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Tuesday 7 February 2012

Choosing Therapy Goals: Broad Swath or Narrow Slice?

Sometimes a person will come to therapy with multiple issues, or with a single type of problem (obsessive compulsive disorder, say) that manifests in dozens of areas. Almost anyone suffering from depression, for example, will have many symptoms (possibly including sleep disorder, lack of exercise, social isolation, lack of enjoyable activity, work conflict, and more), each of which may be contributing to the problem.
Trying to do too much can be discouraging.

In such situations, clinician and client alike are faced with a choice. Do we try to get started on everything at once, or do we pick and choose?

It’s tempting to adopt a broad focus. All of the issues are problematic and likely affect the person’s mood. It would be great to change them all. And indeed, change can feed back and make other changes possible. Improvements in sleep may improve energy, which may help work performance, which may enhance rewards, and so on.

The problem is that therapy has limited potency. When therapist and client work together, they have a certain amount of “push.” If we spread this across too many targets, progress on any one of them may be glacial or absent.

I sometimes discuss this idea with clients using a metaphor. “You’ve got twenty heavy boxes on one side of a big room, like a gymnasium. You need to get them to the other side. You can spread your arms the width of the pile, put your shoulder to it, and push. But they may not budge. What would you suggest?”

People immediately see that a more effective strategy is to tackle the boxes one or two at a time.  Though (granted) a bit obvious, I’ve found that creating a visual image like this seems helpful. And indeed, clinically it’s helpful to identify a lot of the problems the client is experiencing (we’ll never hear the complete list in the assessment phase), then to pick two or three on which to get started.

Why two or three? Why not one?

It would make logical sense to start with one issue, and indeed, we will discuss issues one at a time. But if we spend the first five sessions of therapy on just that one topic (repeatedly checking that doors are locked, for example), the person will soon experience an overwhelming sense of anxiety that only a tiny portion of the problem is being addressed.

Instead, we can make try to make deep inroads in two or three areas. This tends to chop up the problem, making the remaining issues less solidly entrenched. The progress made with our “sample issues” undermines the idea that nothing can change. “I didn’t think my diet would ever get better either, but it did – so maybe I can start clearing the backlog of unopened mail too.”

Where should we start?

The most important consideration is the client’s choice. Where do they want to start? What feels both manageable and significant to them? If we start with issues that seem trivial or beside the point, motivation will flag and we will have little effect on the other problems. If we start wherever the client has the most motivation, we will maximize our likelihood of success, and that success will seem more significant and inspiring than progress on side issues would be.

Sometimes a client will choose the most difficult problem. People trying to learn better assertiveness skills, for example, often choose “battles with my wife” or “supervision sessions with my hostile boss” as their prime targets. It’s best to start with something that’s a bit simpler, but that relates in some meaningful way to the prime target. Perhaps there is an elder brother who is vaguely like the boss, and early practice could focus on interactions with her. Whatever is chosen can be framed as a step toward dealing with the main issue. “If we start by practicing giving your opinion with a good friend, we can work our way up to doing it with your father.”

Then what?

Hopefully we will make a fair bit of progress on the issue at hand – cleaning out the basement, starting an exercise program, resisting the compulsion to unplug appliances before leaving home. If we have chosen well, a sense of confidence will develop, and the person will feel more capable of dealing with the remaining issues.

Sometimes these other issues will have begun to dissolve on their own, without attention. “Yeah once I began eating properly I started walking to work instead of driving. Didn’t I tell you that?” Progress in one area somehow reverberates through the system to impact on other problems. The person’s sleep improved, so they felt more energetic during the day, so they could concentrate better at school, so the procrastination has already started to diminish.

Is this relevant outside therapy?

Therapy is just a microcosm of life. Any of us, faced with a multitude of tasks, will benefit from abandoning any attempt to complete them all at once. Instead, if we pick a small number of critical tasks and push them to completion, our sense of momentum will increase our confidence, and we will find it easier to get the next things done.

In my own life I have often taken on more projects than I can realistically complete, then felt my interest and enthusiasm flagging. This is my cue to set some of them aside and concentrate on two or three. If I have just one project on the go, I get bored and burn out on it too easily. If I have a few, I can switch from one to another and maintain my interest. If I have ten, I’d rather sit on the couch and do nothing.

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