 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. Now this presentation is going to be a little bit different than some of the others because goal setting is something that I think is really important for our clients to understand how to do for themselves. And that's one of the reasons, in my opinion, that a lot of them end up in our offices is because they don't know how to set really good goals, which means they probably don't know how to do the information gathering part at the beginning. So we're going to talk about how to teach clients how to set goals. If you work in a treatment facility, you may have encountered specialists or unlicensed clinicians who have a little bit of difficulty setting goals, and that's okay. It's not something that I was even taught in graduate school. It was something I kind of had to learn along the way. So hopefully this will give you some tips and tricks to impart to your staff if they have difficulty setting treatment plan goals, because I think a lot of times they try to make it harder than it really is. And it's really, it's tedious or it can be tedious, but it's not that difficult. I still have about another minute. I want to welcome everybody who's here. And we may have some people join as we go along and that's super cool. I can't remember if I said this since I started talking this particular time. Feel free to put any questions, comments, tools, anything that you want to add to the course in the chat window as we're going. And if it's a question, I will try to segue into it as gently as possible. There will also be a time for Q&A at the end of the presentation. Q&A is not mandatory in order to get your CEUs. So if you've got somewhere else to go, or if you're just ready to go, then you can go ahead and bug out as soon as the actual presentation part is over. To get to the quiz, go to allceus.com, log in, and you will find at the end at the bottom of the course, there's a link for going to the quiz. So I'd like to welcome everybody to today's presentation on goal setting. Over the next hour, we're going to identify the purpose of setting goals, which a lot of us really already know, but some of the nuances are going to become a little bit more clear. One of the reasons, I guess, that I first learned to start setting goals was because I had to. They told me I had to write treatment plans, and in order to do that, I had to set goals. But it wasn't something that somebody had said, hey, do you know why you set goals? And generally when people set goals, they set a big goal, like I'm going to get in shape, or I'm going to lose weight, or I'm going to buy a house this year. And those are wonderful goals, but they kind of set you up for failure if you don't know how to get from point A to point B. We'll learn about SMART goals and how to set them. And obviously SMART is an acronym, which is why it's all capitalized. We'll explore ways to help clients identify their own goals. And this is another reason that it's important to know how to set goals because you need to know how to work backwards in order to identify what your actual goals are, what your hopes are, what your expectations are. And then we'll identify some of the most common pitfalls in goal setting and how to prevent them. And one of them is setting goals that are not correct. I don't know another way to say it, but if you're setting the goal of, I want to lose 20 pounds that way, so and so will like me, probably not going to be a really accurate goal, because you can't control someone else, whether somebody else is going to like you. Now if you want to lose 20 pounds, you know that's cool, more power to you. But we want to make sure that we understand the reasons that we're getting into this. We want to make sure that we care. Goal setting is an integral part of behavior change. You need to know what behaviors to reward. You need to know what behaviors to not reward. I try to avoid punishing behaviors. And you need to know when to do it that way you can keep motivation going. It's something we do pretty much every day. If you think about this morning when you got up, you probably thought to yourself. When I get to the office, I need to get all my files together. I need to review them all so I'm prepared to see my clients need to see my clients do my paperwork and go home. Well, that's goal setting. We do it every day. And going through that step by step process is a way to help you understand how to get from point A to point B. Ineffective goals can have a negative impact on self-esteem. So if you have a client who comes in and they say, you know, I'm really depressed and I've tried to deal with this depression on my own and get undepressed multiple times before and it's failed. And so I feel pretty helpless right now. I don't think this is going to work, but I'm trying one more time. And my first response is well kudos for trying one more time that tells me there's a part of you that still has hope that things can get better. And my next step is to say, let's talk about what you've done in the past and what has worked, even if for a short period and what hasn't, and build up on that self-esteem and show them how they have made some forward progress, but maybe they missed some things in the journey. Ineffective goals can also make people mistakenly think they're helpless to change anything. I want to make sure that they're setting the right goals for the right reasons. One of the first activities I do, and my clients usually have a good time with this, is I say, let's figure out, you know, how you set a goal. And a goal is kind of like a recipe for getting something done. So what I want you to do is try to figure out how you would prepare an authentic Italian meal. And you know, most of my clients are not native Italians, so they have to do a little bit of learning here. And I give them time to break out and figure out what to do. And then we get back together and we talk about all the steps and I put them on the whiteboard, knowing basically what order they need to go in and if there's anything being left out. And then we talk about it. So in this particular example, ultimately, they need to come up with the knowledge that they need to learn what an authentic Italian meal consists of. I mean, besides spaghetti, what is it? Decide what is going to be in your meal, because Italian meals, there's a whole bunch of things from cacciatore to spaghetti to lasagna. Okay, so that's the main dish, but what else goes in it? What is going to be in your meal? All right, we've searched on the Food Network and we figured out some of that, but now we've got to figure out how to do it. We know what it is, but now we need to figure out what, once I get all my ingredients together, how do I put this into something that is edible? So we move on to identifying what ingredients you need for that meal. If you've used a recipe before, you've looked at it and you've gone through your checklist and gone, I've got that in the cabinet, got that in the cabinet, got that in the cabinet. Well, that's kind of like what they're doing when they're trying to do any sort of behavior change. They're inventorying their skills and their knowledge and they're going, I've got this, I've got this, this is a strength, okay, score, got that. But I still need to develop these. Well, in the analogy of the recipe, we're talking about these ingredients. What else do they still need to get in order to be able to put all this stuff together? And then you've got to figure out, what is it, what's the next step that you need to do in putting it together? You have all the ingredients sitting on the counter. Now, how do you put it together to make a meal? Do you just dump everything in at the same time? And the answer is no. You want to make the sauce first so the seasonings can blend and it can sit. And then you want to make the pasta towards the end so it doesn't get all glitchy. But there's a specific order that you need to do things in. And there's a specific order, give or take, that we need to do things in when we're talking about behavior change. Once we go through the analogy, you know, I'll let them put it up there. And then I'll look at it knowing, sometimes, and usually, there's a step or two left out. And I'll say, well, you know, I see that you learned how to prepare the meal, and then you went to starting to cook it. But do you have all the ingredients? Or, you know, identify a step that they missed and talk about how the ability to prepare a good, edible, authentic Italian meal might come out without that step in there. But we also talk about using or being able to drop back and punt. And sometimes we don't plan for everything or sometimes we forget something. And that's where we need to be a little bit flexible. If you go to the store and you forget to get basil, okay, you know, so you may either have to try to find a basil substitute, which isn't really easy. Or you may need to go back out and get the basil and come back, which is akin to learning a new skill, you know, stopping and going, okay, I missed something. Let me go back, figure out what I missed, get it, and then I can proceed with the process. Yes. So these smart goals that we're talking about are specific. It's not, I want to lose weight, or even I want to buy it. Sorry, I want to buy a house is somewhat broad. Now, a house is a house, but are we talking a $150,000 house, or are we talking a small mansion? You know, what are we talking about? So a smart goal is specific, because that gives you an idea of what you need to do to get there. The down payment on $150,000 house is going to be much different than one on half a million dollar house. Likewise, what you're going to have to do to save for it may be different. It's measurable. You can tell when it's been done and you can measure the progress. And we're going to talk about different examples from behavior modification and from, you know, depression and stuff when we get through this but you want to be able to have any person look at it and go, Yes, you've made progress. So it needs to be measurable in terms of frequency intensity or duration. Well, if you can't do it, if you want to buy a house and at the end of the year, and maybe you want to buy a half a million dollar house but you won't know that you're only going to be able to save $3,000 by the end of the year. Then you're kind of setting yourself up for failure because you're not going to make a down payment of $3,000 on that kind of house. So we need to kind of adjust our goals to make them achievable in the time span that you're looking at. You know, some things can be done, you know, over a longer period of time, but which takes us down to time limited. If something takes too long before a reward is realized, people are going to get frustrated. You know, you want to get some sort of reward. Think about, I was just talking about this the other day with my partner. When I started work, you know, way back in the day when we had paper checks, you would get your check at the end of the week. And, you know, it was every two weeks, you got the same check depend. It didn't matter how much work you did. You just got that check but it was still rewarding for showing up and doing your job and yada yada yada. And you would get that check and you'd look at it and feel a sense of accomplishment. And it's like, cool. Okay, moving on. Today, they've really moved in most organizations to automatic deposit. And so you don't even get slips or notifications anymore. You don't get an email that says, hey, you got paid today. It's just, you just kind of assume it's there. So you don't have that frequent reward. And yes, you can go into your bank account and look for it. But there's a different behavioral effect if you're actually being provided something and it says, you know, on a, on a kind of like pressing a lever and getting a treat for it. I hate to look like an Esther rats but there is a different response when you get something that says how much you got paid. So understanding that we need to make sure that we're providing rewards. Now if it's, we want to be able to reward ourselves. So if you're setting a goal for yourself. If your client is setting a goal, they need to be able to access that reward themselves and not depend on it from other people. So I asked them to think about the last goal they set that was successful. And if I'm working with staff and trying to help them learn how to set goals, we still go through this same process, because a lot of people. Once they can apply it to something that they know they can translate it to things in the future. Interestingly, they're usually is a little bit of a hiccup, even if they do it for themselves really well. For some reason, they start getting making it too complicated when they try to transfer it to somebody else. But so we start out with think about the last goal you set that was successful. And then the last one that you set that was unsuccessful. And we've all set unsuccessful goals. Put them kind of side by side. And what is the difference between the two. Smart goals, specific measurable achievable realistic and time limit. If so, alright, well that's good. And was the motivation level for the successful one the same as for the unsuccessful one. And what happened the unsuccessful one, the motivation weighing somewhere. So we want to look at what happened when things got difficult when you kind of had to drop back and punt, go out to the store and get that basil. So helping people figure out what they know how to do and what strengths they have. When I work with clients again a lot of times I'll say, think about the last time that you tried to achieve this goal, you know, sobriety happiness, getting rid of anxiety, whatever it is. And it was successful, even if it was for a day, you know, tell me about that what were you doing. What did you try to do and what did you not do. And then, when it started to fall apart or when you relapsed or however you phrase it with that particular client. You know what was different what changed goals or the overarching region a person begins to do something. I mean we got to get motivated, but you can have a lot of goals and not be motivated to get off the couch. Often we set goals that are broad and abstract like I want to be healthier or I want to be happy. And that's a great place to start. You know, if you think of the miracle question. Ask somebody if you want to be healthier, if you woke up tomorrow and you were healthier, what would be different. That gives you an idea of the more specific goals that you need to set and the more specific directions that someone needs to take. That also help you break the goals down into manageable, meaningful, observable objectives. If you want to be healthier. That's great. Wonderful. That probably means improving your sleep, improving your nutrition, starting to exercise or at least get some more movement and let's say stop smoking. You know, let's just throw that one in. Remember, four goals that are still pretty big goals for somebody to accomplish. But we can make them meaningful, observable and manageable. So with exercise, for example, all right. One part of this getting healthier goal is starting to exercise. So what's the first thing you need to do. Maybe it's get a good pair of sneakers. You know, it doesn't have to be $100 rebox. It can be just a decent pair of sneakers so you can go out and walk around the neighborhood. But that's the first step. Once they accomplish that is like, All right, you know, I bought into this I spent a little money. I'm feeling optimistic. So let's keep with that motivation. We want to phrase goals as adding positive instead of removing a negative. And what I mean by that is a lot of times we have a tendency and I saw see this a lot. When I audit charts. We have a tendency to make goals that are negative to stop smoking to alleviate depression to get rid of anxiety. Well, that's great. That's, you know, the problem, but that's not the goal. The goal is what are you going to do instead. So if you're not depressed, what are you, you're happy if you're not anxious, you are calmer you are, you know, find some antinom there that you can use. Because if you eliminate and continue to eliminate behaviors and eliminate statuses, without replacing them, eventually you have somebody who doesn't do anything. It's just, if you're not depressed, but you're not happy, what are you. So we want to add what are you working towards. This is a positive goal, not an elimination goal. I want to start with the problem definition. How is the problem evidenced in this client. So we do that I mean that's on my assessment that's like the second question after demographics. What brings you here today and tell me about it. So if they're depressed, I said, okay. Depression has been bothering you. Tell me a little bit about your symptoms. What makes it worse. What makes it better. And you know, then we'll talk a little bit about the course of what's going on. So we want to know how does this client define depression or anxiety. So we know exactly what sub goals we're working on. What's the problem affecting the client's overall functioning. Well, obviously we're going to take get this in the assessment, but this is important for people to do with regular goals to, because we need to create a crisis. If we create a crisis we're going to increase motivation but we've also got to provide a solution in the same session, because if we create a crisis and kick them out the door, then they might be going I don't know if I can do this, you know, I don't know if the problems exist but I don't see anything getting any better. So we want to make sure that there's some sort of a solution. We want to look at what's the absence of the problem. If you are. Whoops, for some reason I am advancing automatically. What's the client's perception of the problem. The client's overall functioning. But we also want to know what does the client think about this problem. Are they concerned about it. If somebody is involuntary, then they may not be concerned about the problem in the goal setting. I'm sorry the motivation presentation on Tuesday we talked about how there are different levels of motivation from pre contemplation all the different levels of action. So if they don't think it's a problem, you're going to have a hard time motivating them to change that. And what are the client strengths. What have they done in the past to sort of try to achieve this goal. Now think about people who every year for New Year's decide to set the goal of getting healthier. You know that's great. But every year, they seem to make it until February 1. And then they're throwing in the town. Well okay you made it till February 1 so let's talk about how you made it till February 1. And then what things got in the way that made you decide that you know what. No. What was the first motivation what hurdles were in the way or what new skills do you need. But the first thing to figure out is what were the strengths that kept you going for that first month. The broad goal for the resolution of the problem is generally not super specific like I said if they come and their problem is depression. The broad goal is to be happier. Well how are you going to know if you're happier. What is the absence of the problem. How will your best friend know when you've achieved your goal, you know how will they know that you're happy. You want to go out, you have more energy, you're, you know, obviously, generally there's something involved with mood there. But happiness can be defined differently by different people. So we want to make sure there's something measurable. The explicit goals is through the miracle question. We talked about there's a couple slides ago if you woke up tomorrow and you were filling the blank whatever your resolution is. What would be different if you were happy, if you were healthy if you were, you know, this gives you insight into the symptoms and definition of the problem for that patient and their motivations for change. You know, not everybody thinks of being healthier as going to the gym every day. So I don't want to necessarily force that on them. If that's not something that they're enjoying or wanting to work toward. So the first step in those specific measurable achievable realistic and time limited goals is what's the problem, and we'll stick with depression for this one. So the example is depression. How will you know when the problem is resolved and I really have people narrow this down or go through it in a detailed fashion. Emotionally what will be different when you are happy. Mentally, what will be different when you are happy so we're going to talk about their cognitive functioning we're going to talk about concentration we're going to talk about memory we're going to talk about. Sometimes negative thinking styles come in under mental sometimes they come in an under emotional wherever they put it I'm not going to correct it but you know we obviously want to have more optimistic thinking. Physically, when you are not depressed, what's going to be different. And we'll talk about energy will talk about pain. We know that with depression there's generally low serotonin, not always. And when we when there's low serotonin generally the pain sensitivity is higher. So people who have depression tend to feel more pain. So they may have more energy. They may lose some weight they may not be stress eating or emotionally eating there's a lot of different things that might change physically. What will be different. And if they get stuck on some of these I go back to the problem and go. Okay, how is your depression impacting you socially. You know, do you want to go out with friends. Do you enjoy spending time with people. Are you as patient with other people. Obviously having written dozens and dozens of treatment plans for depression. I can throw out some ideas. Another way you can do this is and you know I'm a fan of flip charts and group activities. Make the general problem for the group to identify or the, the resolution of and put emotional mental physical, social and environmental on different flip charts throughout the room and have them go around and identify how things will be different when they're happier. So sub goals, and this gets a little tricky here. And this is where a lot of people kind of jump off the rails. The main issue is the fact that they're depressed and they want to be happier. Great. First thing we need to do is learn about what causes depression in order to deal with something we got to know where it's coming from. That's great, but not everybody presents the same way when they're depressed. So I asked the clients okay now that you know generally what causes depression, what causes chronic pain what causes whatever the present presenting issue is. Now let's learn about your symptoms. Exactly how is it that it presents in you and which ones are most bothersome. Then we talk about the causes for them. You know maybe fatigue is a symptom that they have in depression. Well there is a bunch of different stuff that can cause fatigue, not just poor sleep. So we'll talk about all right what causes your fatigue, what do you think makes it better what do you think makes it worse. And what are some triggers for you for the problem. Sometimes people mean we'll stay with fatigue here are fatigued by the end of the day, because they dealt with a lot of stressful stuff. So when they have to go to work and sit in meetings all day long, maybe that contributes to their fatigue and we might want to talk about that. So we're learning about the global problem and resolution, we're learning about their particular presentation of that problem. And then we're going to identify ways to address their specific symptoms causes and triggers. So if they're not feeling lots of guilt, then obviously that's not something I'm going to pursue in a treatment plan right now. If it's fatigue, difficulty concentrating and apathy lack of pleasure those are the three that they name off as their primary bothersome ones. Then we're going to address those and not go off in, you know, tangent land. Why are we going for symptoms instead of diagnosis. And it's exactly like I said because the big diagnosis or the ultimate goal of happiness is different for everybody. So if I just try to plug somebody into a depression treatment plan, it's hit or miss whether it's going to be accurate for them. So I want to know what is it that I'm trying to help you figure out how to deal with. So in this particular example, the person says, what one of the things is I won't dread getting out of bed each day. And I'm like, okay, great. So we'll reframe it to something positive. I'll be happy to wake up and face the day. And we have I have them imagine that when they're in my office I'm like, you know, take a minute and close your eyes and think about what would it be like if you woke up in the morning, I'm like, you know, close your eyes and you said, gosh, I can't wait to get on with my day. And a lot of times they look at me like I've got three heads and they're like, yeah, I haven't felt that way and like, well, ever. Okay. But have them try to envision what this positive change looks like. I'll start identifying one of the things that they have in their fatigue is this dread of getting out of bed each day. So I want to say what causes this dread. What causes you to just wake up and go, oh, I am too tired. I am. No, no. And how can we intervene in that if it is because you know, stay with the meetings, they have to sit in meetings all day long. And in those meetings, it tends to be very conflictual. We might talk about ways they can set boundaries and deal with that stress, or what they can do to feel less drained by those interactions. Another thing they may say is I'll have more energy, or I won't be tired all the time, depending on how they say it, but the positive statement is I'll have more energy. Great. So let's learn about what causes fatigue and low energy. And then we'll figure out what causes your fatigue and low energy. Is it sleep? Is it poor nutrition? Is it something hormonal? Is it something that has to do with, I guess it goes back to poor nutrition if you are not getting, if you're anemic. Another thing that could cause the fatigue and low energy is actually not getting enough oxygen. Most of us yawn each day, not because we're really all that tired, but because our body's going, you are not getting enough oxygen. While you're sitting there right now, just think about it. Are you breathing through your belly and getting good deep breaths? Or are you doing what the typical American does and short shallow breaths? If you're doing short shallow breaths, I mean, you're breathing and, you know, great. I really want you to keep doing that. But it's not efficient in getting oxygen to your body. Does having people start deep breathing just spontaneously make their depression go away? Of course not. Or they would have figured that out a long time ago. But it can help. And it's also a good intervention to help them deal with anxiety. So if they can take a few deep breaths each day, practice some mindfulness, you know, it helps step by step. So the overall problem is I'm depressed. Fatigue is their number one problem. They say, okay, I am exhausted. I said, all right. So what behaviors, feelings and thoughts are causing or triggering the problem? And they say, well, I'm not sleeping well and not wanting to get out of bed. I'm not eating well. And, you know, that's just not good because I just feel sluggish and hungry all the time. And I'm anxious or angry a lot because I'm surrounded by negative people and it's just exhausting. I stop them right there often and I say, okay, if this is the most important symptom for you to address right now, let's stop there because those are three really involved goals. And they can't have a pretty significant positive impact. So then we go back to talking about, so tell me if you're not sleeping well and not getting out of bed, what's causing that? And a lot of times I'll have them keep a sleep diary for a week for not eating well. We'll keep a food journal for a week. And for feeling anxious or angry, we'll keep a mood diary and what triggers their anxiety or their anger episodes. And we'll talk about those. And they can keep all three. It's not really all that much to ask. But you can also do it one at a time. But maybe they say, you know what, I also want to address this nutrition thing. And I say, okay, well, eating too much, you identified that part of your fatigue is probably for not eating well. And you also identified that overeating is one of your symptoms. So that's a two for right there because maybe if part of your fatigue is due to nutritional deficiencies, we can help you get more sleep. Then I'll also educate them about how insufficient sleep or insufficient quality sleep can mess up our hormones that tell us when it's time to eat and when we're satiated. But my goal is to help them identify specific steps that they need to do and specific things they need to address with just fatigue and overeating or under eating for some. We have six treatment plan problems. All of these could be their own treatment plan problem. Does that get them to recovery? Oh heck no. But if you start putting these huge goals in there, then it's going to be six months a year, 18 months before they accomplish them. Not sleeping well and not wanting to get out of bed with appropriate interventions and helping them audit their sleep routine and take some steps, maybe go to the doctor if they need to have their hormones checked, whatever. But generally, they can start feeling some positive benefits from this in three to six weeks. Sometimes right away, they'll realize that yeah, sleeping with the TV on all night long and the dogs in the bed probably isn't helping. Guilty. Anyway. So helping them identify what can you do today to start working on this? And once they accomplish that goal, that problem 1A, not even problem one, but problem 1A, they accomplish that you're giving them a feeling of self-efficacy. They're going, okay, I did that. And I'm probably feeling better. We're going to have them keep a sleep diary throughout just to make sure they can see their progress. When we talk about the ultimate goals, remember I said go through it emotionally, mentally, physically, socially, talking about relationships and environmentally if you want to go there. How will your environment change? The next part is measurable. So we talked about specific and, you know, when we went through those one A, B and C and two A, B and C, those are pretty darn specific. But again, I'm doing that intentionally because I want people to achieve a goal, not just achieve part of a goal, but achieve a goal and be able to go, okay, I did that score. I can do the next one. So now how do we measure it so they know when they've accomplished it? And there are a lot of different ways and too many measurements can get tedious for a lot of clients. So I usually choose one. But if you have somebody who likes measuring, then you can do this. If we're talking about crying episodes, you can do a number of crying episodes per day. If you're talking about duration of crying episodes, how long did you cry for? Was it just a brief moment in the bathroom or did you have kind of a meltdown for 45 minutes? And intensity. When you had this crying episode, how bad was it? One of the keys with Likert scales is to always anchor them. One through four means nothing to people and you're not going to get good rating reliability if it's not anchored. So one way to anchor it for crying, for example, would be mild, moderate, intense or excruciating or just bawling or whatever you want to call it. But that'll help the person figure out, okay, where am I? And you'll notice it's four, not five. One of the things that they found is if you give people five options, they are more likely to default to three, middle of the road, one, three or five. So two and four just kind of get left out. So if you have to have a middle one for whatever reason, you feel like you need a middle one, do three instead of five, you're going to get more accuracy. So if we're talking about eating episodes, if they're trying to improve their hunger or improve their hunger, improve their nutrition or stop emotionally eating, we can talk about the number of eating episodes not due to hunger per day. So, I mean, yeah, they're going to eat and they may eat four times because they're hungry. Let's not focus on those right now unless that's what they want to do. But generally we want to eliminate the eating episodes that are due to something besides hunger. Duration, if we're talking about somebody who mindlessly eats or binges, duration can be helpful to understand, did they start eating when they came home from work and then graze until they went to bed for four and a half hours, or did they, you know, eat for 30 minutes. This can also help when you're setting goals to cut down that time span. So, okay, you come home from work and you start making dinner and you eat. And so that's an hour. Can you stop there? You know, we want to shorten that period so they're not grazing all night long or at least make them discreet episodes. We can also look at the intensity. How many calories per binge or how many calories did you eat in that four and a half hours you were grazing? Because you can ingest a whole lot of calories and a lot of times they're empty calories if you're grazing all night long. So we may want to look at that and cut down the intensity. One technique for doing that, for example, would be to replace your typical preferred grazing foods like chips and buttered popcorn with air popped, unbuttered popcorn, unsalted pretzels, apples, something that has some crunch to it and you have to chew, but it has a whole lot less calories. And then you can start addressing the reasons for the grazing, whether it's habit or stress or whatever. But if you can start reducing the intensity, they'll feel like they're making progress. If you're talking about glasses of water consumed per day, you know, obviously that's an easy one to measure. Number of wake ups per night if we're talking about improving sleep. For duration of sleep, you may want to look at either how long you slept, how many hours of deep sleep you got, or how long you were awake each night. The person can decide what they want to measure, but they need to have something tangible, something quantifiable that they can look at kind of on a chart so they can see progress, and they can go back and note if they start not seeing progress, what changed. They can look back and go, oh yeah, you know, this kind of started about two weeks ago. I do that with my activity tracker. I will note when I'm, my resting heart rate is increased a whole lot. And generally, I don't pay attention to it right away, but you know, over the course of four or five days, if I look down and I see that, okay, my resting heart rate has increased for the past week, then I start going, okay, what changed. Maybe I'm just working out a lot harder, or maybe stress has increased or I'm drinking too much caffeine, but it helps me monitor and keep that mind body balance thing going on. So if the main issue is depression, you can use that Likert scale. Remember I said you can anchor it. So some examples of how to anchor it are, I can't go on. I'm doing okay. I'm doing pretty good today, or I'm doing awesome. I'm not going to get a lot of awesomes out there. But if you can get okay and pretty good, you know, that's that's a whole lot of progress, and it's looking over a week. You know, maybe one day you had a really low day, but the other six days, you were either a two or a three. Well, that's good. So next week, let's see if, you know, even if you have one low day. And maybe we can either make it a two and have more threes. And you see how we're going, we're just improving it, making little tweaks and going, okay, you did that. That's good. Can you do something a little bit more next next week. If they're exhausted, we want to record their hour slept number of awakenings or qualities of sleep. This is another activity I use with my clients. We'll write these goals down. And sometimes they do it on paper, sometimes we do it on the flip charts. Lose weight. A lot of people have that goal. Get in shape. Feel better about myself. Be happier. You know, those are all normal goals that people set, but there are also normal goals that people fail to achieve. So identify at least two ways for each goal that identifies goal achievement. How will you know when you are happier? You know, two ways. I'm not asking for the world here, but I have them go around the room and for each one they identify two ways they would know for them that they had made progress. We don't know how to measure them. We go over this whole broad goal to specific goal to measurement a couple of times during a group and then we usually do it in the next group to the following week to make sure that they've solidified this concept and they don't get stuck somewhere. So it's all realistic and time limited. I kind of put all three of these together. Rome wasn't built in a day so we cannot expect to change overnight. And that's a mistake that I made as an intern. And I see a lot of people make either for their own clients or for themselves that they think that as soon as they start something, you know, in six weeks I'm going to have this late. Let's talk about what we know you can have linked in six weeks. If you've been doing it for 16 years, you're going to have a lot of progress in the first six weeks because there's a pretty good learning trajectory there and you've got hope and momentum and all kinds of stuff now. So that's great. But to say that you're going to be recovered in six weeks. Not necessarily. And I try to hedge that and most people don't come out and say well I think I'm going to have it licked in six weeks, but I'm exaggerating. We want to identify what can you do in six weeks. And once they start going down and breaking down the goals into specific measurable things. I think that, yeah, there's maybe there's a little bit more to this change stuff that I thought, and maybe that's why prior goals failed, because I didn't stop to learn about the problem first. I didn't stop to learn about how the problem applied to me, you know, how, what are my symptoms of the problem or how do I evidence this, this problem. Maybe they just to live healthier. Maybe they already go to the gym every day and and work out and eat healthy, but they want to be healthier. So what does that mean for them. We need to figure out what need what they think needs to change. And maybe it stops smoking or stop drinking or something else. So Rome wasn't built in a day. Let's figure out what's realistic to achieve this week, this month, and then this quarter. And generally I don't put treatment plans out more than 90 days, because life happens. And if I set stuff out further than that. Almost all the time, it's going to need to be adjusted or fixed a little bit. So, you know, I try to stay with three month or less intervals. Goals need to be built on prior strengths and individualized. Yes, they're going to learn some new skills. My personal feeling, and obviously, you know, it's my personal is that when a client walks out of my office every time I want them to have some kind of useful tool that they can implement to work toward their goal, even if it's just learning about depression, and ways, different interventions to address depression, or anxiety or, you know, learn about nutrition. It gives them something to learn about and it keeps them excited, or even keeping a baseline, figuring out how often this happens before we start intervening. It gives them knowledge it gives them something to do so they're feeling proactive they're feeling involved in their feeling empowered. We want to make sure that the client is motivated and able to do the change. I'm motivated to run a marathon. I would love to run a marathon, but at my age and with my knees, it's not going to happen, most likely. I mean, theoretically, I probably could people run marathons in a lot worse shape, but I'm not that motivated. So we need to make sure that it's something the clients motivated to do. My mother for many, many years always talked about losing weight, and we would start eating healthfully, and she'd get a gym membership and she'd go like twice, and then she wouldn't go again. And, you know, the gym is not for her. She is not motivated to go to the gym. She doesn't mind going out walking. She doesn't mind walking the dog. She doesn't mind, you know, puttering around the house and doing that sort of stuff. There's a lot of different activities that she doesn't mind doing, but the gym is not one of them. So okay, if you're not motivated to do that, what are you motivated to do? I had a client tell me one time that she came in didn't know me from Adam's house cat sat down. And before the assessment even started, she said, I know I use drugs. I don't have to use drugs no more, but I am not going to any of those meetings and you can't make me. You know, something very close to that. Okay. And she said, you can't make me go to those meetings and I said, okay. Well, this went went on a little bit longer and she kind of looked at me skeptically as it. I'm not interested in what you're not going to do because you've already told me that you're not motivated to do that what I want to know is what you're going to do instead. The client is not motivated to do something one way we can address this difference, and I avoid the term resistance address this difference is to say, okay, if you're not going to do that, what are you going to do instead. We want to make sure that the goals are time limited and realistic weekly goals. They're great. And this is good for somebody who's in once a week outpatient therapy, or just your average Joe. Daily goals. This is more appropriate for someone who's in IOP intensive outpatient counseling, which meets three to five days a week. Or who is setting a really intensive goal. You know, it's good to be able to look back at the end of the day and pat yourself on the back and go hey, I made it through today. Stop smoking cessation is one of those that may need to be on a daily goal basis at first. And then sometimes it comes down to hour by hour if somebody's in crisis, or if they are right on the precipice of a relapse. What can we do to get through this hour. And then the next hour, and once they've made it through four hours, you can say look, you made it through half the day, you know it's afternoon now. Once they've made it through an entire day, you can say how awesome was that when I started talking to you at eight this morning, you didn't think you could go an entire day without smoking. And now it's six in the evening and you haven't lit up. How awesome is that. So we can reinforce those goals. And obviously, with certain goals you're not going to be on the phone with the client every single hour, but you want them to be able to know that all right today I'm feeling really edgy. And like I want to smoke so maybe instead of saying I need to get through the whole day. I just need to focus on getting through the next hour, and then the next hour after that. And then they can look back on the day and go, darn, I did it. Cool beans. So the hook, we want to make sure that if we're setting goals with a client, or if a client is setting goals is very clear who's responsible for doing what when where why and how got to throw the h in there. This is the action plan or the map so a lot of times the client is going to do most of it, but there may be some things that they need family friends supports therapists to pitch in and help with. Everybody needs to know what they're responsible for doing when and where think think about planning a wedding. You know, a lot of times the bride kind of takes control, but there are times when you need other people to do stuff. So if you're trying to plan this out, everybody needs to know what they're responsible for doing and when they need to be there. We want to know why they're doing it. You know, we have to keep that motivation in the forefront of their mind. What is your motivation for doing this. And how is it helping you meet your ultimate goal. So if they're working on improving their sleep. Great. And let's, you're doing this because one of your symptoms is fatigue and you want more energy. Awesome. Your ultimate goal is to be happier and have more energy. So, you know, you see how all this connects. So it seems like working on sleep doesn't make a whole lot of sense with being happier, but ultimately it all let's connect the dots. So one example treatment plan Sally will learn about depression by reading one chapter of XYZ book and the handouts provided by Dr. Snipes each week for five weeks. So we've got a five week treatment plan here, but she's learning. She will learn about her symptoms, what causes them, what triggers them by taking notes on what sounds like her as she reads the book and handouts about depression. She'll process those notes in counseling each week. Sally will identify ways to address her specific symptoms causes and triggers by completing the my symptoms and triggers worksheet. And each morning and evening Sally will rate on a scale of one to four her happiness and explain her response, which will also be discussed. So we're keeping them, we're keeping Sally accountable because she's going to be bringing this back to treatment every week. But it's helping her learn about depression about her depression, identify the skills that she has and the skills that she needs, and then start implementing them. We call this the knowledge skills abilities progression goals need to be meaningful to the person. So they need to be motivated to do them. They need to be observable measurable incremental. So step one, like I said with getting in shape step one is to get some shoes. Step two is to figure out what you want to do. If you want to draw it out like a, like stairs, you can do that. If you want to draw it out like a map, put two points on either end. And you know there's going to be times that you've got to kind of get off the interstate and take a bathroom break. But you want to know what your desk, along your, along your journey. What do you need to do and those bathroom breaks are the accomplishment of each of the sub goals, you know that's when you go stop and go, I did a good job. And it uses the KSA progression knowledge skills and abilities objectives are always steps toward the main goal. So when you look on treatment plans. A lot of times it says the, the goal and has objectives and you're like, well, I, I try to make mine so they say problem goal and objectives because then it's a little clearer. The problem is what they're presenting with the goal is where they want to end up what they hope the resolution will be. And the objectives are the steps they need to take to get there or the things they need to address to get there. You need to prioritize goals sometimes and a lot of times clients will do this on their own and they will say I'm motivated to work on this or that, and it's like score. But other times the client doesn't have an opinion or doesn't have a preference. I look to Maslow's hierarchy and I say, okay, let's start with the easy stuff. Let's start with the biological stuff. Let's have you get a physical rule out any physiological causes let's look at nutrition and sleep and activity. And oxygen and sunlight. Let's rule all those out or rule them in. And then we can start talking about some other stuff. And talking about what is it that triggers makes this problem worse for you in failing to consider why people currently do or do not engage in certain behaviors. We set them up to fall. There's a benefit to their current behaviors. There's a reward to their current behaviors and we need to be cognizant and sensitive to that. We need to provide them alternate behaviors that meet that same need. We need to make sure that they don't set goals that are too big to accomplish in that timeframe, or that are too hard. Instead of thinking about running a marathon, going from being a couch potato to a marathon. And there is actually a book by that title, but I digress. Have them say, okay, let's run a 5k, you know, sitting from being couch potato to running five kilometers, not so bad. And then maybe bump up to a 10k than a half marathon. Those are reasonable progressions. Setting too many goals. You don't want to be trying to work on your self-esteem and enhance your relationships and improve your sleep and work on your nutrition and all this other stuff. Maybe they all need to be addressed, but you got to prioritize. Otherwise, you made you all of them halfway and none of them really well. Make sure there are sufficient rewards for those goals. It's got to be something that you really want to achieve and you feel a sense of accomplishment. You can set goals that are a little bit too specific that don't give you any wiggle room or fail to individualize the goals to your temperament. So if you tend to be somebody who likes to fly by the sea of your pants and be spontaneous and this goal is really rigid, you may not follow through with it. So yet another activity, I haven't break into different groups and I give them each group a different goal. Groups need to create a plan to achieve that goal and none of these are simple goals. Rebuilding a car. Where do you even start? Becoming a nurse or a carpenter or pick some occupation. There's a lot to it. So they need to figure out how to identify where to start and how to set those steps. We want to make sure they identified sub goals that were observable, measurable and realistic. We want to make sure they identified the reason someone would be motivated to put forth the effort to achieve the goal. And did they make sure they had the knowledge and then practice the skills before they launched into the real thing? You wouldn't want somebody wiring your house who's walking around with an electrician's textbook going, okay, completing a circuit, you do this. All right, hang on a second. And then trying to wire something in your house. Not to say that some of us haven't done that, but we want to make sure they have the knowledge. We want to measure the skills in a safe environment, i.e. therapy, and then they take it out and launch it on the real world, if you will. So good goals are smart. You can measure intensity or quality with an anchored Likert scale. Make sure the behaviors you're trying to change will actually help you achieve the goal you're setting. Goals should follow the knowledge, skills and abilities progression and knowledge in general, knowledge about how it applies to you, skills in general, what skills you already have, what skills you need to develop, and then the abilities. Sub goals need to be small and reinforcement should be frequent. I'm all about providing that reinforcement. And if motivation wanes, we need to revisit that decisional balance exercise to figure out why is this change not motivating or why is the old behavior more motivating than this current one. 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