Sam is feeling a bit despondent. He is not depressed but he feels he does not know where he is heading in life. Working with his rehabilitation practitioner is helping with some specific challenges but he is feeling a bit lost in the bigger picture.

I know what I don’t want, like I don’t want to go back to hospital, I don’t want to be broke or homeless. Who I want to be is all a bit vague to me though. I have tried setting goals for myself before, but when it comes down to making them happen I kind of lose motivation, I can’t get my head together and just forget about what I promised myself to do. I find the rehab boring at times. Some of the activities are OK I guess. I go along because it is expected of me. I guess it helps but I just don’t seem to be getting anywhere. I remember saying to one of the guys at the rehab that I wanted to go to university one day and get a degree and make something of myself. He laughed at me and said I was being unrealistic, that I can’t even remember to take my medication so how could I get through a degree. I felt crushed. Perhaps he’s right.

This chapter describes collaborative goal-setting steps and a protocol that is underpinned by goal-directed principles. It is important to recognise that goals have different sources of motivation and that a major strategy in our approach involves linking goals with underlying values and strengths to tap into those sources of motivation. As part of this process, we try to help the person shape a personal life vision. Thus, goal setting creates ‘a concrete road map that mediates between where the person is and where he or she desires to go’ (Ades, 2004, p.15). Whilst collaborative goal setting is important, the values underpinning the goal and the vision driving the goal are also very important. This chapter focuses particularly on helping the person with a mental illness clarify life values and a vision. This vision is a great source of motivation and is essential for identifying goals, particularly approach-oriented goals (i.e. goals moving towards something positive).

Goal setting is most effective when it occurs within a working relationship where the practitioner is sensitive to the client’s readiness, motivations and orientation to his/her recovery process. There is often a need to socialise the client to goal setting and to build hope. Most clients come with needs-based goals that tend to be driven by an ‘avoidance’ motivation (i.e. to move away from or change an undesirable experience) and while these should be attended to, the aim is to help the client move toward growth-based goals that tend to have an ‘approach’ motivation.

Goal setting is a fundamental part of psychosocial rehabilitation and recovery support. The quality of goal setting is determined by:

the authenticity of collaboration
the degree to which the client ‘owns’ the goals
the number of goal-directed principles used
the effective balance of the meaning and manageability of goals
how well specific goals are integrated with the action steps to attain the goals.

Clarke et al. (2009a) found that the goal attainment of people with enduring mental illness mediated the relationship between their ratings of symptom distress and their perception of personal recovery. That is, goals are central to the recovery process, particularly in relation to facilitating growth, empowerment and wellbeing. The steps outlined below are designed to operationalise the goal-setting principles.

Socialising the person to goal-setting processes

It is important to recognise from the start that people will have a range of reactions to goal setting that often include increased anxiety, refuting the value of goal setting, feeling that goal setting is a bit like a test or something they may be held accountable for, or not understanding what it means or involves. Therefore, an important part of ‘authenticity in collaboration’ is making sure the person is appropriately engaged and socialised to each of the steps along the way, including exploring and explaining how the collaborative relationship works. The aim here is to help the person understand that recovery involves taking appropriate risks and accepting that progress will feel uncomfortable at times. It is important to clarify with the client that they are the one who makes the decisions about what they want to work on and that the practitioner’s role is to support the person in making the changes they want. Finally, the practitioner should reinforce that goal setting helps improve the chances of people moving forward in the desired directions (Box 7.1).

A care plan audit tool based on goal-setting theory and research evidence (‘Goal-IQ’, Goal Instrument for Quality) has been developed to assess the quality of goals being set in mental health services (Clarke et al., 2009b). A revision called the Goal and Action Plan Instrument for Quality (GAP-IQ) incorporates the action-planning components of the goal-planning and -monitoring process and is displayed in Box 7.2. This is an audit tool and consists of 17 key goal quality and action-planning domains that provide a structured guide for practitioners when reviewing their care planning with clients. Reviewing each of the 17 items of the GAP-IQ provides a useful way to specify the various steps that should be considered when goal planning with clients.

Before engaging in the specific steps, it is important to have established rapport and a good working alliance with the client. This increases client engagement, collaboration and ownership of any plans and actions. This initial relationship development process also helps the practitioner identify motivation, prior success, strengths, confidence and other resources that will help the person move forward with their goals. If the practitioner imposes goal setting on the person before they are ready to explore goal options, it is likely to be met with resistance. Strategies to operationalise these principles are elaborated on in Box 7.2.

Box 7.1 Goal-directed principles

The degree of goal agreement between the client and the practitioner is linked to increased satisfaction, decreased distress, reduced symptomatology and improved rehabilitation outcomes (Michalak et al., 2004).
The more the client is actively engaged in their own goal setting, the better their rehabilitation outcomes (Tryon & Winograd, 2001).
Goal attainment is improved when meaning and manageability are optimised (Little, 1989).
Goals are more manageable when they are not set too far into the future (Bandura & Simon, 1977) and when the client is at least 70% confident that they could achieve the goal within a set time period (Clarke et al., 2006).
Ensuring that goals are in line with the client’s values, interests, dreams and preferred identity is likely to increase goal ownership and in turn goal attainment (Anthony, 1991; Clarke et al., 2006, 2009; Sheldon & Houser-Marko, 2001).
Goal quality is defined by the degree to which goals are:
- clearly defined
- measurable
- sufficiently difficult/challenging to be engaging without being overwhelming
- ntegrated with an action plan
- time framed
- monitored for goal progress
- inclusive of progress feedback and problem solving of barriers (Locke & Latham, 1990).

In Chapter 6 some of the aims and techniques of motivational interviewing were described. Of particular relevance to goal setting are the issues of ‘what the person is ready for’ and how the conversations regarding goal setting can be ‘shaped’ to maximise ownership, engagement and consequently readiness. It is important to bear in mind that if the person is feeling overwhelmed with unmet needs, they may seem less ready to talk about goals but rather be concerned only with seeking some relief and safety. However, meeting unmet needs does usually involve goal setting. The goals that target unmet needs tend to be quite immediate in focus and more about getting away from an undesirable experience (i.e. avoidance-oriented goals) than about moving towards a preferred life direction (i.e. approach-oriented goals). Avoidance- and approach-oriented goals tend to have different sources of motivation. The practitioner therefore needs to be aware of how to work with these different motivational sources. Avoidance-oriented goals are more about problem clarification and problem solving/management, while approach goals are about clarifying what is important to the person (i.e. what they value) and what they want to move towards. Approach goals involve helping the person shape their life vision and pursuing goals that represent the person’s vision for themselves. Approach goals can be distinguished from avoidance goals by reflecting on whether the motivation is primarily to relieve a current situation or to move toward a more positive situation.

Box 7.2 Goal and Action Plan Instrument for Quality (GAP-IQ)

1. Is there an overall recovery vision?	No	No written record to indicate that any of the following were discussed with the client: meaning, hopes, dreams, values and/or preferred identity that the person wishes to head towards or practise in their life
	Partial	Written record that hopes, dreams and values for the future have been discussed but the goals selected do not appear to be in line with the client’s values or there is no record that the client has been asked why they would like to achieve their set goals
	Yes	Written record that hopes, dreams and values for the future have been discussed. There is a direct link between the meaning, hopes and dreams that the individual holds for their future and goals selected within case management and these are documented (e.g. ‘Client reported that doing his own shopping (goal) would lead him to feel more independent (recovery vision)’)
2. Collaboration between client and practitioner	No	Language in the care plan does not suggest that collaboration between client and practitioner occurred when identifying care plan goals (e.g. ‘client was instructed to work on medication adherence’, ‘client was provided with goals set out by his mental health team’). Or there is language in the file that describes the client or their goals in negative terms (e.g. lacks insight, unrealistic, unmotivated)
2. Collaboration between client and practitioner	Yes	Language in the care plan indicated that collaboration between practitioner and client occurred when developing goals. Goals are recorded in layperson’s terms void of technical jargon
3. Goals	No	No goals are recorded
	Partial	Some goals are recorded yet they are not clearly defined, making measurement difficult (e.g. to feel better, to be happier)
	Yes	Goals are recorded and defined so that a clear outcome is measurable (e.g. to do my own shopping, improve my medication taking, find a job)
4. Goal importance	No	No record that the client’s perceived importance of goals selected or prioritisation of the care plan goals was determined
	Partial	A written record that the client’s perceived importance for each goal has been considered and resources allocated accordingly (e.g. ‘client stated that ___ goal was most important for them, so the session was spent working toward this’)
	Yes	A record that goal importance has been ranked numerically or ordered and resources allocated accordingly (e.g. ‘client placed goals in order of importance (1, 2, 3) so session time and tasks were allocated with this in mind’)
5. Confidence	No	No written record that the client’s level of confidence was rated for the goals selected
	Partial	Written record that confidence was asked (e.g. a statement or rating) in relation to one of the goals but not others. A written record that client confidence was assessed, yet goals were not adjusted to enhance the client’s self-efficacy related to goal attainment
	Yes	A written record that confidence was determined in relation to each case management goal and goals were adjusted to enhance the client’s confidence for goals attainment
6. Timeframe for goals	No	No timeframe established for goals achievement
	Partial	Some record of a timeframe for goal completion but this is vague (e.g. end of the year, rather than a specific date). Or the timeframe seems unrealistic for the type of goal selected (e.g. to commence and complete a TAFE course within 3 months)
	Yes	Written record of an established timeframe and a date set for the review period
7. Levels of goal attainment	No	No varying levels of goal attainment defined for the treatment goals recorded
	Partial	Some but not all the case management goals have different levels of goal attainment defined and recorded. Levels for goals are defined but they are not behaviourally defined, making outcome difficult to measure (e.g. lacks specifications such as frequency, what, where and with whom)
	Yes	Attainment Levels for each of the case management goals are specified and behaviourally defined (e.g. frequency, what, where, with whom) so outcome can be clearly measured
8. Identifying and solving barriers to goal attainment (coping planning)	No	No written record that barriers to goal attainment are identified in the care plan. Or, if no barriers are described, there is also no evidence that potential barriers were discussed and solutions to address these identified
	Partial	A written record that some potential barriers were discussed but no problem solving around these is evident (e.g. lack of money may be a problem yet attempts to assist budgeting or identify alternative solutions are not evident). Only some of the treatment goals were recorded as being the focus of coping planning
	Yes	A written record that barriers and potential solutions for each of the treatment goals have been discussed
9. Social support	No	No written record that social support was enlisted to assist with goal attainment
	Partial	Written record that some social support was identified, either only at a service level (case manager) or personal level (family member)
	Yes	Written record that social support was discussed and identified to assist with goal attainment, at both a personal and service level. Roles for different members have been discussed and outlined. This can include practical (e.g. transportation), emotional (e.g. to hear the person’s concerns) or informational support (e.g. information on harm minimisation or side-effects of medication, etc.)
10. Monitoring	No	No written record regarding how goal progress will be monitored
	Partial	General written reference made to monitoring progress (e.g. ‘will check progress with client’)
	Yes	Specific written record of how progress of behaviours in specific settings will be monitored (e.g. ‘in addition to homework tasks, client has agreed to keep a graph of his number of walks or a mood diary’)
11. Action plans for goals (general rating)	No	No record that discussions about pathways or strategies for any of the goals have taken place (e.g. steps to the goals)
	Partial	A written record that some of the case management goals have plans outlining how the goal will be achieved. Or a written record that the treatment goals have plans developed, yet these are not defined or specified clearly
	Yes	A written record that all goals selected have clear pathways of how to attain the goal and the specific details about when, where and how the goal will be carried out. Target goal must be specified in action plan
12. Action *Description*	No	Not completed
	Partial	Item attempted but insufficient or inappropriate information
	Yes	Item completed well. The task should be described in sufficient detail that the client and practitioner have a clear understanding of what the task is
13. Action *How often* specified	No	Not completed or inappropriate (e.g. run in the park)
	Partial	Item attempted but insufficient or inappropriate information. Description is not specific but an attempt has been made to record a response (e.g. ‘as required’, ‘when I feel like it’)
	Yes	Item completed well. Clearly describes the number of times the task should be completed (e.g. numeric 2 times, each morning, daily)
14. Action *When* specified	No	Not completed or inappropriate response (e.g. run in the park)
	Partial	Item attempted but insufficient or inappropriate information. Description is not specific but an attempt has been made to record a response (e.g. ‘when required, when I feel in the mood, when I think about it’)
	Yes	Item completed well. Clearly describes the time and/or date that the specific task is to be completed (e.g. morning, afternoon, night; 12pm, 3am, etc.; Monday, Tuesday, etc.; each morning before breakfast)
15. Action *Where* specified	No	Not completed or clearly inappropriate (e.g. run every morning). Where the task should be completed
	Partial	Item attempted but insufficient. Description is not specific (e.g. Wherever I get a chance)
	Yes	Item completed well. Clearly describes where the task should be completed. Specific location (e.g., home, around the block, at the hospital).
16. Action *Confidence rating*	No	Not completed. No confidence rating provided
	Partial	The confidence scale has a number circled that is less than 70
	Yes	The confidence scale has a number greater than or equal to 70 circled
17. Action plan *Review*	No	Not completed. Neither a rating nor comment is provided to indicate that a review was conducted
	Partial	There was either a comment made or a formal rating, but not both.
	Yes	Item completed well. There is a formal rating of the quantity or quality of task completion made by either the client or mental health practitioner. There is a comment indicating that a review was conducted