Selasa, 17 September 2013

Making client goals and preferences central

The Hare was boasting of his speed before the other animals. 'I have never yet been beaten,'he said, 'Ichallenge any one here to race with me.'The Tortoise said quietly, 'I accept your challenge.'
'That is a good joke,'said the Hare. 'I could dance round you all the way, it will be easy.'
The race was fixed and the Hare and Tortoise lined up. The Hare shot out ahead at the beginning of the race, leaving the Tortoise behind. But he couldn't resist playing to the crowd. To make a fool of the Tortoise he ran back and forth and around him. He even stopped and had a nap. 'Look I can beat him easily, I can even take a rest in the middle.'
The Tortoise simply ignored the Hare and concentrated on the race, plodding forward at his own pace, his eyes fixed on the finishing post. In taking his nap,
the Hare forgot the time, and awoke suddenly to see the Tortoise nearly at the finishing line. He charged forward to try and catch up, but it was too late and
the Tortoise won the race.
The Hare and the Tortoise, adapted from The Fables of Aesop

In the above story, the Tortoise beat the Hare by ignoring the Hare's flash attempts to distract him, by plodding along at his own pace, however slow, and by keeping his eye firmly fixed on the finish line. This could also be a metaphor for counselling and psychotherapy. Even the therapeutic models essentially con­ceptualised as being 'brief', such as solution-focused therapy, work best when the process moves gently at the client's pace towards the client's goals. The aim is not to rush ahead of the client or to distract from the process using 'flashy' techniques or exercises, but rather to stay with them, keeping their goals central to the process and to make progress at their own pace. Like the Tortoise in the above story, the aim is to plod along making progress, with your eye firmly on the finishing line.
In this way, an overall guiding principle for the recent strengths-based collab­orative therapies is a focus on client goals and preferences. The shift is from con­sidering problems and unwanted pasts to elaborating goals and preferred futures. What the client(s) wants and wishes to happen by coming to therapy becomes the compass that guides the entire process. In the reformulation of brief solution-focused therapy, distil it down to core principles and start each session with 'What are your best hopes for coming to these meetings?' (George et al., 1999).This becomes the central question of the entire therapy and the subsequent conversation is focused on elaborating these hopes and goals in evermore rich and meaningful detail.
The importance of therapeutic goals is borne out by many outcome studies. Orlinsky et al. (1994), reviewing the literature, reported that having clear goals that are agreed between therapist and client is strongly associated with positive therapeutic outcome. A process study of solution-focused therapy (Beyebach et al., 1996) found that clients who had formulated clear goals in the first session were twice as likely to complete the therapy successfully. Other studies have shown that tailoring drug and alcohol treatment programmes to client goals and preferences (rather than having a 'one size fits all' approach) means that clients are more likely to enter treatment early and to complete the course successfully (Miller and Hester, 1989; Sanchez-Craig, 1980).
A focus on client goals and preferences has also run like a thread through many of the traditional psychotherapy models, such as cognitive therapy and rational emotive therapy (Beck, 1976; Ellis, 1998). Carl Rogers (1961) conceptualised that individuals had a preferred or ideal view of self and experienced distress when there was a gap between this ideal and their perceived self. In others words, people experience misery when their life is out of sync with their aspirations, values and life goals. Strengths-based therapy aims to help people articulate these goals and values and in doing so to discover how these preferred ways of being can happen in their lives. Shifting the focus from problems to goals has a number of other ben­efits, as is illustrated in Case Example 2.5 (originally explored by Sharry, 2001b).

Case example 2.5  The power of goals

Paul was 15 years old when he was referred to me on account of his long recurrent history of joyriding and theft. He was described on his report as having a cynical attitude towards social services and having no remorse about his crimes. When I met Paul for the first time, instead of going over his problem history we started talking socially about differ­ent things he was interested in. I asked him about what work he thought he'd like to do in the future. For some reason Paul took this question seri­ously, thought for a while and then gave a clear answer: he would like to be an airline pilot. I was surprised by the answer. Paul was poorly edu­cated and barely literate. It was hard to imagine that he had the skills to be a pilot. But I resisted the temptation to dismiss the idea and suggest a more suitable career, realising that this is probably what usually hap­pened. Instead I asked what attracted him to be a pilot. This opened up a long conversation and he spoke non-stop about the interest he had in planes, stemming back to his childhood. Over the next few meetings, the subject of planes and other vehicles became our dominant discussion. I took seriously his interest in becoming a pilot and we discussed the steps he'd have to take to move towards this career, for example return­ing to education. We negotiated a goal of him gaining an apprenticeship as a mechanic, which he achieved within the next two months. When my work with him ended he was working happily in this position. He still spoke of wanting to work with planes, though he had now modified his goal to working as a mechanic with them.
This case illustrates how much energy and motivation for change can be released when we identify client-centred goals, as opposed to those imposed from the outside or formulated from problem descriptions. Large, idealistic goals that are important to clients are highly motivating and once these are understood and supported, 'small' focused goals, which are realistic in a thera­peutic contract, can be negotiated. Once Paul's desire to be a pilot was vali­dated and supported, the more realistic goal of an apprenticeship could be negotiated. Coincidentally, this satisfied many of the referrer's goals, since working as a mechanic, Paul did not commit crime. Most importantly, this was a goal that motivated him and one he was willing to work hard for to achieve in the short term.
Establishing therapeutic goals and helping clients elaborate their preferred views is by no means always an easy process. Steve de Shazer, the co-founder of solution-focused brief therapy, has described therapy as two people in a small room trying to find out what the hell one of them wants!
When working with families, the process is further complicated by the fact that you have to help several individuals articulate their goals, some or all of which may appear to be in contradiction with one another. Family members often start out with problems statements such as 'he never listens to me' or negatively for­mulated goals such as 'I just wish he would stop being so moody,' which often attribute blame and create conflict and counter charge. The aim is to help family members reformulate their goals to a format that is more positive and inclusive and which other family members can support and even take responsibility for. When goals appear to be in conflict it is often a case of seeking a formulation of a goal which takes into account both party's needs and wants. For example, in working with a couple where one party feels swamped and wants space and the other feels distant and wants more intimacy, the question becomes 'What would it be like when there is both space and intimacy in your relationship in a way that both of you feel happy?'.
When working with families, often goals go through stages of development as they are formulated in more positive and inclusive ways. For example:
1       'I just wish he wasn't so moody' (critical problem statement).
2       'I wish he would be more cheerful' (positive but focused exclusively on another's actions).
3       'I wish we had happier conversations' (positive, specific, shared responsibility).
4       'I love the times we joke together after dinner and would love there to more of these times' (positive, more specific, shared responsibility, meaningful and rich detail).
5       'I want to be more cheerful and positive when we spend time together after dinner' (positive, specific, meaningful and focused on what client can do to bring about goal).
Goal formulations 4 and 5 are particularly effective, as not only are they positive, clear and meaningful to the client, they also focus on the client's thoughts, actions and feelings and thus what he or she can do to bring it about.
Even when goals appear to be diametrically opposed there can still be a way of establishing an agreed therapeutic goal which respects the needs of both parties. For example, when working with a couple where one wants to leave the relation­ship and the other wants the relationship to survive, the therapeutic goal can be to help both parties understand their differences and to reach a decision about how to move forward.
When families are in a great deal of conflict, it can be very hard for them to move from a critical problem focus and to formulate positive goals. Indeed, it can be very hard for them to sit in the same room without descending into damaging rows or negative communication. In these cases, it may be better to work with family members in individual sessions, at least initially, before embarking on family work. Similarly, individual sessions are often the best way forward when the goal concerned is private to an individual family member, for example, a parent wanting to come to terms with her childhood abuse, or a parent in a violent relationship wanting to make plans for her safety, or a teenager wanting to 'fit in with' and meet new friends.
To illustrate some of these ideas, consider the following case of the Walsh family, consisting of a mother, father and a 14-year-old son, Gerry, who come to therapy with different goals.
Therapist:   [Addressing family] So what are your best hopes for coming
to these family meetings? Mother:     Well, I just want Gerry to start studying again and to stop
hanging around with those friends of his. They're bad news. Gerry:        [Mutters under his breath] You don't know what you're talking
Mother:      See what I mean, he never used to be like that. Therapist:[Addressing mother] What do you hope would happen by
Gerry staying in and studying a bit more? Mother:     Well, I want him to get on better in school, I want him to pass
his exams - to have a future. Therapist:   Ah, I see, you want him to have a good future .   [Pause]
Gerry, what do you hope for, coming to these meetings? Gerry:        I just wish she'd get off my back. Therapist:   You'd like your mother to give you some space? Gerry:        Yeah, I'd like her to realise that I have to make my own
Therapist: So you'd like to be able to make some of your own decisions . [Pause] And Mr Walsh, what would you hope to get out of these meetings?
Father:       I just wish the rows would stop at home.
Therapist: I understand . What way would you like things to be going in the home?
Father:       Well, I'd like everyone to be getting on better.
In the above sequence, the therapist has attempted to get each family member to articulate their goals in a way that is less contentious and more likely to be accepted by each other. The mother has moved from simply stating that she wants Gerry to stop hanging around with his friends to her deeper and more positive goal that she wants him to have a better future. Similarly, Gerry has moved from stating that he 'wants his mother off his back' to a wish to make more of his own decisions and the father has moved from wanting 'no rows' to wanting 'everyone to be getting on better'.

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