Using SMART Goals in therapy

When you are working with patients in therapy, the first session or two are generally focused on learning more about the patient in terms of their challenges and establishing rapport. Once you’ve gotten a good handle on the patients presenting problem and history, the next step is to develop treatment goals.

Goal-setting is a collaborative process that should be informed by the patients preferences and values. Treatment goals are helpful because they allow for reflection to evaluate whether treatment is progressing well or if changes are needed to properly support the patient.

As clinicians, I believe our purpose is to make sure the goals are well-suited for the specific intervention. For example, if a patient’s goal is to have other people treat them more nicely, this may require some additional thought because we can’t directly control how other behave; we can only change how we think and behave.

Reaching the far-end goal requires actionable steps to get there. This is where SMART goals come into play. SMART goals make sure the objectives we set are relevant, actionable, and measurable (i.e., we can assess if the work we are doing is helping the patient as intended). This is where SMART goals become a useful skill that clinicians can draw from to set our patients up for success!

Below, I define SMART goals and provide some clinical considerations for each of the components of the acronym that you should consider when developing a SMART goal.

SMART Goals: Definition and clinical considerations

S – Specific. When setting up SMART goals, whether as behavioural experiments or home practice, it’s important for our goals to be specific. If a goal is vague, we won’t quite know if the patient has successfully completed the goal. For example, if the SMART goal is to be more sociable, this could mean many different things. A specific goal to be more sociable might be to call a friend and invite them to lunch.

M – Measurable. It’s also important to assess how engaging in certain tasks affects the patient and measure this change quantitatively. For instance, when treating a patient with depression, we might get them rate their mood before and after engaging in a specific task, like taking a walk. They might rate their mood as a 3/10 before the walk and a 6/10 during and after the walk. This provides evidence that the home practice was successful in its goal to increase mood. Moreover, having this direct evidence can tackle beliefs that maintain depressed mood, such as “I can’t do anything to change how I feel”.

A – Achievable. When you are setting goals with your patient, it’s important to ensure that the goal is achievable for the patient to set them up for success and build momentum. If a person who is depressed wants to get up earlier (e.g., 7:00am every morning) but has generally woken up closer to noon every day over the past 3 months, this may not be the best goal to set over the next week. It may be a long-term goal in therapy, but it may be helpful to encourage the patient to slowly get there over time. For example, setting the goal to wake up and get out of bed before 10:00am for at least 3 out of 7 days.

R – Relevant. The goal should be challenging but manageable, and relevant to the person’s overall goals for treatment. For example, a person may have a goal of being more sociable in person, but then set a SMART goal to talk to someone on the internet. This SMART goal may not be relevant to improving their overall goal of being more sociable in person because it’s an online situation. Moreover, the person may already feel comfortable talking online and is setting this goal to avoid putting themselves anxious situations, which can maintain anxiety.

T – Time-bound. Having a timeline for how and when you are going to achieve this goal can be important to keep the patient accountable, especially when you are regularly meeting with a patient. For example, the goal might be to run for 15 minutes at least 3 days of the week. To further create specificity, you and patient may also collaborate on what day and time is the best time to stay consistent with the goal.

Increasing likelihood of success in accomplishing SMART Goals

As a clinician, another goal when engaging in goal setting is to ensure that we are considerate of potential barriers that might affect the patient’s chances of success. Here are a few suggestions to consider when developing SMART goals to stack the cards in your favour in supporting patients.

1. Figure out potential barriers to completing the goal. Let’s say your patient wants to jog in the morning for at least 15 minutes. What could be some barriers to the patient completing this goal? Perhaps she might oversleep. Perhaps she feels more cozy in bed and doesn’t want to get out. Or something might come up, such as her son needing her to take him to his soccer practice. As a clinician, it’s our job to determine the best ways to support the patient for success. In this case, it might be inquiring about the use of an alarm and putting it further away from the bed to make sure that she must get out of bed to turn it off. It might also be planning specific times to run to minimize potential distractions or people pulling her away from her goal. Be curious and creative about troubleshooting!

2. Determine values. People are more likely to engage in a task when they feel that doing so is consistent with something very important to them. Inquire to the patient: why is important that you engage in this goal? This type of motivational interviewing can help the patient explicitly flesh out their reasons for engaging in the goal despite it being potentially anxiety-provoking or challenging to complete. In the case of being more physically active, the values associated might be being able to better take care of kids and being a part of their lives or being able to live a fuller life themselves and travel in the future.

3. Check-in on the patient. Sometimes, the easiest way to know if a patient is likely to complete the task is to ask them yourself! “From a confidence level of 0 to 10, how confident are you to complete this task, 0 being not confident at all and 10 being extremely confident?”. If the patient says 5 (neither confident nor unconfident), this might be helpful to inquire further about potential barriers to troubleshoot. Ways to support this may be asking a scaling question: “why isn’t this score a 6 or why isn’t this score a 4?”. These questions are helpful to reinforce confidence and address concerns to support a higher rating. The higher the confidence level, the better. Usually, I strive for at least a rating of 7 or 8 out of 10 in terms of confidence for a patient before I assign a home practice.

An example of SMART Goal setting with a patient

Therapist: Okay, so I hear that your goal is to spend more time with friends this week. What do you think might make sense as home practice?

Patient: I was thinking I could call a friend and invite them for a Saturday brunch this week.

Therapist: That’s a great idea! I like that you have a specific plan in mind regarding the timing of the brunch (REINFORCE). Is there a specific friend that you could call and when might you do that? (SPECIFY)

Patient: I was thinking my friend Ashley would be a good choice. I’ll probably call her tomorrow morning.

Therapist: That sounds good. What would do if Ashley didn’t pick up, or she already has plans and is not available for a brunch this Saturday? (NOTE BARRIERS)

Patient: That’s a good point. I guess if she doesn’t pick up, I can always send her a text. If she’s not available, I can offer alternatives such as dinner or I can ask another friend. Perhaps Brenda.

Therapist: Fantastic! I think having an alternative method of contact and another person you can ask will be really helpful to set yourself up for success (REINFORCE). How confident do you think you will contact Ashley tomorrow morning from a scale of 0-10? (QUERY)

Patient: Hmm, I’d say somewhat likely. I have a couple things I have to do tomorrow morning, so there’s a reasonable chance that I might get distracted and sometimes I am forgetful…I’d say 6/10”

Therapist: Gotcha. I hear that you are fairly confident in sending her a message but it’s possible things can come up and it may slip your mind. I wonder if there’s a way to increase the likelihood that you and Ashley can set up a plan as early as possible. (TROUBLESHOOT)

Patient: That’s a good point. I guess I could set up reminders tomorrow so that it’s more likely that I will find a time to call her.

Therapist: This is a little unconventional, but will you hear me out on a possible idea that might really increase your chance of success? (ELICIT PERMISSION)

Patient: Sure, go ahead.

Therapist: I wonder if you’d be comfortable just calling her right now in our session and sending her a text if she doesn’t pick up (TROUBLESHOOT). This would eliminate the barrier of having to remind yourself and we can always think of something else if she ends not being available. What do you think? (RATIONALE AND OBTAIN PATIENT CONSENT)

Patient: Well, it’s definitely unconventional and maybe a little awkward. But yeah, I guess that would be a good way to just get something set up as early as possible.

Therapist: Great, thank you for being so flexible (REINFORCE)! Let’s give Ashley a call now. (ACTION)

As you can see in this example, the patient was well-versed in setting up a SMART goal and was able to come up with alternatives to increase her chances of success. However, she was a little bit skeptical in being able to make the call because of her other commitments. To support success, the therapist came up with a creative idea to avoid the whole issue altogether by getting the patient to make the call during the session. Although your ideas don’t have to be as unconventional, it can be helpful to consider strategies to troubleshoot potential barriers to success.

I hope this post was helpful in learning more about how to come up with SMART goals for patients and set them up for success! For people interested in creating SMART goals themselves, here’s a self-help guide to developing SMART goals.

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Best wishes,