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Tuesday, 3 July 2012

Process: The Negatives of Positive Client Goals

In the last few posts I’ve been focusing on agenda-setting at the outset of therapy.

Eventually our clients may come up with one or more positive goals (things to move toward, rather than away from).

  • Become physically fit.
  • Let go of the grief for my father, who died 12 years ago.
  • Forgive myself for the car accident that injured my niece, and move on.
  • Become able to ask someone out on a date.

Parrot the client’s goal(s) back to them, and they may say “Sounds good” and mean it. But if you both just dive in, you may soon find the tide turning beneath you, pulling you away from the intended destination. What’s going on?

Often there are unexamined downsides to what sound like perfectly good goals. Though the client may not hold them in consciousness, they will act as brakes on the process anyway, causing slow progress or apparently inexplicable therapeutic sabotage.

David Burns recommends conducting a “paradoxical cost-benefit analysis” at the start of therapy. He has quite a specific set of ideas in mind here, and if you get the chance to hear him speak about them at a workshop or conference, you should take him up on it. I will paraphrase here.

A cost benefit analysis, as we all know, involves tabulating the advantages and disadvantages of taking a given course of action, such as quitting a job we hate. We list all the considerations, rate how important they are, and add up the positives and negatives.

A paradoxical cost benefit analysis is, in effect, a one-sided brainstorming exercise in which we come up only with the disadvantages of the course we have already nominated.

“So John it sounds like you’ve decided you want to let go of this grief over your father, but hang on a minute. You haven’t done this so far. You beat yourself up for not moving on with your life, but there are probably some good reasons why you keep the grief alive. Maybe we should look at those.”

John may look slightly betrayed. We pushed him to name a goal in the first place, now we’re pulling back. And he may or may not be able to think of any good reason to keep grieving. If he comes up with anything, we should write it down, preferably where he can see it. If he doesn’t, we can start making nominations. This is where our understanding of the client (our formulation) comes in.

“Well John you had a really great relationship with your father, and his final illness was an awful experience. You know we can’t bring your dad back. If you resolve your grief you’ll be happy and cheerful and your father will still be dead. What does that look like? It might feel to you like you’re betraying him, like he never really mattered to you. 

“Plus, you mentioned that your sister has never gotten over it either. The two of you are both there, stuck in that place. If you get over it, you’ll be abandoning her too, won’t you? She might resent you, or feel that she’s the only one who ever really cared. In a way, you have to keep grieving to convince her that your father mattered to you.

“You’ve also said that if you could get over this, you’d go to graduate school like you planned years ago. Graduate school is quite a commitment. Maybe you’ll fail, maybe it’ll turn out you don’t like it, maybe it’s not for you. You know, some dreams are best left as dreams. If you let go of your grief, it puts you on the highway to some of your greatest fears.”

This sounds somewhat cruel and perverse, but the point is to bring the reluctance to achieve the goal into awareness so that it can be dealt with. Perhaps John could decide to work on his father’s grief and put off any decision to enter graduate school. Maybe he could talk to his sister or suggest that she too seek help. Perhaps he could think of other people who cared for his father but who have moved on, or ask what his father would have wished for him: Perhaps there is another way of honouring his memory apart from being crushed.

Until we examine these forces, movement toward the client’s stated goals is likely to be inexplicably slow. Once these roadblocks are removed (if they can be), progress can often become very swift.

1 comment:

  1. I have not used this approach in years. I'll have t try it again soon. Thanks for making me think of creative ways to offer new insights.