Agreeing on goals and formulating a treatment plan is important. If you’re lucky, your new client will offer up some values-guided goals as treatment goals to facilitate real change. However, many clients will initially give you “emotional goals,” “dead person’s goals,” or “insight goals.” Let’s take a look at each of these.
1. EMOTIONAL GOALS
“I just want to be happy,” “I don’t want to be depressed,” “I want to stop feeling anxious,” “I want more self-confidence,” “I need more self-esteem,” “I want to move on,” “I want to feel calm,” or “I want to stop worrying.” In ACT, we call these “emotional goals” because in each case, the goal is to control how one feels: to get rid of “bad” thoughts and feelings and replace them with “good” ones.
If we agree to these goals, we’ll reinforce experiential avoidance, a core pathological process that is the very opposite of mindfulness. However, if we bluntly announce this to the client, it will probably be counterproductive. So it’s better to say something like, “Okay. So can I put it this way? There are painful thoughts and feelings that you’ve been struggling with, and one goal of therapy is to learn better ways of handling them.”
Having said all that, there are a few special circumstances in which it’s probably better to be crystal clear from the outset that our agenda is not to eliminate unwanted thoughts and feelings. For example, suppose you have a client with PTSD who says, “I just want to get rid of these memories.” A useful response to this might include the Horror Movie Metaphor.
THE HORROR MOVIE METAPHOR
Therapist: You know, there are quite a few scientifically proven models for treating PTSD—we call them “empirically supported” treatments—but not one of them works by eliminating bad memories. What they all do is help you to respond to your memories differently so they have less impact and influence over you. If I can give you an analogy: right now when these memories show up, it’s like watching a terrifying horror movie late at night, all alone by yourself, in a rickety old house, with all the lights off.
Now suppose you have exactly the same movie playing, but this time the TV’s in the corner of the room, it’s broad daylight, sunlight’s streaming in through the windows, your house is full of friends and family, and you’re all interacting together—talking, laughing, eating, having fun. The movie hasn’t changed one bit—it’s still playing on the TV in the corner of the room—but now it’s having much less effect on you. Mindfulness skills will enable you to do this sort of thing. I don’t know any way to permanently delete these memories, but we can change your relationship with them so you can get on with your life and do the things you really want to do.
2. DEAD PERSON’S GOALS
Often your client’s goals will be to stop feeling or behaving a certain way—for example, “I want to stop using drugs,” “I want to stop yelling at my kids,” “I don’t want to have any more panic attacks,” or “I don’t want to feel depressed.” In ACT, these are called a “dead person’s goals”(Lindsley, 1968). A dead person’s goal is anything that a corpse can do better than a live human being. For example, a corpse will never use drugs, never yell at the kids, never have a panic attack, and never feel depressed.
In ACT, we want to set “living person’s goals”—things that a live human being can do better than a corpse. To move from a dead person’s goal to a living person’s goal, you can ask simple questions like these:
- “So let’s suppose that happens. Then what would you do differently? What would you start or do more of? And how would you behave differently with friends or family?”
- “If you weren’t using drugs, what would you be doing instead?”
- “If you weren’t yelling at your kids, how would you be interacting with them?”
- “If you weren’t having panic attacks or feeling depressed, what would you be doing
- differently with your life?”
3. INSIGHT GOALS
“I want to understand why I’m like this,” “I need to figure out why I keep doing this,” or “I want to discover who I really am.” Treatment goals like these easily lead to “analysis paralysis”—to session after session of intellectual/theoretical/conceptual discussions and endless reflections on the past instead of to the development of new skills for mindful, valued living.
As it happens during ACT, clients will develop a lot of understanding and insight into their own behavior, thoughts, feelings, personality, and identity. They will generally have powerful realizations around who they are, how their mind works, what they really want in life, how the past has influenced them, and why they do the things they do. But in ACT, they develop this insight via experiential work, not through lengthy analytical discussions. Furthermore, this insight is not an end in itself: it’s simply something that happens on the journey toward the desired outcome of mindful, valued living.
Thus to move to a more useful treatment goal, I say, “As part of the work we do together, you’ll certainly get a lot more insight into who you are, how your mind works, why you do the things you do, and what you really want in life. All of that is already a given; it happens as part of the process in ACT. When I ask what you want out of therapy, what I mean is, once you have that insight and understanding, what do you want to do differently? If you had that knowledge, what would you do that you’re not doing now? How would you behave differently? What would others notice that was different about you?”
GENERIC TREATMENT GOALS
Sometimes, despite all your best efforts, your client will be unable or unwilling to give you any specific values-oriented treatment goals. She may just keep answering, “I don’t know,” “Nothing matters,” or “I just want to stop feeling like this,” or “I just want to feel happy.” In such cases, don’t try to force the point; just accept that for now your treatment goals will be vague and generic. Below are two alternatives you could use in these cases.
Therapist: So how about we agree to this? The work we do here will be about two things. First, learning new ways to handle your thoughts and feelings more effectively so they can’t hold you back from living the life you want. Second, even though right now you have no idea what you want and you feel like nothing matters, let’s make this a place where you get to discover what does matter to you and what sort of life you do want to have. And once we’ve discovered that, let’s set about making it happen.
Therapist: So for now, let’s just say that the work we do here will be about giving you a life that grabs you, a life that you feel is worth living. At this point, you don’t know what that life looks like, but that’s okay. We’ll find out as we go along. So one aim of our work here will be to discover what’s important to you and what sort of life you want to live. And another aim will be to learn better ways to deal with the pain that life is currently giving you. And both of those aims are ultimately to serve one purpose: creating a rich and meaningful life.
This passage appears in the book ACT Made Simple by Russ Harris.
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