Collaborative goal setting: what works for whom in therapeutic relationships?
by Dr Jenna Jacob
In 2020 we carried out focus groups with young people and professionals, to explore the “best bets” about what works for young people experiencing anxiety and/or depression. To “set small goals that gradually make you feel better” was something that young people who took part in that research said helped them to feel better. It is this pivotal feedback which underpinned the reason we chose to focus on this area in our next research project.
We started to wonder about the interplay between goals and therapeutic relationships, given that 1) goals are considered to be a main part of therapeutic relationships, and 2) therapeutic relationships are considered to be a key driver in positive mental health outcomes. Research suggests that collaborative goal setting can be crucial to help focus young people’s therapeutic work, and is central to shared decision-making, which leads to agreement between practitioners and young people on best ways forward. We were commissioned by the Wellcome Trust in the summer to explore collaborative goal setting and tracking as an effective element of therapeutic relationships for young people aged 14-24 years experiencing anxiety and/or depression.
In our experience, the research we had come across relating to the use of goals in young people’s therapeutic settings was overwhelmingly positive. Our curiosity was piqued in two ways – why does it seem to be so effective? and it can’t be helpful for everyone, so when and for whom is it not helpful? Because of this, a key aim of the study was to explore the research gaps relating to understanding the nuances of “for whom” and “why/not”.
What did we do?
First, we conducted a review of over 10,000 sources of information including published and unpublished literature and websites. We then held consultations with international advisors from Brazil, Norway, Pakistan, Spain, Turkey, and the UK: 8 young people with experience of anxiety and/or depression and therapy, and 6 academics/clinicians. In the consultations, we discussed the findings from the literature, and contextualised them in lived experience.
What did we find?
In summary, we found that collaborative goal setting is generally helpful for young people aged 14-24 years old experiencing anxiety and/or depression. We found that goal setting can provide a shared language, a shared understanding and a common ground, to help to build trust within relationships, to enable work to move forward. Preferences to not work on goals are potentially driven by some limiting factors such as negative past experiences of goal setting and some specific elements such as hopelessness, high levels of distress, overthinking, and perfectionism.
Youth advisors’ perspective
Youth advisors said that goals being a channel for open communication and allowing young people to feel in control of their own care were the most helpful things, as well as being beneficial to help break things down into manageable steps. However youth advisors said that in their experiences, goal setting was not possible or helpful in some country and therapy contexts. For example, they said that in Pakistan where decisions about care are made by the family, and that in long-term therapy, both the complexity of difficulties, and length of support were limiting factors. There was a disconnect in the language, where youth advisors said that young people associate “goals” with school/work, whilst “therapeutic goals” had more personal and significant meanings; they highlighted the importance of language around this topic. Some youth advisors said that agreeing goals had helped them to build trust with their practitioner, whilst others said trust had to come first, and that it was important for therapists to work on the relationship before they felt able to share goals with them.
Experience of the research
This was a really interesting piece of research for me, having been interested in goal setting and tracking as a way of monitoring progress and outcomes for some time. I am really curious about the mechanisms for which this is an effective way of working, and cognisant that not everything works for everyone. I particularly enjoyed working on this project because of the ingrained nature of the perspective of experts by experience, which we did in two ways: via the advisors, and via the peer researchers embedded in our research team. There are key elements of this project, and the findings, that were contextualised and made sense of through the lived experience lens, which made the world of difference to what these findings mean, and how we understand them. There were key insights from youth advisors and peer researchers that would have been absent otherwise, for example, that communication and trust are the most important factors to effective therapy for those we spoke to, that there are cultural and country-specific factors that must be considered: for some, they just don’t have agency at all to agree goals, even though they could see the benefit of doing so.
What is next?
Our findings identified some research gaps, e.g., the exploration of therapeutic relationships in the youth field, and links between goals, relationships, and symptom outcomes. Our project findings also lend themselves to a few considerations moving forward: for clinical practice, it is important that young people’s preferences to work on goals or not, are given priority; for research, priority must be given to exploring unhelpful mechanisms of goal setting, to avoid potential harmful effects; and for policy, cultural considerations are likely to be a limiting factor in some places. We will be shortly submitting our study for publication, so watch this space for our full findings, interpretations and recommendations for practice, research and policy!
With thanks to the project team: Milos Stankovic, Inga Spuerck and Farhad Shokraneh, and the project advisors: Duncan Law, Elmas Aybike Yılmaz, Hanne Oddli, Isabella Valério, Jacob People, Josh D., Julian Edbrooke-Childs, Katya Proctor, Laura Calomarde Juárez, Mick Cooper, Nick Morgan, Panos Vostanis, Syeda Zeenat R., and Theo Jackson.
As part of this year's online CORC Forum (25th November 2021), we had a wide selection of focus sessions for our attendees to choose from. Each of the 45 minute focus sessions explored a different area of interest relating to mental health and wellbeing outcomes of children and young people. The sessions were led by specialist speakers with time for questions at the end. In Focus Session 1 (Slot A) Dr Jenna Jacob presented the findings from the two Wellcome Trust research projects focused on ‘what works’ for young people aged 14-24 experiencing anxiety and/or depression. Part a) What do young people and professionals around the world think? Part b) Findings from an insight analysis of goal setting as an important part of the therapeutic relationship: what works for whom? In 2020, the CORC team were commissioned by the Wellcome Trust to explore an existing list of ‘Active Ingredients’, which may or may not help young people experiencing anxiety and depression. From that work, goal setting was identified by young people as something that helps them and Jenna presented the findings of this insight analysis in this area: what works, for whom and under what circumstances?
Active ingredients for preventing and managing depression and anxiety in young people