3.6: Setting the Tasks

David Featherston

Problem and goal statement

Identifying a problem and setting goals should be a structured process. The goal should be measurable so that achievement can be determined. The acronyms SMART or SMARTER are often used to support the process of setting goals. Relevant terms can be seen in the table.⁽¹⁾

S	Specific	Significant, Stretching
M	Measurable	Motivational, Manageable
A	Attainable	Achievable, Agreed, Appropriate
R	Relevant	Realistic, Results, Resourced
T	Time	Timeframe, Trackable
E	Evaluate
R	Re-evaluate	Revisit, Re-assess

There are a number of methods to establish a problem and goal statement. A couple of options are provided.

5 As Behaviour Change Model⁽²⁾

The first two steps of the 5 As model were covered previously as a method of assessing the capability of the patient and carer for self-management (assess and advice).

Assessing the capability of the patient and carer for self-management Module 3.5.

The final three stages are explained below.

Agree – The patient looks collaboratively at different options prior to developing specific and measurable self-management goals. Input from the carer is important at this stage. The key here is shared decision-making.
Assist – Help the patient to develop strategies to address barriers to change. Refer patient to evidence-based education or behavioural counselling and discuss resources with family. Action planning and problem solving support should be included here.
Arrange – Give patient a copy of the action plan, follow-up call to the patient and set timeframes for follow-up meeting and contacting resources. Establish community group links.

Southern Mental Health⁽³⁾

What is the problem/goal? – Talk through, ask questions and record a range of problems, taking into account the patient’s and carer’s feelings. Determine which problem is to be solved.
List possible solutions – Record possible suggestions.
Discuss each possible solution – Examine the advantages and disadvantages of all solutions on the list.
Choose one of these solutions – Select a solution which both the patient and carer agree on.
Plan how to carry out this solution – Define the goal and set a statement.
Review progress (or lack of it) at next appointment – Discuss the success of the goal statement and make amendments if necessary.

Flinders Program⁽⁴⁾

This process involves inserting the problem and goal statement on a self-management care plan, similar to the example provided.

Client Problem Statement: Because I lack the confidence in myself and fear being judged and rejected, I avoid social situations, which makes me feel lonely and isolated.

This problem interferes with my daily activities

0 1 2 3 4 5 6 7 8

does not definitely severely

Client Goal/s: Arrange and go out with best friend/friends for dinner and a social activity once a fortnight.

My progress towards achieving this goal

0 1 2 3 4 5 6 7 8

complete success 50% no success

The psychiatrist asks the patient to identify the main issues of problem(s) in the patient’s life.
The problem is agreed on.
The psychiatrist asks the patient questions based on a three-step process:

A patient problem statement is recorded.
Through discussion, a measurable and realistic goal statement is made.
The statement is reviewed at a predetermined time.

Case study – problem and goal statement⁽⁴⁾

In this video extract, Kelly and her psychiatrist aim to set a problem and goal statement. The problem or the challenge is considered by following three steps: the actual problem, what happens because of it and how she feels about that. At the conclusion of this session Kelly’s statement is to ‘Arrange and go out with best friend/friends for dinner and a social activity once a fortnight’.

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Psychiatrist Have you ever done a problems and goals statement before?

Patient No.

Psychiatrist Basically, a lot of people try to set goals but we are notoriously bad at not following through with them and sometimes that’s because we set goals that are too easy so we never get round to them or we set goals that are too hard and we give up. It sounds like this social issue is an important one, so potentially what we can do is – a good way of looking at problems is to split them up into three steps: the actual problem, what happens because of it and how you feel about that. So if you were to choose this social issue as the main problem how would you like to express this, is it the problem of getting out socially, or not having enough social contact or…

Patient It is having the confidence in myself, to actually put myself in social situations and feel confident in talking to other people without thinking that they are going to judge me or reject me. I would like to actually develop the confidence and believe in myself.

Psychiatrist So the problem is like a lack of confidence and a fear of being judged.

And what happens because of that?

Patient I avoid any form of social situations whatsoever.

Psychiatrist So you avoid most social situations. How does that make you feel when you do that?

Patient Lonely and isolated.

Psychiatrist So if you were to put that into a single sentence that captures those three things…would you like to have a try at doing that?

Patient Because I lack the confidence in myself and fear being judged or rejected I avoid social situations, which makes me feel lonely or isolated.

Psychiatrist If you were to rate that on a scale of 0–8, 8 being the worst case scenario, where would you rate yourself at the moment, the degree of that being a problem?

Patient Probably about a 7 or 8.

Psychiatrist Now the next thing to think of is the goal step and if you were to think of a goal that was related to this problem, somewhere that you want to be in potentially three to six months or six to twelve months time, what would be your main wants?

An example of the problem and goal statements – Kelly has set the client goal as:

‘Arrange and go out with best friend/friends for dinner and a social activity once a fortnight’.

Early intervention and early warning signs

Early intervention

Early intervention refers to interventions targeting people displaying early signs and symptoms of a mental health problem or mental disorder.⁽⁵⁾Strategies need to be put in place offering immediate access to treatment or support from a key worker or someone who the person trusts. Early intervention strategies are best determined in collaboration with the patient and carer. There is now an accumulation of positive research evidence for early intervention, which shows particular promise in the area of early psychosis⁽⁶⁾ and some support for early intervention in the area of alcohol abuse.⁽⁷⁾

Early warning signs

When someone has experienced one or two episodes of mental illness, it is helpful to work with them to determine their early warning signs of relapse. This allows treatment to be implemented before relapse occurs, or helps to lessen the severity of relapse. Providing the patient and carer with skills to recognise and control relapse is another essential component of self-managing the chronic condition. Patient confidence will grow with increased self-control and trust in the ability to recognise signs and take appropriate action.⁽⁸⁾

With time it should be possible for each individual to identify their ‘relapse signature’, that is, typical feelings, thoughts and behaviours associated with the onset of the condition. It is also an appropriate time to develop an advance statement. This is a statement which sets out a person’s wishes and preferences for future treatment and care in the event that the person becomes unable to make such decisions and this should be recorded for clinicians to utilise.

Symptom action plans

In the Cue and Response Interview there are questions directed at monitoring, managing and understanding symptoms. This will identify whether a symptom action plan is being used. One objective for the psychiatrist is to assist the patient in learning about their condition (including recognition of symptoms and signs of relapse). For example in a patient with BPAD mood disorder, vegetative sign monitoring and thought pressure monitoring is important. This can include identifying general and specific triggers e.g. anniversary issues, grief and loss situations of hostile dependency can pre-empt the development of specific actions that need to be taken to prevent relapse or to minimise it.

Reflective exercise

Reflect on the process that you currently use to support a patient to determine a goal statement.

References

Available from http://en.wikipedia.org/wiki/SMART_criteria
Glasgow et al, Whitlock et al. 5 A’s Behavior Change Model Adapted for Self-Management Support Improvement. 2002. Available from http://www.ihi.org/IHI/Topics/PatientCenteredCare/SelfManagementSupport/EmergingContent/5AsBehaviorChangeModel.htm
Leggatt M. Working Together. A short, practical guide for consumers, family carers and mental health professionals to work together in collaboration and partnership. Southern Mental Health Association, 2006.
Flinders Human Behaviour & Health Research Unit Self-management Program. The Flinders Model DVD.
Commonwealth Department of Health & Aged Care. Promotion, Prevention and Early Intervention for Mental Health—A Monograph. Mental Health and Special Programs. Canberra, 2000. Available from http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-p-prommon
Wyatt RJ, Henter ID. Early intervention in schizophrenia: What do we know and what does it mean? Decade of the Brain. Spring 1997.
Saunders JB, Lee NK. Opportunistic brief interventions. Medicine 1999;27:22–3.
Smith J. Early Warning Signs. A self-management training manual for individuals with psychosis. Worcestershire Community and Mental Health Trust.

Continue to Module 3.7: Completion and Follow-up

3.6: Setting the Tasks