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Getting Started in Therapy: Setting Treatment Goals

At some point during my first session with a client, I’ll ask him/her “why did you come to see me today” or “what would you like to get out of therapy.” In other words, I’m trying to figure out what our treatment goals will be. This is important for two reasons: 1) Depending on your treatment goals, I can determine whether or not I will be able to help you. 2) Once we know our goals, we can start to brainstorm the steps to achieve those goals. Without a destination, we can’t start planning our journey. Once we have our destination and our routes planned out, it will also be easier for us to recognize if we start veering off course or not making progress.

Too often I hear the responses, “I want to be happier” or “I don’t want to feel anxious anymore” to my question about treatment goals. These responses highlight people’s tendency to label certain emotions as positive/good (eg happy, excited, joyful) and others as negative/bad (eg sad, angry, anxious, depressed). The natural consequence to that of course is to eliminate the negative and pursue only the positive. The problem with this mindset is forgetting that all emotions, positive or negative, have a purpose and to be human is to experience a broad spectrum of emotions, so to get rid of one particular emotion or all the negative ones is akin to cutting off an arm or leg. As a clinician, I like to categorize emotions as those that make us comfortable and those that make us uncomfortable, rather than good versus bad or positive versus negative. Just because feeling anxious makes us uncomfortable, doesn’t necessarily make it bad and mean we have to get rid of it. If you read the previous blog (and tried to not think of a green polka-dotted elephant), you will also realize that it is impossible to not feel anxious, sad, or whatever “negative” emotion you’re trying to push away. We cannot isolate any one emotion to get rid of. That is to say, to numb out one emotion is to numb out all of them.

So what do I do when I hear those common responses? We change them into S.M.A.R.T. goals:

  • Specific – What has to happen for me to feel happier or less anxious?
  • Measurable – How will I know that I am making progress towards my goal?
  • Achievable – How will I know when I’m “happier”, What kinds of things will I stop doing or do more when I am not anxious anymore?
  • Realistic – Is this within my control? Are there aspects of my goals that are within or out of my control?
  • Timely – What changes do I want to make or see in the next week? month? year?

Another quick exercise for you to try:  How would you change those two treatment goals that you see above in bold?
Possible solutions:

  • “I want to manage my anxiety so that I can attend social functions without experiencing a panic attack.”
  • “I will know my depression is better when I am able to go shopping and cook dinner three times a week.”

Sometimes it takes an entire session to develop treatment goals, but it is so necessary.

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Welcome to Therapy

New clients in therapy often ask me, “How long will this take? When will I feel better?” The short answer is “it depends – on your treatment goals, on your level of engagement with therapy.” Particularly in the beginning of therapy, I emphasize that it’s very important to attend sessions consistently, usually on a weekly basis, and to actively participate in the between-session activities that we discuss in our sessions. I make this recommendation based on findings from research performed across more than 10,000 therapy cases, which find that “it takes more than 20 sessions, or about six months of weekly therapy, before 50 percent of patients show clinically meaningful improvement.”

Here’s a quick exercise you can do right now while reading – whatever you do, do NOT think about a green polka dotted elephant. DON’T. DO. IT. See what happened? This is why you can’t tell someone to not be anxious or not be depressed. It just doesn’t work and sometimes, it can make it worse. The more you try to NOT think about the green polka dotted elephant, the image almost gets more vivid. Similarly, the more we try to suppress our anxiety, depression, or any uncomfortable emotions, the more likely these internal experiences will become magnified. This is why I approach therapy using a cognitive behavioral therapy (CBT) framework. CBT does not teach you how to get rid of negative thoughts. CBT teaches you how to address these negative thoughts head-on.

Clinicians, like myself, who practice CBT, emphasize that thoughts have the power to guide our feelings and behaviors, sometimes outside of our awareness. Individuals with anxiety or mood disorders tend to have thoughts that are global, negative, and recurring. Global, meaning these thoughts/beliefs are broad generalizations about the individual, those around them, and their future. Negative, meaning these ideas are not optimistic or positive. Recurring, meaning these beliefs often come up time and time again, across various situations and life phases. Most importantly, these thoughts are inaccurate and unhelpful, meaning they are not supported by facts and can drastically worsen a person’s quality of life.

Together, we will explore the anxious, depressed, and/or negative thoughts that have been swirling around in your mind, challenge them, and REPLACE them with accurate and helpful thoughts. For example, instead of thinking about a green polka dotted elephant, think of a purple giraffe. For many clients, negative thoughts have become the soundtrack in their lives, constantly playing on repeat, quietly when stress levels are low, yet deafeningly loud when stressors emerge, blocking out supportive and helpful messages. Together, we will find a new soundtrack, new melodies that sing about your resilience, strength, and courage.

  1. Lambert, M.J., Hansen, N.B., Finch, A.E. (2001). Patient-Focused Research: Using Patient Outcome Data to Enhance Treatment Effects. Journal of Consulting and Clinical Psychology, 69, 1590-172.
  2. Morrison, K.H., Bradley, R., Westen, D. (2003). The external validity of controlled clinical trials of psychotherapy for depression and anxiety: A naturalistic study. Psychology and Psychotherapy: Theory, Research and Practice, 76, 109-132.
  3. Mental Health: Does Therapy Help (1995, November).  Consumer Reports, 734-739.
  4. Seligman, M.E.P. (1995). The Effectiveness of Psychotherapy: The Consumer Reports Study. American Psychologist, 50, 12, 965–974.