From the Editors
Beyond SMART goals: A humanistic approach to treatment planning that satisfies managed care requirements
By Andrew Bland , PhD
As the newsletter editors, Justin Karter, Kevin Gallagher and I will rotate authoring an editor's note for each issue under an agreed upon theme. The theme for this issue is “Remaining Humanistic in a Managed Care World” and in this editorial contribution I aim to suggest an alternative, humanistic approach to treatment planning which I have successfully employed in my therapeutic practice during the last decade.
Treatment planning based on specific, measurable, attainable, relevant and time-bound (SMART) goals has become convention in the era and climate of managed care. While this approach has merits and is appropriate in certain contexts, it also has notable limitations for both clients and therapists. I begin this article by addressing these limitations. Thereafter, I provide theoretical/philosophical support for an alternative approach from contemporary literature on person-centered and transdiagnostic approaches to treatment planning, and I supply practical strategies and examples of statements that clinicians may employ when writing treatment plans. I conclude that such an approach values clients' input, accommodates a realistic level of flexibility in the therapeutic process, and maintains footing in the realities of client change while it also satisfies the requirements of managed care.
The Limitations of SMART Goals
SMART goals were introduced in the early 1980s. They were proposed originally by business managers and quickly extrapolated to the medical profession. Applied to counseling/psychotherapy, they include statements such as, “Client will participate in two social activities per week” (for depression) and. “Client will report at least six hours of restful sleep per night” (for anxiety, among other conditions). Appealing as they appear at first glance, SMART goals are problematic for helping professions for several reasons. First, they are based on the assumption that the principal purpose of counseling/psychotherapy is first-order change—i.e., symptom reduction and stabilization. They do not adequately address the complexity of potential presenting concerns for which clients may seek counseling/psychotherapy (Frank & Davidson, 2014), many of which may not be conducive to preordained prescriptive strategies intended to tackle isolated symptoms and reduce tension.
That said, second, SMART goals can preclude the possibility of second-order (transformative) change processes (see Bland, 2013; Fraser & Solovey, 2007; Hanna, Giordano, Dupuy, & Puhakka, 1995; Murray, 2002) which may not be easily predicted at the outset of treatment but that emerge as a result of it ( Mølbak, 2012). They can impose unnecessary limits on the treatment process insofar as issues that are not explicitly identified in advance on the treatment plan are effectively proscribed from discussion. Likewise, they run the risk of disempowering clients by imposing therapists' roles as experts (Frank & Davidson, 2014) at the expense of clients' preferences, wisdom and readiness for change. They also can limit clients' perceptions of the possibilities of the therapeutic process and thereby foster dependence on the therapist. To illustrate, I once worked with a client who identified insomnia as her presenting concern. However, as our work progressed, it became clear to both of us that the necessary focus of treatment was her authoritarian upbringing, her perfectionism, and her guilt and fear related to a positive lifestyle change she was undertaking at the time. (See Bland, 2013 for more details on this case.) Had we stuck only to the sleep issue as her principal goal and focus of interventions, the progress that she made in becoming more comfortable in her skin and in taking healthy risks would have been encumbered.
Third, SMART goals are not compatible with the fuller range of theoretical orientations from which therapists may operate. They are best suited for conventional cognitive-behavioral (CBT) interventions and arguably have contributed to the “powerful forward march of CBT and its promotion as an empirically supported treatment approach” (Angus, Watson, Elliott, Schneider, & Timulak, 2014, p. 3) at the expense of other equally-legitimate modalities. Conversely, SMART goals are less user-friendly for humanistic and related approaches which emphasize phenomenological understanding of clients' concerns and the therapeutic relationship as a catalyst for second-order change via assisting clients with stimulating/deepening their immediate experiencing and ongoing awareness; with living authentically in accordance with their values, aspirations, and limitations; and with assuming an active role in their growth. While CBT has a legitimate place at the counseling/psychotherapy table, humanistic approaches have been empirically demonstrated as being as effective as—and, in some cases, more effective than—CBT for addressing interpersonal/relational issues, depression, chronic medical issues and even psychosis (Angus et al., 2014).
Fourth, once SMART goals have been met, counseling/psychotherapy can become abruptly halted by external sources (i.e., insurance companies) when clients are arguably at their most vulnerable. That is, their symptoms may have subsided but their need and readiness for preventively addressing underlying foundational issues within an established collaborative therapeutic relationship may be at its peak. This is ironic insofar as such a focus on prevention arguably would save insurance companies money in the long run.
Fifth, although therapists certainly are capable of proactively updating their treatment plans from time to time, doing so generates a problem of unnecessary paperwork. This takes away from both therapists' and clients' time together as well as therapists' mental/emotional resources which could be better devoted to self-care, consulting with peers and accessing the literature for treatment ideas, preparing for sessions with other clients, etc.
A Humanistic Alternative
Person-centered planning emerged during the 2000s as a model for promoting clients' preferences and opportunities by sharing control in the treatment planning process for case management (Smull, 2007). During the last decade, I have applied principles of that model to my outpatient therapeutic practice in a variety of settings. To give clients the opportunity to establish for themselves the goals for treatment, I conclude each intake interview with the question, “ If you were to name two or three things that you would like to get out of working together, what would they be?” I then carefully write down the clients' words verbatim. When it comes time to formalize a treatment plan document, I employ the clients' words as a goal statement.
Thereafter, for objectives, I incorporate statements of my own which tend to be general, but not generic. For example, for almost every client I include, “ Client will learn and utilize mindfulness-based techniques to improve his/her ability to center/focus” and, “Client will explore the connections between his/her formative history and his/her current struggle with __.” Taken together, these objectives relate to the therapeutic process providing opportunities for self-reflection, corrective experiences and appropriate catharsis—which clients have identified as most conducive to facilitating sustainable second-order change (Murray, 2002). From there, for clients whose presenting concerns involve relational issues and/or other aspects of Yalom's (1980) isolation/connectedness dialectic, I may also include, “Client will develop clear boundaries in relationships” or, “Client will balance healthy independence with healthy dependence.” For clients whose presenting concerns have impeded life domains, I may also include, “Client will discuss potential barriers to __.” For clients whose presenting concerns involve developmental or other life transitions and/or entail other aspects of Yalom's (1980) dialectics of death/existence, freedom/destiny, and meaning/meaninglessness, I may also include, “Client will explore fears/frustrations about __ in the interest of developing acceptance of his/her condition.” Accordingly, given the likelihood that client change will take on a two-steps-forward, one-step-back dynamic as treatment progresses, it typically can be argued that at any point in the therapeutic process, session content intended to meet the client's immediate needs is consistent with the treatment plan without becoming off-topic.
In their transdiagnostic model of treatment planning, which aims to transcend the problems associated with unilaterally applying interventions based on narrowly-defined goals based on specific diagnostic categories, Frank and Davidson (2014) argued that treatment planning needs to maintain a realistic level of flexibility and to account for the complexity of change. The humanistic treatment planning model described above accommodates clients' unique needs and narratives, their ever-shifting readiness for change, and the often mercurial transformative processes that promote sustainable and transformative change. In addition, it prioritizes the healing power of the collaborative therapeutic relationship which clients typically seek when they find the predictable advice they have received from family, friends and “Dr. Google” insufficient and which, at its best, enables clients to make changes on their own between sessions that surpass therapists' expectations or agendas. Finally, at the same time that it better aligns with the principles of counseling/psychotherapy in the humanistic tradition, it satisfies managed care requirements insofar as it still entails measurable and concrete goals and objectives which, as of this writing, I have yet to encounter an insurance company argue against.
Angus, L., Watson, J. C., Elliott, R., Schneider, K., & Timulak, L. (2014). Humanistic psychotherapy research 1990-2015: From methodological innovation to evidence-supported treatment outcomes and beyond. Psychotherapy Research, 25, 330-347. http://dx.doi.org/10.1080/10503307.2014.989290
Bland, A. M. (2013). A vision of holistic counseling: Applying humanistic-existential principles in the therapeutic relationship. Journal of Holistic Psychology, 2, 277-282.
Frank, R. I., & Davidson, J. (2014). The transdiagnostic road map to case formulation and treatment planning: Practical guidance for clinical decision making. Oakland, CA: New Harbinger.
Fraser, J. S., & Solovey, A. D. (2007). Second-order change in psychotherapy: The golden thread that unifies effective treatments. Washington, DC: American Psychological Association. Hanna, F. J., Giordano, F., Dupuy, P., & Puhakka, K. (1995). Agency and transcendence: The experience of therapeutic change. The Humanistic Psychologist, 23, 139-160. http://dx.doi.org/10.1080/08873267.1995.9986822
Mølbak , R. L. (2012). Cultivating the therapeutic moment: From planning to receptivity in therapeutic practice. Journal of Humanistic Psychology, 53, 461-488. http://dx.doi.org/10.1177/0022167812461305
Murray, R. (2002). The phenomenon of psychotherapeutic change: Second-order change in one's experience of self. Journal of Contemporary Psychotherapy, 32, 167-177. http://dx.doi.org/10.1177/002216781246130510.1023/A:1020592926010
Smull, M. W. (2007). Revisiting choice. In J. O'Brien & C. L. O'Brien (Eds.), A little book about person-centered planning (pp. 37-49). Toronto, ON: Inclusion.
Yalom, I. D. (1980). Existential psychotherapy. New York, NY: Basic.