3. 制定治疗目标

第三章

制定治疗目标

在第二章中，我们重点讨论了评估客户的问题和优点，以及如何解释CBT。你尝试使用《了解客户问题的问题》了吗？使用这些问题后，你是否对客户的优点有了不同的看法？我很好奇，你是否已经开始注意到自己的思维？这是否对你的生活有所影响？

当客户完成家庭作业时，治疗效果更好，客户也更有可能在生活中真正做出改变（Rees, McEvoy, & Nathan, 2005）。同样，你将CBT融入自身工作的程度取决于你如何使用书中的材料并进行练习。每章末尾的家庭作业只是鼓励你练习的一种结构。

如果你没有机会完成第二章的家庭作业，试着找出阻碍你的因素。也许你没有见到任何客户，或者你特别忙。有时，治疗师的思维会妨碍他们与客户一起尝试家庭作业。你是否有以下任何想法？

我不需要做家庭作业，或者我已经理解了材料。
家庭作业与我的客户无关，或者如果我尝试CBT家庭作业，我的客户会反应消极。
做家庭作业会让我感到尴尬。

这些想法是否阻止了你完成家庭作业和练习CBT技能？还有其他想法阻碍了你的练习吗？现实是你除非尝试，否则无法知道家庭作业是否有帮助。如果你感到惊讶，发现家庭作业真的有帮助呢？如果你担心第一次尝试干预时会感到尴尬，这是正常的；因为你正在做新的事情，可能会感到不自在。我猜你第一次尝试任何新技能时也会感到尴尬。如果你每次感到尴尬时就放弃，你的生活会怎样？

什么可以帮助你完成本章的家庭作业？记住，你练习得越多，就越容易。如果你没有完成第二章的家庭作业，在开始这一章之前，尝试以下两个练习：

进一步的知识点阐述

评估客户的问题和优点：
- 问题评估：在第二章中，我们介绍了如何使用《了解客户问题的问题》来评估客户的问题。这些问题帮助治疗师全面了解客户的问题及其影响。
- 优点识别：通过这些问题，治疗师还可以识别客户的优点和韧性领域，这有助于制定更积极的治疗计划。
家庭作业的重要性：
- 治疗效果：研究表明，当客户完成家庭作业时，治疗效果更好，客户也更有可能在生活中真正做出改变（Rees, McEvoy, & Nathan, 2005）。
- 个人实践：治疗师将CBT融入自身工作的程度取决于他们如何使用书中的材料并进行练习。每章末尾的家庭作业是为了鼓励治疗师练习。
常见的阻碍因素：
- 思维障碍：治疗师可能会有以下几种想法，这些想法会妨碍他们完成家庭作业和练习CBT技能：
  - 不需要做家庭作业，或者已经理解了材料。
  - 家庭作业与客户无关，或者客户会对CBT家庭作业反应消极。
  - 做家庭作业会感到尴尬。
- 克服障碍：现实是你除非尝试，否则无法知道家庭作业是否有帮助。第一次尝试新技能时感到尴尬是正常的，但如果每次感到尴尬时就放弃，就不会有进步。
完成家庭作业的方法：
- 坚持练习：完成家庭作业的关键是坚持练习。你练习得越多，就越容易。
- 具体练习：如果你没有完成第二章的家庭作业，在开始这一章之前，尝试以下两个练习：
  - 重新评估一个客户的压力源和优点。
  - 选择一个客户，尝试使用《了解客户问题的问题》中的一个新问题。

通过这些练习和反思，治疗师可以更好地理解客户的问题，制定更有效的治疗计划。这些练习不仅帮助治疗师了解问题的性质和影响，还能发现客户已有的应对资源，为后续的治疗提供支持和方向。

1. 思考你目前正在合作的一位客户。尝试思考他或她生活中的压力源和优点。参考第二章中的《探索优点的问题》，想一些好的问题来评估他或她的优点。

2. 如果你还没有开始注意自己的思维，选择一个最近让你有中等到强烈情绪反应的情境。花点时间回忆当时的想法。尝试把它们写下来。注意自己的思维如何影响了你的情绪反应？

设定议程

CBT是一种积极的治疗形式，治疗师和客户在治疗开始时设定目标，并朝着这些目标努力。

议程项目#1：设定目标

议程项目#2：制定具体、可衡量的目标

议程项目#3：首先关注哪个目标？

执行议程

目标与问题是不同的。问题描述了客户生活中存在的问题，而目标则是客户希望他的生活有所不同，或者他希望为之努力的方向。设定有效目标是CBT的关键要素。

议程项目#1：设定目标

治疗师和客户达成一致的目标非常重要，否则治疗过程可能会漫无目的，感觉没有什么进展。此外，当客户觉得你理解了他的目标，并且治疗将集中在对他来说重要的目标上时，治疗关系会得到加强。

在治疗中设定目标类似于开始一段公路旅行。如果有人问我想要走哪条路，我必须先知道我要去哪里。去多伦多的路线与去底特律的路线是不同的。目标越具体和明确，我就越能规划如何到达目的地。目标为治疗提供了方向。

明确的目标  聚焦的治疗  有效的治疗和满意的客户

进一步的知识点阐述

思考客户的压力源和优点：
- 压力源：思考客户生活中的压力源，如家庭、朋友、工作、健康等方面的问题。
- 优点：使用《探索优点的问题》中的问题来评估客户的优点和韧性领域，这有助于全面了解客户的情况，制定更积极的治疗计划。
注意自己的思维：
- 情绪反应：选择一个最近让你有中等到强烈情绪反应的情境，回忆并记录当时的思维。注意这些思维如何影响了你的情绪反应。这有助于你更好地理解自己的思维模式，从而在治疗中更好地引导客户。
设定议程：
- 积极的治疗形式：CBT是一种积极的治疗形式，治疗师和客户在治疗开始时设定目标，并朝着这些目标努力。
- 设定目标：治疗师和客户达成一致的目标非常重要，否则治疗过程可能会漫无目的，感觉没有什么进展。
- 具体、可衡量的目标：目标应该是具体和可衡量的，这样更容易跟踪进展。
- 优先目标：确定首先关注哪个目标，这有助于集中精力，提高治疗效率。
执行议程：
- 目标与问题的区别：目标描述了客户希望他的生活有所不同，而问题描述了客户生活中存在的问题。
- 明确的目标：目标越具体和明确，就越能规划如何达到目标。
- 聚焦的治疗：明确的目标为治疗提供了方向，使治疗更加聚焦。
- 有效的治疗和满意的客户：设定明确的目标有助于实现有效的治疗，从而让客户感到满意。

具体和可测量的目标是什么？

客户常常从非常一般的目标开始，比如“我希望不那么抑郁[或焦虑]”，“我希望有更好的自尊”，或“我希望与伴侣有更好的关系”。这些一般目标的问题在于，你没有一个具体的概念，客户希望他的生活有什么不同，客户也没有办法知道他是否正朝着实现目标的方向前进。具体和可测量的目标为治疗提供了方向，并提供了一种衡量治疗是否走上正轨的标准。最简单的方法是通过一些例子来理解一般目标和具体目标之间的区别。

目标示例

一般目标	具体、可测量的目标
更加自信	• 与伴侣谈论我对关系的一些担忧。 • 对老板设置更多限制（例如，告诉老板我不能接受新客户；要求老板不要在周末或晚上打电话给我）。 • 当与朋友外出时表达我的意见。
减少焦虑	• 在工作中做一次演讲。 • 不那么频繁地检查孩子的情况（例如，如果孩子晚了10分钟，不要打电话，而是等他们晚半小时才打；每晚只问一次作业是否完成）。 • 不因为小事发脾气，比如丈夫忘记给孩子打包午餐。

轮到你了！

识别具体、可测量的目标

最初，区分一般目标和具体、可测量的目标可能比较困难。请看下面的目标，并决定你会如何评价它们。你可以在附录中找到我的答案。

进一步的知识点阐述

一般目标 vs. 具体、可测量的目标：
- 一般目标：客户常常从非常一般的目标开始，例如“我希望不那么抑郁”或“我希望与伴侣有更好的关系”。这些目标缺乏具体性和可操作性，难以衡量进展。
- 具体、可测量的目标：具体和可测量的目标为治疗提供了明确的方向，并提供了一种衡量治疗是否走上正轨的标准。例如，“与伴侣谈论我对关系的一些担忧”就是一个具体、可测量的目标。
目标示例：
- 更加自信：
  - 一般目标：更加自信。
  - 具体、可测量的目标：
    - 与伴侣谈论我对关系的一些担忧。
    - 对老板设置更多限制（例如，告诉老板我不能接受新客户；要求老板不要在周末或晚上打电话给我）。
    - 当与朋友外出时表达我的意见。
- 减少焦虑：
  - 一般目标：减少焦虑。
  - 具体、可测量的目标：
    - 在工作中做一次演讲。
    - 不那么频繁地检查孩子的情况（例如，如果孩子晚了10分钟，不要打电话，而是等他们晚半小时才打；每晚只问一次作业是否完成）。
    - 不因为小事发脾气，比如丈夫忘记给孩子打包午餐。
识别具体、可测量的目标：
- 区分难度：最初，区分一般目标和具体、可测量的目标可能比较困难。通过练习和实例，可以逐步提高这种能力。
- 评价标准：在评价目标时，可以考虑以下几个方面：
  - 具体性：目标是否具体明确，可以清楚地描述出来？
  - 可测量性：目标是否可以量化，可以通过某种方式衡量进展？
  - 可行性：目标是否可行，客户是否有能力实现？

通过这些练习和反思，治疗师可以更好地帮助客户设定具体、可测量的目标，从而提高治疗的效果。这些目标不仅帮助客户明确方向，还能提供一种衡量进展的标准，使治疗更加有效和有针对性。

评估目标是一般性的还是具体且可测量的

目标列表

目标	这个目标是一般性的还是具体且可测量的？
与老板谈加班费
对朋友的要求少一些
在月底前戒烟
更好地照顾自己的健康
与父母相处得更好
每周与伴侣进行一次愉快的活动
学习更好的育儿管理技巧，以应对八岁孩子的发脾气

详细分析两个目标

让我们详细看看上面的两个目标。目标“与老板谈加班费”是一个具体的目标。我们知道客户希望采取的具体行为，并且可以衡量他是否能够完成这一行为。目标“对朋友的要求少一些”是一个一般性的目标。由于我们不知道客户希望增加或减少的具体思维、情感、身体反应或行为，因此我们无法知道客户是否成功地朝着这个目标努力。

进一步的知识点阐述

一般性目标 vs. 具体且可测量的目标：
- 一般性目标：这类目标通常较为模糊，缺乏具体的操作性，难以衡量进展。例如，“对朋友的要求少一些”。
- 具体且可测量的目标：这类目标明确具体，可以量化，容易衡量进展。例如，“与老板谈加班费”。
目标示例分析：
- 与老板谈加班费：
  - 具体性：目标明确，具体指出了客户希望采取的行为。
  - 可测量性：可以衡量客户是否成功与老板谈成加班费。
- 对朋友的要求少一些：
  - 一般性：目标模糊，没有具体指出客户希望改变的具体行为。
  - 不可测量性：难以衡量客户是否成功减少了对朋友的要求。
如何将一般性目标转化为具体且可测量的目标：
- 明确具体行为：将模糊的目标转化为具体的行为。例如，“每周至少减少一次对朋友的过高要求”。
- 量化目标：设定具体的数量指标。例如，“每月至少与朋友进行两次轻松的聚会”。
- 设定时间框架：明确目标的时间框架。例如，“在年底前减少对朋友的要求”。

通过这些练习和反思，治疗师可以更好地帮助客户设定具体且可测量的目标，从而提高治疗的效果。具体且可测量的目标不仅帮助客户明确方向，还能提供一种衡量进展的标准，使治疗更加有效和有针对性。

帮助客户制定具体且可测量的目标

将客户的普遍目标转化为更具体的目标可能具有挑战性。以下是一些可以帮助客户的问题。你可以在 http://www.newharbinger.com/38501 下载这些问题的手册形式（《制定有益目标的问题》）。你可以将客户的一个普遍目标（例如“不那么抑郁”）代入以下问题中。

问题列表

是否有特定的情境是你希望处理得不同的？你希望在这些情境中表现出怎样的行为？
如果你实现了目标（例如，不那么抑郁），你会有什么不同的行为？或者你会对情境作出怎样的不同反应？
如果你实现了目标（例如，不那么抑郁），你觉得你的生活会有哪些不同？

案例分析

我的一位客户芭芭拉因为自尊心低下和“希望更喜欢自己”而来接受治疗。当我问她：“如果你更喜欢自己，你会有什么不同的行为？”她停顿了一下，回答说：“我从来没有想过这个问题。”她列出了许多具体的问题，包括申请升职、在朋友利用她的情况下不再轻易答应她们的要求、以及勇敢地面对母亲。我们探讨了每一个目标。最后，她转向我说：“你真的听到了我的心声。我觉得我们有了具体的目标可以努力。”

进一步的知识点阐述

普遍目标 vs. 具体目标：
- 普遍目标：客户常常从非常普遍的目标开始，例如“希望更喜欢自己”或“不那么抑郁”。这些目标缺乏具体性和可操作性，难以衡量进展。
- 具体目标：具体的目标明确具体，可以量化，容易衡量进展。例如，“申请升职”或“在朋友利用我时不再轻易答应他们的要求”。
帮助客户制定具体目标：
- 提问引导：通过提问帮助客户思考具体的情境和行为。例如，问客户“如果有特定的情境是你希望处理得不同的，你希望在这些情境中表现出怎样的行为？”
- 行为变化：询问客户实现目标后会有哪些具体的行为变化。例如，“如果你不那么抑郁，你会有什么不同的行为？”
- 生活变化：探讨客户实现目标后，生活会有哪些具体的改变。例如，“如果你不那么抑郁，你觉得你的生活会有哪些不同？”
案例分析：
- 芭芭拉的案例：芭芭拉因为自尊心低下和希望更喜欢自己而来接受治疗。通过提问，她列出了许多具体的问题，包括申请升职、不再轻易答应朋友的要求、以及勇敢地面对母亲。这些具体目标为治疗提供了明确的方向，使客户感到有具体的任务可以努力。
灵活性：
- 保持灵活：在制定具体目标时，不要过于僵化。如果客户希望保留一个对其有意义的普遍目标，可以保留，但同时添加一些具体目标以指导治疗。

通过这些练习和反思，治疗师可以更好地帮助客户将普遍目标转化为具体且可测量的目标，从而提高治疗的效果。具体且可测量的目标不仅帮助客户明确方向，还能提供一种衡量进展的标准，使治疗更加有效和有针对性。

劳尔的目标变得更加具体

劳尔的初始目标之一是减少焦虑。这是一个很好的普遍目标。让我们看看劳尔的治疗师如何使用《制定有益目标的问题》来帮助他。

治疗对话

治疗师：减少焦虑是一个很好的普遍目标，也是个不错的起点。我认为如果你能更具体或具体一些会更有帮助。

劳尔：你是什么意思？

治疗师：我认为思考一些具体的方法，让我们知道你正在朝着目标前进会很有帮助。例如，有没有特定的情境是你希望减少焦虑的？（问题1）

劳尔：我想在工作中，我真的很紧张。

劳尔的目标开始变得更加聚焦，但我们仍然没有具体、可测量的目标。如何使用问题2来使劳尔的目标更加具体？

治疗师：如果你对工作不那么焦虑，你在这些情境中会有哪些不同的行为？（问题2）

劳尔：主要是我不再拖延大项目。

劳尔开始变得更具体。花点时间思考一下如何将他刚才说的话转化为一个目标。

治疗师：一个目标可能是不再拖延大项目？

因为劳尔没有明确表示这是他的目标，所以治疗师在将劳尔的话转化为目标时使用了“可能”这个词。使用“可能”允许劳尔不同意治疗师的观点。

劳尔：当然。

劳尔使目标变得更加具体，但仍然难以测量。如何使用问题2来使劳尔的目标更加可测量？

治疗师：如果你不再拖延，你希望在这些情境中有什么不同的行为？（问题2）

劳尔：我会停止避开项目中的同事，开始工作，并与老板讨论项目。

治疗师：听起来你的目标可能包括停止避开同事，与老板讨论项目，并开始工作。

劳尔：是的，这些都是好的目标。我不确定是否想与老板交谈，但开始项目会是个好的开始。

治疗师：看起来第一个目标可能是联系同事并开始项目，长期目标可能是与老板交谈。这样对吗？

治疗师意识到与老板交谈可能不是劳尔目前的目标。治疗师考虑将目标分解为短期和长期目标是否更符合劳尔的意愿。

劳尔（看起来更有活力）：是的，我觉得这会很有帮助。

治疗师：这些是很好的目标。我们把刚才讨论的目标写下来，然后再看看是否有其他目标。当你想到我们刚才讨论的内容时，你会如何写出这些目标？

请注意，治疗师对劳尔制定良好目标给予了积极的肯定。

劳尔的具体目标

治疗师和劳尔继续探讨他的一般目标“在工作中减少焦虑”。他们制定了以下具体目标清单：

劳尔的目标：

更好地应对工作，特别是集中精力完成工作并按时完成项目。
与同事像以前一样社交，包括与人交谈、在休息室吃午饭、外出就餐和在走廊聊天。
每次老板与我谈话时不再感到焦虑。
开始重新喜欢工作。

你会发现，劳尔的一些目标非常具体且可测量，例如“按时完成项目”。有些目标仍然相当普遍，例如“开始重新喜欢工作”。治疗师认为他们已经开了个好头，不想在建立关系初期过度推动具体目标的制定。具体目标可以立即用于指导治疗，而更普遍的目标可以在治疗后期继续努力。

进一步的知识点阐述

普遍目标 vs. 具体目标：
- 普遍目标：客户常常从非常普遍的目标开始，例如“减少焦虑”。这些目标缺乏具体性和可操作性，难以衡量进展。
- 具体目标：具体的目标明确具体，可以量化，容易衡量进展。例如，“按时完成项目”。
帮助客户制定具体目标：
- 提问引导：通过提问帮助客户思考具体的情境和行为。例如，问客户“有没有特定的情境是你希望减少焦虑的？”
- 行为变化：询问客户实现目标后会有哪些具体的行为变化。例如，“如果你对工作不那么焦虑，你在这些情境中会有哪些不同的行为？”
- 具体化目标：将客户的回答转化为具体的目标。例如，“一个目标可能是不再拖延大项目”。
案例分析：
- 劳尔的案例：劳尔的初始目标是减少焦虑。通过治疗师的引导，劳尔列出了一些具体的目标，包括不再拖延项目、与同事社交、不再因老板的谈话而焦虑等。这些具体目标为治疗提供了明确的方向，使客户感到有具体的任务可以努力。
灵活性：
- 保持灵活：在制定具体目标时，不要过于僵化。如果客户希望保留一个对其有意义的普遍目标，可以保留，但同时添加一些具体目标以指导治疗。例如，劳尔的治疗师将目标分解为短期和长期目标，以适应客户的需求。

轮到你了！

帮助苏珊使她的目标更加具体

假设你刚刚向苏珊介绍了目标设定。尝试帮助苏珊设定可以测量的具体目标。

苏珊：好吧，首先，我的主要目标是减少抑郁。

请看以下三种可能的回应，并选择最有助于苏珊制定具体目标的那一个：

我很高兴你愿意解决抑郁症。你能做些什么来减少抑郁？
我明白你现在感觉多么沮丧。你的生活中有很多事情。我很佩服你来寻求帮助。这是很重要的第一步。
这听起来像是一个很好的目标。它相当广泛。如果你不那么抑郁，你觉得你的生活会有哪些不同？

回应#3是最有可能帮助苏珊制定具体目标并开始思考她希望生活中有哪些不同。回应#1开始解决问题，但这在治疗早期阶段为时尚早。回应#2是一个支持性的评论，但它不会帮助苏珊变得更具体。

治疗师：这听起来像是一个很好的目标。它相当广泛。如果你不那么抑郁，你觉得你的生活会有哪些不同？

苏珊：好吧，我肯定会更多地外出，而不是总是待在家里。

请判断“更多地外出，而不是总是待在家里”是否足够具体。请看以下三种可能的回应，并选择你认为最能帮助苏珊变得更具体的那一个：

我听到你想更多地外出。你以前是不是经常外出？现在有什么阻碍你更多地外出的因素？
如果你更多地外出，你希望做一些什么事情？
我听到你想更多地外出。你能告诉我更多关于这一点的信息吗？

回应#2最有可能让客户专注于识别她希望进行的具体活动。回应#1开始了一个问题解决过程，但还不清楚“更多地外出”具体指的是什么。回应#3太模糊了。你可能会得到有用的信息，但苏珊也可能泛泛地谈论她的抑郁情况。

治疗师：如果你更多地外出，你希望做一些什么事情？

苏珊：当然，带孩子们参加一些活动，可能见见朋友，或许和丈夫一起外出。

苏珊和她的治疗师继续探讨她的目标，以及哪些可能是她走向减少抑郁的良好指标。以下是苏珊和她的治疗师共同制定的目标：

苏珊的目标

适应新学校。尝试与其他老师交朋友并加入一些课外活动。
不那么不知所措，感觉更能掌控局面；改善早晨和下午的例行事务。
不那么频繁地对孩子大喊大叫，更多地与孩子玩耍。
与丈夫共度美好时光，不再总是生气。
与朋友重新联系。
享受与丈夫和孩子的时光，开始做一些有趣的事情。
有更多的精力，不再总是感到疲惫。（作为这个目标的一部分，苏珊同意审视生活方式问题。根据客户的不同，这可能包括吸烟、饮酒、锻炼、饮食和睡眠卫生。）

当你查看苏珊的目标时，你会发现有些目标仍然非常模糊，例如“有更多的精力”；然而，有些目标是具体且明确的。你还会注意到，有些目标是以否定的形式表述的，涉及苏珊希望停止做的事情，例如“不再总是生气”，有些目标是积极的，即她希望做的事情。如果客户有一个否定的目标，重要的是要平衡一个积极的目标。

进一步的知识点阐述

普遍目标 vs. 具体目标：
- 普遍目标：客户常常从非常普遍的目标开始，例如“减少抑郁”。这些目标缺乏具体性和可操作性，难以衡量进展。
- 具体目标：具体的目标明确具体，可以量化，容易衡量进展。例如，“带孩子们参加一些活动”。
帮助客户制定具体目标：
- 提问引导：通过提问帮助客户思考具体的情境和行为。例如，问客户“如果你不那么抑郁，你觉得你的生活会有哪些不同？”
- 行为变化：询问客户实现目标后会有哪些具体的行为变化。例如，“如果你更多地外出，你希望做一些什么事情？”
- 具体化目标：将客户的回答转化为具体的目标。例如，“带孩子们参加一些活动”。
案例分析：
- 苏珊的案例：苏珊的主要目标是减少抑郁。通过治疗师的引导，苏珊列出了一些具体的目标，包括适应新学校、减少对孩子的大喊大叫、与丈夫共度美好时光等。这些具体目标为治疗提供了明确的方向，使客户感到有具体的任务可以努力。
目标的多样性：
- 具体与模糊：有些目标非常具体且可测量，例如“带孩子们参加一些活动”，有些目标仍然相当模糊，例如“有更多的精力”。
- 积极与消极：有些目标是以否定的形式表述的，涉及客户希望停止做的事情，例如“不再总是生气”，有些目标是积极的，即客户希望做的事情。如果客户有一个否定的目标，重要的是要平衡一个积极的目标。

练习 3.1：米里亚姆希望拥有更好的婚姻

练习使用《制定有益目标的问题》

议程项目 #3：首先关注哪个目标？

目标设定的第三个阶段是选择从哪里开始。治疗师可以直接说：“让我们看看你的目标，选择一个开始。” 客户的目标通常是相互关联的，在这种情况下，可以在一次治疗中同时处理多个目标。例如，劳尔的许多目标都与工作有关。你应该从可行的目标开始，这些目标有较高的成功机会。当治疗帮助客户在生活中做出改变时，客户会对治疗更加投入，并且更有希望生活会有所改善。

当苏珊和她的治疗师回顾她的目标时，苏珊的首要目标是适应新学校，并尝试与其他老师交朋友。她的第二个目标是与孩子和丈夫一起做一些有趣的事情。苏珊的治疗师认为这些是很好的起点，并且在治疗初期可以同时处理这两个目标。

视频 3.1：设定具体目标

作业：练习认知行为疗法

在进入下一章之前，请花一些时间尝试以下作业。

将所学应用于临床案例

完成以下练习。

练习 3.1：米里亚姆希望拥有更好的婚姻

将所学应用于你自己的生活

在本周与客户练习技能之前，让我们先从关注你自己的目标开始。

作业 #1：为自己设定目标

步骤 1：花点时间思考你开始阅读这本书时希望学到什么。你希望如何改变你的治疗实践？现在想想你希望你的生活有何不同。确定一个与学习认知行为疗法相关的目标，以及一个与个人生活相关的目标。

步骤 2：使用《制定有益目标的问题》使你的目标更加具体和可测量。对于每个目标，尝试找出一个可测量的指标，这将帮助你实现目标。

步骤 3：完成以下表格。

你的目标	你的普遍目标	具体且可测量的目标	设置具体目标的感受	与客户治疗相关的学习
学习 CBT
个人生活

将所学应用于你的治疗实践

选择一个新客户和一个你认为愿意为治疗设定目标的现有客户。如果你本周没有新客户，可以选择两位现有客户。

进一步的知识点阐述

普遍目标 vs. 具体目标：
- 普遍目标：客户常常从非常普遍的目标开始，例如“希望拥有更好的婚姻”。这些目标缺乏具体性和可操作性，难以衡量进展。
- 具体目标：具体的目标明确具体，可以量化，容易衡量进展。例如，“每周与配偶进行一次愉快的活动”。
帮助客户选择起点：
- 选择起点：治疗师应帮助客户选择一个可行且有较高成功机会的目标。当客户在治疗中取得进展时，他们会更加投入和有信心。
- 目标的关联性：客户的目标通常是相互关联的，可以在一次治疗中同时处理多个目标。例如，劳尔的许多目标都与工作有关。
案例分析：
- 苏珊的案例：苏珊的首要目标是适应新学校，并尝试与其他老师交朋友。她的第二个目标是与孩子和丈夫一起做一些有趣的事情。治疗师认为这些是很好的起点，并且在治疗初期可以同时处理这两个目标。
练习设定具体目标：
- 步骤 1：思考你希望从书中学习什么，以及你希望如何改变你的治疗实践和个人生活。
- 步骤 2：使用《制定有益目标的问题》使目标更加具体和可测量。
- 步骤 3：完成表格，记录设置具体目标的感受和与客户治疗相关的学习。

作业 #2：与客户一起设定具体目标

按照以下步骤与你选择的每位客户一起完成。

步骤 1：让客户确定治疗目标

询问客户他在治疗中的目标是什么。

步骤 2：让客户选择对他最重要的目标

使用《制定有益目标的问题》帮助客户将目标具体化和可测量化。尝试找出一个可测量的指标，这将帮助客户实现他的目标。

步骤 3：为新客户和现有客户完成以下表格

客户的普遍目标	客户 #1	客户 #2
具体且可测量的目标
客户对设定具体目标的反应
你学到了什么？

让我们回顾

回答议程项目下的问题。

议程项目 #1：设定目标

如何向新客户和现有客户介绍设定目标？

议程项目 #2：制定具体、可测量的目标

具体、可测量目标的一个例子是什么？

议程项目 #3：首先关注哪个目标？

你如何决定从哪个目标开始？

对你来说重要的内容

你希望记住的观念或概念是什么？
你希望应用于自己生活的观念或技能是什么？
你希望在接下来的一周内尝试与哪位客户进行什么操作？（选择一个具体的客户。）

进一步的知识点阐述

普遍目标 vs. 具体目标：
- 普遍目标：客户常常从非常普遍的目标开始，例如“希望拥有更好的婚姻”或“减少焦虑”。这些目标缺乏具体性和可操作性，难以衡量进展。
- 具体目标：具体的目标明确具体，可以量化，容易衡量进展。例如，“每周与配偶进行一次愉快的活动”或“每天花10分钟进行深呼吸练习”。
帮助客户选择起点：
- 选择起点：治疗师应帮助客户选择一个可行且有较高成功机会的目标。当客户在治疗中取得进展时，他们会更加投入和有信心。
- 目标的关联性：客户的目标通常是相互关联的，可以在一次治疗中同时处理多个目标。例如，劳尔的许多目标都与工作有关。
案例分析：
- 苏珊的案例：苏珊的首要目标是适应新学校，并尝试与其他老师交朋友。她的第二个目标是与孩子和丈夫一起做一些有趣的事情。治疗师认为这些是很好的起点，并且在治疗初期可以同时处理这两个目标。
练习设定具体目标：
- 步骤 1：询问客户他在治疗中的目标是什么。
- 步骤 2：使用《制定有益目标的问题》帮助客户将目标具体化和可测量化。尝试找出一个可测量的指标，这将帮助客户实现他的目标。
- 步骤 3：为新客户和现有客户完成表格，记录客户对设定具体目标的反应以及你学到了什么。

CHAPTER 3 Develop Goals for Therapy In chapter 2 we focused on assessing your client’s problems and strengths and on how to explain CBT. Did you try using Questions to Explore Your Client’s Problems? Did you see your client’s strengths dif- ferently after using any of these questions? I am curious whether you have started noticing your own thoughts. Has this made a difference in your life? When clients complete their homework, therapy is more effective and clients are more likely to make real changes in their lives (Rees, McEvoy, & Nathan, 2005). Similarly, the extent to which you incorporate CBT into your own work will depend on how much you use the material in the book and practice. The homework at the end of each chapter is simply a structure for encouraging you to practice. If you did not have a chance to do the homework from chapter 2, try to identify what factors got in the way. Maybe you did not see any clients, or you were particularly busy. Sometimes therapists’ thoughts get in the way of trying the homework with their clients. Did you have any of the following thoughts? •I don’t need to do the homework, or I already understand the material. •The homework is not relevant to my clients, or if I try the CBT homework, my clients will react negatively. •I will feel awkward doing the homework. Did any of these thoughts stop you from doing the homework and practicing your CBT skills? Did you have other thoughts that got in the way of practicing? The reality is that you won’t know whether doing the homework is helpful unless you try. What if you were surprised and the homework really helped? If you are worried about feeling awkward the first time you try an intervention, you are right; you probably will feel uncomfortable because you are doing something new. I would guess that the first time you tried any new skill you felt awkward. What would your life be like if you gave up whenever you felt awkward? What would help you complete the homework for this chapter? Remember, the more you practice, the easier it will be. If you did not do the homework from chapter 2, before starting this chapter, try these two exercises:

Think of a client with whom you are currently working. Try to think of both the stressors and the strengths in his or her life. Look at Questions to Explore Strengths from chapter 2 for ideas of good questions to ask yourself to assess his or her strengths.
If you have not started noticing your own thoughts, choose a recent situation in which you had a moderate to strong emotional reaction. Take a moment to remember your thoughts at the time. Try to write them down. How did noticing your thoughts affect your reaction? Set the Agenda CBT is an active form of therapy where the therapist and client set goals in the beginning of therapy and work toward these goals. Agenda Item #1: Set goals. Agenda Item #2: Develop specific, measurable goals. Agenda Item #3: Which goal do I focus on first? Work the Agenda Goals are different from problems. Problems describe what is wrong in your client’s life. Goals are how your client would like his life to be different, or what he would like to work toward. Setting effective goals is a key element in CBT. Agenda Item #1: Set Goals It is important that the therapist and client agree on the goals they are going to work on, or the sessions will tend to wander and feel as though nothing is getting accomplished. In addition, the therapy relationship is strengthened when your client feels that you understand his goals and that therapy is going to focus on those goals that are important to him. Having goals in therapy is similar to starting out on a road trip. If someone asks me which road I want to take, I have to first know where I want to end up. The road I would choose to get to Toronto is different from the road to Detroit. The more specific and clear the goal, the more I can plan how to get there. Goals give direction to therapy. Clear Goals  Focused Therapy  Effective Therapy and Satisfied Clients

WHAT IF MY CLIENT HAS MORE THAN ONE PROBLEM? If a client identified two problems, you would most likely set goals for both problems and then focus on the one he identified as his first priority. However, clients often have multiple problems. In this case, you and your client need to pick one or two problems that he wants to work on first and develop goals for those problems. Later in therapy, when the client is ready to start working on a new problem, you would develop goals for the new problem. Often as therapy progresses, goals change. I encourage my clients to write down their goals. It makes their goals more concrete, and it gives us a written document to refer back to. Most importantly, research indicates that setting goals early in therapy significantly increases client satisfaction and the likelihood of a positive outcome (Safran & Wallner, 1991). EXPLAIN GOAL SETTING Below are some suggestions for how to introduce goal setting with new clients as well as current clients with whom you have been working for some time but had never set goals. You can download a handout with these prompts (Explain Goal Setting) at http://www.newharbinger.com/38501. When explaining setting goals to a new client, you might start with the following: What I would like to do next is spend some time exploring your goals for therapy. I find that having clear goals gives therapy a sense of direction. I would like to start with identifying goals for the first problem you said you would like to work on. The explanation would start off differently for a current client with whom you had not set goals at the beginning of therapy: I have been thinking about our sessions. At this point, I think it would be helpful for us to spend some time thinking about your goals, and what you would like our future sessions to focus on. Setting goals can be helpful in giving therapy a sense of direction. But from that point on, the explanation would be the same with both clients: I also want to spend some time making your goals as specific as we can, as I find the more specific the goal, the more helpful it is. Specific goals can also help us measure whether therapy is working for you. As we talk about each goal, I would like to write it down. Would that be okay with you? YOUR TURN! Practice in Your Imagination: Explain Setting Goals I am going to ask you to imagine explaining goal setting first with a new client and then with a current client. Before you start this exercise, rate from 1 to 10 how comfortable you feel introducing setting goals with your clients, with 1 being very comfortable and 10 being very uncomfortable. At the end of the exercise, rate your level of comfort again to see whether it changed. Now, let’s try the exercise. Practice with a new client. Imagine yourself in your office with a new client. Take a moment to look around; notice the sounds and smells of your office. Now, imagine that you have just gone over your client’s problems and you want to introduce goal setting. Read over how I sug- gested explaining goal setting while imagining yourself saying the words. You can also use your own phrases. Really hear and feel yourself explaining goal setting. Now imagine explaining goal setting two more times with the same client. Each time imagine that your client responds positively. Practice with a current client. Choose a current client who you think would benefit from setting goals, and who you also think would like the approach. Try to get a picture of him or her in your mind. Now imagine yourself in your office. Read over how I suggest explaining goals with a current client while imagining yourself saying the words. You can also use your own phrases. Now imagine explaining goal setting two more times more with the same client. Each time imagine that your client responds positively. Agenda Item #2: Develop Specific, Measurable Goals Once you have introduced goal setting, you need to help your client develop more specific goals. The more specific and clear the goal, the more helpful it is. However, what do we mean by specific, measurable goals? WHAT ARE SPECIFIC AND MEASURABLE GOALS? Clients often start with very general goals, such as “I would like to be less depressed [or less anxious],” “I would like to have better self-esteem,” or “I would like to have a better relationship with my partner.” The problem with these general goals is that you don’t have a specific idea of how your client wants his life to be different, nor does your client have any way of knowing whether he is on his way to achieving his goals. Goals that are specific and measurable give therapy a direction and provide a yardstick for measuring whether therapy is on the right track. The easiest way to understand the dif- ference between general and specific goals is to look at some examples.

Examples of Goals General GoalsSpecific, Measurable Goals Be more assertive.• Talk to my partner about some of my concerns about our relationship. • Set more limits with my boss (e.g., tell my boss that I can’t take on new clients; ask my boss not to regularly call me on weekends or evenings). • Express my opinion when I am out with friends. Be less anxious. • Give a presentation at work. • Don’t check on my kids as much (e.g., don’t phone them on their cells if they are 10 minutes late, but wait until they are half an hour late; only ask once a night whether their homework is done). • Don’t blow up over little things, like my husband forgetting to pack the children’s lunch. YOUR TURN! Identify Specify, Measureable Goals At first the difference between a general goal and a specific, measurable goal can be hard to identify. Look at the goals below and decide how you would rate them. You can find my answers in the appendix.

Assess Whether the Goal Is Gener al or Specific and Measur able Goals Is This Goal General or Specific and Measurable? Talk to my boss about getting paid for working overtime Be less demanding of my friends Stop smoking by the end of the month Take better care of my health Get along better with my parents Do a pleasant activity with my partner on a weekly basis Learn better parent management skills for when my eight-year- old has a temper tantrum Let’s look at two of the above goals in detail. The goal “talk to my boss about getting paid for working overtime” is a specific goal. We know exactly what behavior the client wants to do and we can measure whether he was able to do the behavior. The goal “be less demanding of my friends” is a general goal. Since we don’t know what specific thoughts, feelings, physical reactions, or behaviors the client would like to increase or decrease, we will have no way of knowing whether the client was suc- cessful in working toward this goal.

HELP YOUR CLIENT DEVELOP SPECIFIC AND MEASURABLE GOALS It can be challenging to move your client from general goals to more specific goals. Below are some questions that can help. You can download them in handout form (Questions to Develop Helpful Goals) at http://www.newharbinger.com/38501. You can substitute one of your client’s general goals for “less depressed.” Question 1: Are there specific situations that you would like to be handling differently? How would you like to behave in these situations? Question 2: If you met your goal (e.g., to be less depressed), what would you be doing differently? Or how would you be reacting to situations differently? Question 3: If you met your goal (e.g., to be less depressed), how do you think your life would be different? A client of mine, Barbara, came to therapy because of low self-esteem and “wanting to like myself more.” When I asked, “If you liked yourself more, what would you do differently?” she paused and responded, “I have never thought about that.” She was able to list a number of specific issues, including applying for a promotion, not saying yes to her girlfriends in situations where she thought they were taking advantage of her, and standing up to her mother. We explored each goal. At the end she turned to me and commented, “You really heard me. I feel that we have something specific to work toward.” When developing specific goals, you don’t want to be rigid. If your client wants to keep a general goal that is meaningful to him, I would keep it, but try to add some more specific goals to guide therapy. RAOUL’S GOALS BECOME MORE SPECIFIC One of Raoul’s initial goals was to be less anxious. This is a good general goal. Let’s see how Raoul’s therapist uses Questions to Develop Helpful Goals. Therapist:Being less anxious is a good general goal, and a good place to start. I think it would be helpful if you could be a bit more specific or concrete. Raoul:What do you mean? Take a moment and think about how you could you use Question 1 to make Raoul’s goals more specific. Therapist:I think it would be helpful to think of some specific ways that we could know you were on your way to achieving your goal. For example, are there any particular situations where you would like to be less anxious? (Question 1) Raoul:I guess at work, I am just really stressed. Raoul’s goals are starting to be more focused, but we still do not have specific, measurable goals. How could you use Question 2 to make Raoul’s goals more specific? Therapist:If you were less anxious about work, I am wondering what you would be doing differently? (Question 2) Raoul:Mainly I wouldn’t procrastinate over my big projects. Raoul is starting to be more specific. Take a moment to think about how you could use what he just said and turn it into a goal. Therapist: Might one goal be to stop procrastinating on your big projects? Because Raoul did not explicitly state this as a goal, his therapist used the term “might” when she turned Raoul’s words into a goal. Using “might” permits Raoul to disagree with his therapist. Raoul: Definitely. Raoul has made the goal more specific, but it would still be hard to measure. How could you use Question 2 to make Raoul’s goals more measurable? Therapist:If you stopped procrastinating, what would you like to do differently? (Question 2) Raoul:I would stop avoiding my colleagues on the project, get down to work, and talk to my boss about the project. Therapist:It sounds like some of your goals might be to stop avoiding your colleagues, talk to your boss about the project, and get down to work. Raoul:Yeah, those would be good goals. I am not sure that I want to talk to my boss, but it would be good to start the project. Therapist:It seems that a first goal might be to contact your colleagues and start work on the project, and then a longer-term goal might be to talk to your boss. Does that sound right? The therapist realized that talking to the boss might not be Raoul’s goal at the moment. The therapist wondered whether breaking the goals down into immediate and longer-term goals was more in line with what Raoul wanted. Raoul:(looking a bit more energetic) Yes, I think that would be very helpful. Therapist:Those are good goals. Let’s write down the goals we have talked about so far and then see whether there are any other ones. When you think about what we just talked about—how would you write out the goals? Notice that the therapist gives Raoul positive reinforcement for developing good goals. The therapist and Raoul continue to explore his general goal “be less anxious at work.” They develop the following list of specific goals: Raoul’s Goals: •Cope better at work, particularly concentrate on my work and get my projects done on time. •Socialize with people at work the way I used to. This includes talking to people, having lunch in the lunchroom, going out for lunch, and chatting in the hallways. •Not get anxious every time the boss talks to me. •Start to like work again. You will notice that some of Raoul’s goals are very specific and measurable, for example, “get my projects done on time.” Some of the goals are still fairly general, for example, “start to like work again.” The therapist thought they had made a good start and did not want to push developing specific goals too much, as they were just forming a relationship. The specific goals could be used immediately to give direction to therapy, and the more general goals could be worked on later in therapy. YOUR TURN! Help Suzanne Make Her Goals More Specific Imagine that you have just introduced goal setting to Suzanne. Try to help Suzanne set specific goals that can be measured. Suzanne: Well, to start, my main goal is to be less depressed. Look at the three possible responses below and pick the one that will help Suzanne develop a more specific goal:

I am so glad you are willing to work on your depression. What could you do to be less depressed?
I hear how down you are feeling. You have a lot going on in your life. I am impressed that you came for help. It is an important first step.
That sounds like an excellent goal. It is pretty broad. If you were less depressed, how do you think your life would be different? Response #3 is the most likely to help Suzanne develop a specific goal and to start thinking about what she would like to be different in her life. Response #1 starts to problem solve. This is too early in therapy. Response #2 is a supportive comment, but it does not help Suzanne become more specific. Therapist: That sounds like an excellent goal. It is pretty broad. If you were less depressed, how do you think your life would be different? Suzanne: Well, I would go out more for sure and not just want to stay home all the time. Ask yourself whether “go out more and not want to stay home all the time” is specific enough. Look at the three possible responses below and pick the one you think will help Suzanne be more specific.
I hear you would like to go out more. Did you used to go out more? What are some of the things that are in the way of you going out more now?
If you were to go out more, what are some of the things that you would like to do?
I hear you would like to go out more. Can you tell me more about that? Response #2 is most likely to focus the client on identifying specific activities she would be doing. Response #1 starts a problem-solving process without being clear what “going out more” refers to. Response #3 is too vague. You might get helpful information, but Suzanne may also talk about being depressed in a general manner. Therapist: If you were to go out more, what are some of the things that you would like to do? Suzanne: Well, for sure taking my kids to some of their activities, probably seeing friends, maybe going out with my husband. Suzanne and her therapist continue to explore her goals and what might be some good indicators that she is on the path to feeling less depressed. Here are the goals that Suzanne and her therapist developed: Suzanne’s Goals: • Fit into the new school. Try to make friends with the other teachers and join some of the extracurricular activities. • Not be so overwhelmed, but feel I am managing more; better morning and afternoon routine. • Not yell at the kids so much and play with the kids more. • Have good times with my husband and not be so angry all of the time. • Reconnect with my friends. • Enjoy my husband and children, start to do some fun things with them. • Have more energy, not be tired all of the time. (As part of this goal Suzanne agreed to look at lifestyle issues. Depending on the client, this might include smoking, alcohol consump- tion, exercise, diet, and sleep hygiene.) When you look at Suzanne’s goals, you will see that some are still very vague, such as “have more energy”; however, some are concrete and specific. You’ll also notice that some of the goals are stated in the negative and involve what Suzanne wants to stop doing, for example, not be angry all of the time, and some are positive goals, or what she wants to do. If your client has a negative goal, it is important to balance it with a positive goal. Exercise 3.1: Miriam Wants a Better Marriage Practice using Questions to Develop Helpful Goals. Agenda Item #3: Which Goal Do I Focus on First? The third stage in goal setting involves choosing where to begin. The therapist can simply say, “Let’s look over your goals and pick one to start with.” Frequently a client’s goals are interrelated, in which case it will be possible to work on more than one goal during a therapy session. For example, many of Raoul’s goals are related to work. You want to start with goals that are doable and where there is a good chance of success. When therapy helps clients make changes in their lives, clients become more committed to therapy and more hopeful that their lives can improve. When Suzanne and her therapist looked at her goals, Suzanne’s first priority was to fit into her new school and try to make some friends among the other teachers. Her second goal was to do some fun things with her children and husband. Suzanne’s therapist thought these were good places to start and that it might be possible to address both goals early on in therapy. Video 3.1: Set Specific Goals Homework: Practice CBT Before moving on to the next chapter, take some time to try the homework. Apply What You Learned to Clinical Examples  Complete the following exercise. Exercise 3.1: Miriam Wants a Better Marriage Apply What You Learned to Your Own Life Before practicing this week’s skills with your clients, let’s start with focusing on your own goals. Homework Assignment #1 Set Goals for Yourself Step 1: Take a moment to think about what you hoped to learn when you started reading this book. How did you hope to change your therapy practice? Now think about how you would like your life to be different. Identify one goal for yourself in relation to learning CBT and one goal in relation to your personal life. Step 2: Try to make your goals more specific and measurable by using Questions to Develop Helpful Goals. For each goal, see whether you can identify a measurable indicator that would put you on the road to accomplishing your goal. Step 3: Complete the following table. Your Goals Your General Goal(s) Specific and Measurable Goal What Was It Like to Set Specific Goals? What Did You Learn That Is Relevant to Your Therapy with Clients? Apply What You Learned to Your Therapy Practice Choose both a new client and a current client who you think would be open to setting goals for therapy. If you don’t have a new client this coming week, choose two current clients. Homework Assignment #2 Set Specific Goals with Your Clients Complete these steps with each client you selected. Step 1: Ask your client to identify his or her goals for therapy. Step 2: Ask your client to pick the goal that is most important to him or her. Help your client make the goal more specific and measurable by using Questions to Develop Helpful Goals. See whether you can identify a measurable indicator that would put your client on the road to accomplishing his or her goal. Step 3: Complete the following table for a new client and a current client. Help Your Client Set Specific Goals Client’s General Goal Client #1 Client #2 Specific and Measurable Goal How Did the Client What Did You React to Setting Learn? Specific Goals?

Let’s Review Answer the questions under the agenda items. Agenda Item #1: Set goals. • How could you introduce setting goals in therapy with a new client and with a current client? Agenda Item #2: Develop specific, measurable goals. • What is an example of a specific, measurable goal? Agenda Item #3: Which goal do I focus on first? • How might you decide which goal to start with? What Was Important to You? What idea(s) or concepts would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try with a client this coming week? (Choose a specific client.)