting the patient’s master narrative about being isolated. For example, the patient claims that a belief that nobody likes her keeps her from contacting acquaintances, but examination of her thoughts on a specific occasion of eating ice cream and not calling anyone can reveal that her actual belief is that nobody thinks she’s a princess. Psychotherapy, in this context, can be seen as the resolution of barriers to achieving goals where the barriers are psychological.

Some barriers are not psychological. The therapist cannot arrange for the availability of rewarding work or a reciprocal lover. This is what Freud meant when he said the goal of psychoanalysis was to replace id (“it”) with ego (“I”). He meant that patients must learn to take responsibility for themselves. Other in-therapy goals include resolution of conflicting agendas, reconciliation with reality, acceptance or understanding of the self, and so on. These can lead to engaging work or romantic love, but they can’t guarantee it. Some like to use different words for the patient’s ultimate goal and the desired endpoint of the therapy; goals, objectives, outcomes, endpoints—these all sound the same to me. I prefer to make external benefits the goal of therapy and then clarify that the part we can achieve together is to remove or relax the psychological barriers to achieving those goals. The former never include reducing depression or anxiety; the latter typically do (keeping in mind that the personal function of depression or anxiety is often best discovered in an examination of specific moments).

I have likened the setting of therapy goals to the selection of a play by a theater company (in some respects). The selection of material should consider what the audience wants or needs to see, the talents of the actors and directors, and the artistic agenda of the company. The latter concern is utterly valid, and a therapist’s view of health (in a quasi-medical model) or the meaning of life (in a more psychological model) is ignored at the peril of not fully engaging the therapist in his or her own work. Sure, there’s reason to worry about therapists trying to turn patients into “mini-me’s,” but given the power differential, that’s at least as likely to happen if the therapist pretends not to have an agenda. I think therapists should articulate their therapeutic agendas so as to subject them to the scrutiny of colleagues and supervisors. Therapists who claim not to have an agenda cannot be counted on to pull their oars as energetically as their patients, and this leads to going in circles.

One nomenclature with potential would be to discuss life goals (better relationships with friends, engaging work, and so on) as your (the patient’s) goals. Theory-bound or philosophy-bound goals, often implicit in the therapy (reconciliation with the self, for example, or enhanced freedom through deliberate action, or feminism), are my (the therapist’s) goals. And in-therapy goals derived from the case formulation (tolerance of aversive thoughts, making sense together, understanding oneself, metacommunication, and conflict resolution, for example) are our goals.