Therapy task:
goal setting
How to do it…
Try out the Goal Setting self-completion questionnaire…
About goal setting
Goal setting is at the heart of interventions concerned with some measure of behaviour change.
First, the FP needs to understand where they are now, meaning not just substance use but concerns. This should emerge from a review of the comprehensive assessment.
Next, help the FP reach an honest decision on what they want to change, how much they want to change and where they want to be in the future. Only after doing all this can you set out a plan of action to get there.
Using worksheets
We encourage you to use worksheets - they are not an end in themselves but they do...
help you and your network remember your plans
show how you are doing
highlight success and difficulties
There are examples of two commonly used tools in this task: the drink and drug diary and decision matrix worksheets.
You will find worksheets to complete if you go on to make an action plan at the end - for now they are just examples.
Example of a drink and drug use diary
The aim of this worksheet is to i) identify what drink or drugs are being consumed ii) to see if there is a pattern that might suggest ways to change.
Fill out the diary for the previous week.
Think about the different substances being used and where they are used - is there some indication as to the triggers for drinking or drug taking. If drinking is a significant part then use an alcohol unit calculator to sum the units.
Use a blank diary sheet to set goals for the coming week and monitor achievement.
Repeat the exercise from time to time and keep the diaries as a record of progress.
Example of a decision matrix worksheet
The aim of this worksheet is to increase motivation for change. It is a useful tool for people who have not yet decided to change; it can also be useful if you have started to make changes and got stuck. You might need to be reminded of why you want to change. The idea is to draw attention to the fact that sometimes you like and dislike the same thing or activity.
Complete each of the four boxes.
Reflect on your responses particularly regarding dislikes.
What do you make of what you have written?
Look at the balance in favour of stopping drinking or taking drugs. It is a good idea to test out abstinence in the first instance but the matrix can equally be applied to cutting down.
Change talk comes before a decision to change..
Expressions of concern and/or desire to change are called change talk.
To elicit change talk you could ask:
“What kinds of things happen when you have been drinking/taking drugs?”
“Having looked at your liver function tests, tell me what you think? What does this mean to you?”
Try to establish the one thing that most concerns the FP: “What is the worst thing that has happened?” and continue with “Tell me more about that” or "What worries you the most about your drinking/drug taking?"
Commitment talk is what comes before an action plan...
Commitment talk is an expression of determination to change in a specific way, at a specific time, to a new specific behaviour and is an important predictor of behaviour change. The strength of commitment talk is important.
An example of commitment talk...
“I’m going to stop drinking on Monday.”
An example of how to elicit commitment talk...
"What are you going to do next?"
Goal Setting
Aim
To elicit commitment to change
To establish a SMART goal based on motivational state
To do
Get an account of the recent substance use behaviour
Elicit concerns about the behaviour and its consequences (change talk)
Explore motivation for change and self-efficacy for achieving a concrete plan
Agree a change plan accompanied by optimism about the outcomes of change (commitment talk)
Feedback of test results
If the FP has completed some tests then give feedback as soon as possible - the aim is to inform the discussion and secure a commitment for change. You will need to seek consent for this to be done in the presence of NMs ...
Explain the tests and the results to the FP and NMs
Ensure that everyone understands the results and their implications
Feedback all available results and elicit concerns
Highlight how results are likely to change i) with abstinence or reduced substance use ii) if substance use continues unchanged
Elicit expressions of optimism for the consequences of change
Health problems, physical and mental, that can be improved by a change in substance use can be a powerful motivating tool. Share your opinion with the FP and the NMs, who may all need education on drugs and alcohol harms at this point.
Examples of dialogue
“Tell me what you understand about the effect of your drinking on your liver?”
"Tell me what you expect to happen when you stop drinking?"
"Here are the results of your drug testing - what has changed over recent months?"
"What does the result of your dependence questionnaire mean to you?"
In this video Dr Gillian Tober demonstrates how a practitioner approaches goal setting. She also demonstrates how useful it can sometimes be to use a video call to discuss plans. The two people she talks with are role playing a father and daughter.
It is clear that the drinking goal, at least in the first instance, should be abstinence. Father is resistant and Gillian does not reject the idea of cutting down, but ‘gives way’ to keeping it as an option pending returning to getting agreement that a period of abstinence is the best plan.
Firming up the substance use goal
If the FP has decided on abstinence...
Where the FP has decided that they want to stop drinking or taking drugs, then the assessment results are used to strengthen their resolve and to elicit optimism for the outcome of change, and not to explore concerns about drinking or drug taking that have already been dealt with, as this would be a backward step.
Examples of dialogue
“What is going to be better from stopping drinking/drug taking?”
"Who in the network can help you to stay off drink/drugs?"
"In what ways can they help?"
"What are going to be risky situations for you?"
If the FP expresses a wish to moderate drinking or drug use...
The FP meets the criteria for a moderation goal
The practitioner needs to share the pros and cons of opting for moderation. Particularly share the concept of there being rules to set if moderation is to succeed. Aim to elicit a commitment to some rules:
Examples of dialogue
“What do you make of your responses to the dependence questionnaire?" “If you think it is too difficult to stop now, what other options can we talk about?” "Who will be able to help you?"
The FP does not meet the criteria for a moderation goal
A moderation goal is often perceived as an easy option when in fact it is the more difficult because any substance use increases the likelihood of reverting to the usual pattern of use. It is important that the FP understands the need for strict rules, adherence and support from others.
Moderation is unlikely to succeed when the FP:
has high dependence and loss of control (check responses to the Leeds Dependence Questionnaire)
lacks social support specifically for moderation
is impulsive.
It may be expedient to go along with a moderation goal in the first instance - if it is not successful then abstinence is the next step.
Examples of dialogue
“What do you make of your responses to the dependence questionnaire?" “If you think it is too difficult to stop now, what other options can we talk about?” "Who will be able to help you?"
Steer the FP to abstinence when:
pregnant
the FP has significant physical illness related to drinking or drug use
there is unacceptable occupational risk
there is a co-existing mental health problem
family and friends do not support a moderation goal
Examples of dialogue
“You said in your questionnaire that you can't stop once you have started - what does this mean for your drinking and keeping your job?" "You say you have been given stark warnings about using ketamine while you are pregnant - let's look at what is possible from now?”
Self-efficacy
The practitioner needs to be sensitive to the reasons for resistance to change. The FP might express strong desire and reasons for change, yet have no belief in their ability to change. The network is an important source of enhancing self-efficacy for change by offering help and expressing their belief that change can occur.
Examples of dialogue
“People in your network have said they really want to help - let's decide the best ways for them to do this" "What is going to make a difference to you?" “What is going to make you confident that you can do it?” "How are you going to tell people what will be helpful?"
If the substance use goal is not agreed
From an ethical standpoint the practitioner can only agree to a goal that is likely to be beneficial to the FP. Share your opinion with the FP and the NMs, who may all need education on drugs and alcohol harms. If the FP is not ready to make changes to their substance use then a conversation about harm reduction strategies should follow, but always aim to strengthen motivation to change:
Examples of dialogue
“What do you most dislike about your drinking/drug taking" "How do you see yourself now compared to you at your very best?" "What things would you like to do right away to make things better?" " Who is going to help you?" "How would you like to see yourself in three months?" "How are you going to get there?"
Goal setting is, initially, best done as a group exercise and then be given as a take-home task from the Guided Self-help