Goal setting and monitoring with alcohol and other drug use disorders: Principles and practices

Abstract

Introduction.

This work builds on a small body of literature that explores core processes in psychotherapy, behavior change, and evidence-based alcohol or other drug (AOD) therapies. Here, this paper discusses two separate but dependent processes. The research team defines goal setting and goal monitoring as collaborative processes where clinicians and clients identify and formulate therapeutic goals; actionable objectives; and revisit, measure, and renegotiate these plans via a standardized procedure over time.

Method.

Study methods included a literature review and qualitative content analysis to derive a set of principles and practices of goal setting and monitoring. The research team used source documents (i.e., literature reviews, therapy manuals, and government-issued practice guidelines) and videos (i.e., therapy demonstration videos), and we performed analyses in NVIVO.

Results.

The study identified ten principles and 32 practices. The principles suggest that goal setting and monitoring can be characterized as a collaborative, explicit, and standardized approach to engaging in goal-directed therapeutic work. The term goal-directed therapeutic work connotes a shift toward a more accountable frame for care than has been previously emphasized in the literature. The identified practices were organized into five sub-themes related to goal setting (10 practices), goal monitoring (10 practices), as well as practices specific to mechanisms of goal pursuit and behavior change. These practices involved ways to attend to client self-determination (4 practices), motivation (4 practices), and self-efficacy (4 practices).

Conclusions.

Goal setting and monitoring are a collaborative means of mapping and tracking a course of mutually accountable treatment. The current work is a novel resource for trainees, clinicians, and clinical supervisors interested in care based on evidence-based principles and practices of AOD and other behavior change therapies.

1. Introduction

The fields of psychotherapy, mental health, and behavioral health (e.g., addictions) have suffered for some time from an embarrassment of riches. In a given setting, a client, clinician, or program administrator can select among a range of named and packaged (i.e., manualized) therapies designated as evidence-based via one or more waitlist-controlled clinical trials. When efficacy over another evidence-based treatment is sought, the field for selection shrinks, and for many disorders, it is eliminated. While the field has many empirically supported treatments (ESTs; see Chambless & Hollon, 1998) available for potential implementation in a given setting, the landscape has become both overwhelming (i.e., too many options) and diffuse (i.e., difficulty discriminating options; Chorpita et al., 2005). Even with this availability, the research-to-practice gap continues in many settings, and implementation scientists continue to struggle to identity strategies for getting interventions with known efficacy into the hands of consumers who need them.

Psychotherapy theorists and treatment developers have for some time considered alternatives to the paradigm that a single best available treatment can be identified and implemented widely for a specific clinical population. Some examples of alternatives are psychotherapy integration (e.g., Norcross & Goldfried, 2019), characterizing effective therapists instead of effective therapies (e.g., Miller & Moyers, 2021; Norcross & Wampold, 2018; Wampold, 2011; Wampold & Owen, 2021), and other approaches that emphasize core processes of treatments that can be differentially applied based on client need and clinical context (e.g., Castonguay et al., 2019; Chorpita et al., 2005; Norcross & Wampold, 2019; Michie et al., 2014). The current review is in line with these efforts, and most closely with the latter, process-focused work. Moreover, each process is operationalized to further methods of training and fidelity assessment. This work also targets alcohol or other drug use disorders (AOD) specifically, though applications to behavior change broadly are possible. Finally, terminology is generally consistent with prior work, although some variation in term usage was unavoidable and we thus clarify it below. The current article is one in a series that targets core processes of addiction therapies and operationalizes each process in a manner that research can assess fidelity (i.e., adherence), and ultimately proficiency (i.e., competence). The prior processes reviewed were skills training (Magill et al., 2020) and psychoeducation (Magill et al., 2021), and here we examine goal setting and monitoring. In future work, we will examine developing a working relationship and working with naturalistic support systems. For each process, there is a systematic review and qualitative content analysis to develop a meta-model based on existing sources, such as literature reviews, therapy manuals, government-issued practice guidelines, and therapy demonstration videos. In this sense, the methods of Chorpita and colleagues (e.g., Chorpita et al., 2005; Chorpita & Deleiden, 2009) and Michie and colleagues (e.g., Abraham & Michie, 2008; Michie et al., 2014) have been particularly influential because these projects list and define a set of transtheoretical and transdiagnostic elements shared by a range of treatments available in the literature. For Chorpita, the term practice element (PE) is used and for Michie, it is a behavior change technique (BCT). We use the term process or core process to denote a somewhat broader class of intervention that can be operationalized with a set of principles and practices. A principle is a general understanding or way of being on the part of the therapist that is kept in mind when implementing a specific therapeutic practice. A practice is a more concrete action step or technique that the therapist uses when delivering specific therapeutic content. In this work, we are content agnostic, and instead focus on the how of intervention delivery. The overarching goal of this article is to operationalize core processes of addictions therapies that are broadly applicable to a range of provider types, clinical contexts, and thus content foci.

1.1. Defining goal setting

The acts of identifying, negotiating, and tracking specified goals have been of long-standing interest across a range of disciplines, including addictions (e.g. Cox & Klinger, 2004), mental health (e.g., Law, 2013), rehabilitation (e.g., Ottenbacher & Cusik, 1990), social psychology (e.g., Gollwitzer & Sheeran, 2006), and management (e.g., Doran, 1981). A systematic review of 16 studies of brief behavioral counseling for alcohol use in primary care showed significant effects for intervention, and larger effect sizes when counseling included goal discussions, advice, and feedback (Whitlock et al., 2004). A meta-analysis of 141 studies across a range of populations reported an effect size of d = 0.34 for interventions with, compared to without, goal setting. The authors concluded: “goal setting is an effective behavior change technique that has the potential to be considered a fundamental component of successful interventions” (Epton et al., 2017, p. 1182). For Locke (1969), a goal is the “object of action” and thus its role in regulating human behavior is inherent to its definition. Goals are regulators because they can direct attention and mobilize effort, strategy, and persistence (Locke et al., 1981). The Substance Abuse and Mental Health Services Administration (SAMHSA, 2017) defines goal setting as a collaborative process where clinicians and clients create a written document, both outlining goals and measurable action steps that can serve as a contract for the course of care and that are renegotiated with time as the client’s treatment needs progress. Therefore, goal formulation becomes the first step, and the identification of action-oriented objectives (i.e., sub-goals, proximal steps) is the second in a process where the priorities of treatment are determined. Similar terms in the literature include treatment planning and treatment contracting, and this process is consistent with a client’s right to informed consent to care.

1.2. Defining goal monitoring

Research’s attention to goal monitoring may be of more recent interest, particularly given increasingly popular transdiagnostic approaches such as measurement-based care. Meta-analytic research suggests that when used as a framework to guide psychotherapy, retention and progress can be impacted with effect sizes in the small to moderate range (Lambert et al., 2018). Said differently, the process of goal monitoring increases the chances that clients achieve the goals that they set. Research has framed measurement-based care as a stand-alone approach that can enhance the quality of any treatment (Scott & Lewis, 2015), and similar calls in the literature include progress monitoring (Goodman et al., 2013), routine outcome monitoring (Boswell et al., 2015), and feedback-informed treatment (Prescott et al., 2017). What these methods share is a standardized approach to tracking clients’ goals, symptoms, and/or progress via regular assessment intervals and a specified measurement procedure. Where they might diverge is how the measures are used (e.g., tracking goals versus functioning versus treatment satisfaction and alliance) and in the nature of the conversations surrounding the use of the respective feedback systems. Importantly, the parameters and aims of treatment are made explicit, are agreed upon, and will shape the nature of care in an ongoing way. This review defines goal monitoring as the act of revisiting goals and/or progress, at regular intervals, and with a standardized procedure.

2. Materials and methods

2.1. Core source selection methods

This review draws from data collected in prior work (Magill et al., 2020 [skills training]; 2021 [psychoeducation]). Specifically, a set of addictions therapy manuals, government-issued practice guidelines, and therapy demonstration videos serve as the foundation sources for the project. The initial search involved review of recommended evidence-based modalities (e.g., Principles of Drug Abuse Treatment, National Institute on Drug Abuse [NIDA], 2018) and access to treatment manuals on government websites such as National Institute on Alcohol Abuse and Alcoholism, NIDA, and SAMHSA. For therapy demonstration videos, the review selected all available sources focused on treating AOD (e.g., American Psychological Association [APA]: Specific Treatments for Specific Populations Series; Pychotherapy.net: Brief Therapy for Addiction Series). Magill et al. (2020; 2021) has further detail on source selection.

2.2. Process-specific literature review methods

The review augmented the core source sample with articles and books from a multidisciplinary literature, and for each process of interest, review methods differed. Given a large and diverse set of potential terms for goal setting and goal monitoring, the current review’s search included expert calls and snow-ball methodology. First, members of the research team queried others for suggestions for procedural works related to either goal setting or monitoring in psychotherapy, mental health, or behavioral health (e.g., addictions). Second, the team made several list serv calls requesting: “…any models, frameworks, or guides for having goal setting conversations in psychotherapy…not only guides on formulating goals but also steps in the process are of interest (e.g., goal setting, goal monitoring, shared decision-making, measurement-based care).” This step yielded the majority of sources for the current report, and the study team also reviewed references within these sources. Finally, the team conducted a PubMed search for review articles on goal setting and monitoring in the addictions, and this step yielded an additional five sources. In total, 18 therapy manuals/books, 5 practice guidelines, 11 therapy demonstration videos, and 28 theoretical overviews/literature reviews informed an overview of the principles and practices of goal setting and monitoring in addictions care (see Supplemental One for full list).

2.3. Content analysis methods

The research team conducted a framework guided qualitative content analysis (Erlingsson & Brysiewicz, 2017) to identify principles and practices of goal setting and monitoring. Using the above noted definitions, the team extracted each principle or practice as a single reference from the selection of sources. We placed references (i.e., bullet point, sentence, paragraph, or video observation) in an evolving list that was eventually organized into broader categories, or nodes. The study team based node assignments on shared subject matter. For example, we organized all excerpt references related to how goals should be formulated into two separate nodes: 1) Set goals that are realistic and achievable, 2) Set goals that are specific and measurable. Nodes could stand alone as practices or be organized into superordinate themes as principles. Finally, the team counted each excerpt containing a reference to a given practice to provide a frequency measure of salience across sources. Regarding the latter, we did this to quantify commonalities in the literature and thus empirically ground our assumption that various modalities may differ in their therapeutic content, yet share many core processes and procedures. We report salience indicators along with each practice, when identified in the results section.

To enhance rigor and credibility, a trained research assistant rated sample source references. Specifically, the study team provided the research assistant with the operationally defined principle and practice categories (i.e., Tables 2 and 3) and asked them to make an orthogonal code (i.e., select only one designation) for each excerpt. This process is called a “check on clarity of categories” and allows for an independent assessment of face validity (Thomas, 2006). These results yielded an alpha of .79 for principles and .90 for practices (i.e., reliability agreement with ratings provided by the first author; see Supplemental Two for source excerpt examples for each principle and practice). Krippendorff (2004) suggests alpha values above .80 are acceptable (Krippendorff, 2004). The first author collected all qualitative data in NVIVO (version 12).

Table 2.

The Principles of Goal Setting and Monitoring

Principle	Description
1) Goal setting necessitates goal monitoring	To engage in collaborative goal setting is only the first step in the continuity of care; goals should only be set when goal-related progress will be tracked systematically over time.
2) Goal setting and monitoring require and engender a working relationship	Goal-facilitated therapeutic work requires, but can also foster, a working relationship.
3) Goal setting and monitoring are interactive	Goal setting and monitoring are a dialogue where client needs and presenting concerns are transformed into a specified action plan.
4) Goal setting and monitoring are explicit	Accountability to goals and goal-related progress will only occur if they are made explicit in the treatment process.
5) Goal setting and monitoring emphasize client choice	The client is the actor in goal-facilitated therapeutic work; therefore, client choice, priorities, and preferences should shape goal formulation and the method of progress monitoring.
6) Goal setting and monitoring incorporate assessment data and the best available research	Therapist is the partner in goal-directed therapeutic work; a key therapist contribution is expertise in assessment procedures and research data relevant to the continuity of care.
7) Goal setting and monitoring utilize client self-determination	Therapist works purposefully to emphasize client self-determination, as well as related mechanisms such as optimism and positive outcome expectations.
8) Goal setting and monitoring utilize client motivation	Therapist attends to client values, ambivalence, and motivation to facilitate the formulation and monitoring of therapeutic goals.
9) Goal setting and monitoring utilize client self-efficacy	Therapist attends to client self-efficacy as a needed attribute in pursuing the agreed upon action plan.
10) The goal-setting and monitoring therapist is collaborative, flexible, and highly accountable to a goal-facilitated direction for treatment.	Therapist will put client priorities and preferences first, while maintaining some continuity in relation to the goal-formulation, action, and progress monitoring plan. A culture of accountability, transparency, and openness to feedback in the treatment process is central.

Table 3.

The Practices of Goal Setting and Monitoring

Practice	Description
Goal setting practices
Set goals based on immediate needs	Therapist aids the client in setting a clear goal based on relevant and near-term needs.
Formulate goals that are realistic/achievable	Therapist aids the client in setting goals that are not too complex or too numerous; this criterion facilitates goal achievement.
Formulate goals that are specific and measurable	Therapist aids the client in setting goals in measurable, often approach-oriented, and time-limited terms; these criteria facilitate goal achievement.
Incorporate a vision of the future when formulating goals	Therapist and client envision a future where goals are met versus unmet, which may aid in goal formulation, garner motivation, and solidify commitment.
Formulate goals with specified objectives	Therapist and client identify a task or series of tasks that will facilitate goal achievement; these objectives meet the same criteria as those described for formulating goals (i.e., relevant, achievable, measurable, timed).
Incorporate naturalistic, social support systems when setting objectives	Therapist and client identify a task of series of tasks that, where possible, incorporate available naturalistic supports such as family, friends, and community.
Assess barriers and resources for meeting goals and objectives	Therapist and client engage in problem-solving where barriers, resources, and needed coping skills are discussed.
Provide advice on goal and objective pursuit	Therapist provides advice typically when client resources are exhausted and the client provides a clear signal that advice is wanted and needed.
Get an explicit commitment on goals and objectives	Therapist is very explicit and consistent in seeking client verbal commitment to agreed-upon goals and tasks.
When goals are set, summarize in a written plan	Therapist facilitates creation of an action plan with measurable goals and objectives as well as an explicit plan for goal monitoring.
Goal monitoring practices
Use standardized methods for goal monitoring	Therapist and client agree upon a plan for goal monitoring that includes a standard method of measurement, timing, and structure for the goal monitoring discussion.
Monitor goals at regular intervals	While treatment needs will drive the length of time between goal monitoring discussions, these discussions should occur at regular intervals during treatment.
Carefully select monitoring measures	Therapist selects and proposes a measurement plan that considers feasibility, utility, and psychometric validation.
Recognize the limitations of monitoring measures	Therapist recognizes and is transparent about the limitations of any selected measurement procedure.
Use goal monitoring as a feedback device	Therapist uses goal monitoring to obtain and provide feedback on client progress, needs, and treatment effectiveness.
Use visual, technological, and decisional aids	Therapist uses visual aids such as graphs or other figures, technology such as applications or tablets, and where appropriate, decision aids that inform next steps based on monitoring data.
Engage in a conversation about the goal monitoring data	The therapist and client discuss goal monitoring results, using the data as a platform for affirmation of success and renegotiation of goals and treatment plans, where needed.
Use goal monitoring to maintain client engagement	Therapist uses goal monitoring as a ‘relational check-in’ and as a means of promoting client ownership of their treatment.
Recognize when treatment is working	Therapist uses data on progress to affirm client efforts and promote positive outcome expectancies.
Recognize when treatment is not working	Therapist is open to feedback and transparent about concerns regarding the effectiveness of the selected course of treatment.
Attending to self-determination
Prioritize client choice	Therapist places a clear and explicit emphasis on client choice, responsibility, and autonomy at each step of the goal setting and monitoring process.
Mutually agree upon goals and objectives	Therapist and client agree upon goals, objectives, and monitoring procedures.
Treat client as expert	Therapist recognizes that the client is the expert in their goals, and structures the encounter to reinforce client sense of agency.
Ask questions to promote agency	Therapists uses questions, such as permission-seeking or deferring to client advice and direction, to reinforce client sense of agency.
Attending to motivation
Tailor to stage of change	Therapist is attuned to client motivation, and adjusts their therapeutic approach to match client stage of change.
Explore client motives	Therapist explores a range of factors that may influence client motivation to set and pursue goals; these include values, motives, and the views of others.
Honor client ambivalence	Therapist attends closely to signs of client ambivalence related to agreed-upon goals or objectives, and promptly explores client concerns.
Roll with resistance	Therapist does not fear resistance and rather views it as a cue to renegotiate goals and objectives.
Attending to self-efficacy
Have genuine optimism	Therapist communicates genuine optimism about client capacity to reach goals and pursue objectives.
Provide affirmation	Therapist consistently affirms client qualities, efforts, and progress; these affirmations are thoughtful and genuine.
Reinforce incremental gains	Therapist creates opportunities for client success and incremental goal achievement; when
Ask questions to promote self-efficacy	Therapist promotes client self-efficacy via targeted questions about client qualities, efforts, and progress.

3. Results

Table 1 summarizes 17 guides, models, or frameworks for goal setting and/or goal monitoring from the literature reviewed. While this is not an exhaustive list, it highlights some stand-alone methods from a variety of disciplinary backgrounds (e.g., general and social psychology, medicine, management) as well as some methods that are embedded in one or more evidence-based addictions treatment modalities (e.g., motivational interviewing). Table 1 illustrates some commonalities across sources specific to goal and objective formulation, considerations for goal monitoring, and attention to mechanisms of behavior change that are threaded throughout the principles and practices summarized next.

Table One.

Guidelines, models, or frameworks for goal setting, goal and objective formulation, and goal monitoring

Title (author)	population or field of origin	attends to motivation	attends to self-efficacy	attends to barriers/resources	goal setting guideline	objective setting guideline	role for social support	goal monitoring guideline
Change Plan (Miller et al., 1992)	addictions	yes	yes	yes	specific, behavioral target with timeline for completion	steps toward making the change	yes	---
DIALOG+ (Priebe, 2020)	major mental illness	yes	yes	yes	priorities selected among 11 life and treatment-related domains	brief; precise; expressed as behavior; responsible parties identified	yes	review of actions agreed upon; review should be brief; focus on progress made (i.e., not unmet goals)
Five As (Glasgow et al., 2006)*	general medicine	yes	yes	yes	Assess: behavior, beliefs, motivation Advice: based on health risks Agree: on a realistic goal	Assist: in anticipating barriers and developing a specific action plan	yes	Arrange: for follow-up support
Goal Attainment Scaling (Ottenbacher & Cusick, 1990)	rehabilitation	noa	noa	noa	observable; recordable; time-limited; up to three goals	measurable behaviors that indicate goal improvement	noa	determine mode and timing of review; select 5 levels of progress, ranging from −2 to +2, where 0 = no progress
Goal-based Outcomes (Law, 2013)	child/youth mental health	yes	yes	yes	typically solution-focused; collaboratively set; up to three goals	---	yes	0 to 10 scale where 0 is no progress toward goal achievement and 10 is goal achieved; track at regular intervals (e.g., every session)
Goals Form (Cooper, 2015)	psychotherapy	nob	nob	nob	specific, concise, simple, absolute (i.e., not relative to some baseline), approach, and SMART (i.e., see Doran, 1981 below), up to five goals	---	nob	revisit at regular interval, attainment measured on a 7-point scale and progress can be monitored by subtracting current session attainment from the prior session or at the start of treatment
Goal Setting and Action Planning (Scobbie et al., 2011)	rehabilitation	yes	yes	yes	Developing the goal intention: goal discussion and negotiation Setting a specific goal: consider goal specificity/difficulty	Activating goal-related behavior: action planning; coping planning	yes	Appraising performance and giving feedback: review performance in relation to action plan; provide feedback; use persuasion and modelling; plan adjustments based on performance
Goal Setting Theory (Latham & Locke, 1979)	management	yes	yes	yes	specific; acceptable; sufficiently challenging; with sufficient ability and resources, an explicit commitment, and a supportive supervisor	---	yes	knowledge of performance in relation to the goal is necessary; feedback is most helpful when it is periodic and guided by visual aids
Measurement-Based Care (i.e., Patient-Focused Research; Lambert et al., 2002)	psychotherapy	yesc	noc	noc	four domains in the original Outcome Questionnaire (i.e., intra- and inter-personal distress, role functioning, quality of life)	---	yesc	routinely administer symptom/outcome/process measure, practitioner review of data, practitioner and patient discussion of data, use decisional support, modify treatment, where needed
Model of Action Phases (Gollwitzer & Sheeran, 2006)	social psychology	yes	yes	yes	Predecisional action phase: selected goals will have high desirability and feasibility	Preactionaal phase and Implementation intentions: If-then plan specifying when, where, and how of goal realization	yes	Postactional phase: assess 1) degree of goal attainment and 2) quality of attainment outcomes
Partners for Change Outcome Management System (Routine Outcome Monitoring; Miller et al., 2005)	psychotherapy	nob	nob	nob	---	---	yesb	routinely administer visual analog scale for client intra- and inter-personal functioning, role functioning, and satisfaction with treatment (i.e., alliance). Ratings analyzed in relation to empirical benchmarks and feedback on functioning provided
Personal Concerns Inventory (Cox & Klinger, 2004)	addictions	yes	yes	yes	select among 12 life domains; each domain is rated along 10 dimensions (10-point scale e.g., commitment, likelihood of success, happiness if resolved	describe actions that will be taken to resolve each concern	yes	monitoring may occur via numeric changes on ratings, particularly for likelihood of success and happiness/unhappiness items
Progress monitoring (Goodman et al., 2013)	addictions	nob	nob	nob	---	---	nob	feedback to clinician and client, at regular intervals, progress-oriented, and with decision supports
Seven Steps for Problem Solving (Tober & Raistrick, 2020)	addictions	yes	yes	yes	7 steps for a problem-solving exercise: 1. clearly define the problem 2. think of solutions 3. weigh advantages and disadvantages 4. choose a solution	5. plan and agree to steps	yes	6. carry out the plan 7. review the outcome (e.g., was it successful? did I achieve the goal? What did I learn?)
Shared Decision-Making (Elwyn et al., 2012)	general medical care	nod	nod	nod	Choice Talk (e.g., offer choice, justify choice, check reaction) Option Talk (e.g., check knowledge, describe options, harms and benefits, decision support) Deliberation Talk (e.g., elicit preferences, move to decision, provide review)	---	nod	---
SMART (Doran, 1981)	management	noe	noe	noe	Specific Measurable Achievable Relevant Time-bound	Specific Measurable Achievable Relevant Time-bound	noe	---
Practice Dimension II (Tip 21; SAMHSA, 2017)	addictions	yes	yes	yes	specific measurable realistic timed mutually agreed upon	specific measurable realistic timed mutually agreed upon	yes	regular intervals; negotiate changes; openness to critically examine one’s work

Notes.

^*See also Smoking, Nutrition, Alcohol, Physical Activity Framework (The Royal Australian College of General Practitioners, 2015).

^aMethod highly specific to goal formulation and tracking.

^bThese dimensions are not explicit in (Ottenbacher & Cusick, 1990).

^cThe importance of patient buy-in regarding selected measures discussed.

^dThese dimensions are not explicit in Elwyn et al., (2012). However, a review of the SDM Toolkit for Mental Health Practitioners (Karlin & Wenzel, 2018) illustrates a broader application of the framework to goal setting and monitoring conversations where motivation, barriers, and use of social support systems are emphasized.

^eOriginal Doran (1981) model highly specific to goal or objective formulation.

3.1. Principles of goal setting and monitoring

The study team derived ten principles of the goal setting and monitoring process from the source data. These principles capture the nature of the process (i.e., key ingredients) and the importance of attending to specific client mechanisms that have been implicated in the literature as uniquely pertinent to successful goal pursuit (e.g., self-determination). The first principle is that any goal setting in treatment will require follow-up and progress monitoring (Harkin et al., 2016). In other words, one step cannot exist without the other, and this brings to the fore the theme of accountability in the goal setting and monitoring process. The next principle highlights the importance of the working therapeutic relationship (e.g., Eubanks & Goldfried, 2019; Karlin & Wenzel, 2013; Prescott et al., 2017; SAMHSA, 2017), which is a principle highlighted in both of our prior reviews. However, what is unique here is the role of goal setting and monitoring in facilitating a working relationship by promoting client engagement and ownership over the course of care (Lewis et al., 2017; Scott & Lewis, 2015). In principles three and four, the nature of the interaction is described, and five and six identify the sources of input. Principle three highlights that both goal setting and goal monitoring are interactive processes (Elwyn et al., 2012; Law & Wolpert, 2014). These processes are not deliberations that occur as part of the clinician’s planning or in professional team meetings without any involvement from the client. Granted, some settings will incorporate treatment planning and progress assessment that occur outside of the client’s knowledge, but the primary actor in change is the client; thus, the client must be an involved architect of their treatment. Principle four similarly speaks to the process as explicit, which means goal setting and monitoring provide a direction for both therapist and client that is mutually agreed upon and renegotiated as treatment progresses (SAMHSA, 2017). Principle five argues that the primary input for goal setting and by extension, goal monitoring, are client values, needs, and preferences (Elwyn et al., 2012), and principle six frames the therapist as merely a partner with professional tools such as assessment data and knowledge of evidence-based treatment options (Prescott et al., 2017).

The next three principles speak to the need for the therapist to be mindful of and attend to specific mechanisms of behavior change. Because the client is the actor and architect of their treatment, principle seven highlights self-determination. Several practices noted below (i.e., Practices for attending to self-determination) describe the how of facilitating and capitalizing upon this natural human tendency. In a practical sense, this principle involves prioritizing client choice, responsibility, and autonomy wherever possible (Siegert & Taylor, 2004). While self-determination may be considered a trait that is a foundation for goal setting and monitoring processes, motivation is more of a state, with dynamism the therapist adjusts to continuously, including enhancing motivation, working with ambivalence, and accepting when motivation is lacking (principle eight; e.g., Miller et al., 1992; SAMHSA, 2019; Scobbie et al., 2011). Self-efficacy (principle nine), another dynamic state, complements the two prior mechanisms to yield three needed conditions for purposeful action and change. As such, attention to each of these is conscious and strategic, with several candidate practices described below (i.e., Practices for attending to motivation; Practices for attending to self-efficacy). The final principle, as in our prior work, is about the stance of the therapist when engaging in goal setting and goal monitoring. As always, this process includes client-centered qualities such as a collaboration, but we add three ideals of accountability, transparency, and openness to feedback as uniquely important to this particular process (principle ten; Duncan & Sparks, 2017; Prescott et al., 2017; SAMHSA, 2017; see Table 2 for a list of ten principles with corresponding definitions).

3.2. Practices of goal setting and monitoring

The research team derived numerous practices from the data and organized them within five subthemes of goal setting (10 practices), goal monitoring (10 practices), and specific practices related to attending to client self-determination (4 practices), motivation (4 practices), and self-efficacy (4 practices). Table 3 summarizes all practices with definitions.

3.2.1. Goal setting practices.

The 10 practices of goal setting, as derived from the source data, include the optimal form of goals, steps in goal setting and objective planning, and methods of collaboration. Goals should be set based on the most relevant needs and desires of the client (consistent with principle five), although selecting among numerous goals or other competing directives may require the therapist to facilitate (consistent with principles two and three; Marlatt, 1997; 2000; Miller, 2002; Woody et al., 2003). This facilitation may include some form of triaging based on needs that are most immediate (19 of 62 sources) with some sources recommending no more than three goals (Law et al., 2013; Priebe, 2020). Goals should be achievable (18 of 62 sources) such that experiences of success can create further momentum for future goal pursuit (Meyers & Smith, 2001; Monti et al., 2001). With that said, a number of sources spoke to appropriately challenging goals, but these recommendations were typically in the context of laboratory studies of goal directedness and non-clinical samples such as employees (e.g., Epton et al., 2017; Locke, 1981). The more pertinent criterion is the concept of realistic and achievable due to the number of stressors that may impact goal pursuit in the context of addictive behavior change. The next criteria are related to the exact form that goals should take and were commonly referred to as SMART goals, which is an acronym for Specific, Measurable, Achievable, Relevant, and Timed (Doran, 1981). While relevant and achievable have been noted in the prior two practices, the remaining criteria of specific, measurable, and timed were cited in 28 of 62 sources (e.g., Glasgow, 2006; Kadden et al., 1992; Meyers & Smith, 2001; Miller, 2002), with some sources also encouraging solution- or approach-focused framing for goals (Law, 2013; Ottenbacher & Cusick, 1990).

The next series of practices include techniques for facilitating goal and objective formulation. Consistent with principles seven and eight, questions related to envisioning the future where the goal was achieved, not achieved, or the problem was absent or present, can engender meaningful exploration leading to several potential outcomes such as goal identification, increased motivation, and may help to solidify commitment (7 of 62 sources; Cox et al., 1999; Law & Wolpert, 2014; Priebe, 2020). When considering principle nine, the action planning process comes to mind where a set of objectives, also meeting SMART criteria, for each goal are identified (18 of 62 sources; Latham & Locke, 1979; Locke et al., 1981). This process can be referred to as problem-solving, action planning, or objective planning, but important considerations are barriers and resources (19 of 62 sources; e.g., McCrady, 2000; Zweban, 2000), including potential social supports (9 of 62 sources; Webb et al., 2010), as well as advice, when needed, from the clinician (14 of 62 sources; Elwyn et al., 2012). While we do not prescribe a linear process, potential final steps in goal setting include seeking and solidifying commitment, or “closing the deal” (20 of 62 sources; Miller et al., 1992), as well as writing up the goal and objective plan in a “public document” (23 of 62 sources; Epton et al., 2017). Consistent with principle one, this document should include a plan for progress monitoring.

3.2.1. Goal monitoring practices.

The 10 practices of goal monitoring, as derived from the source data, describe considerations and best practices for the process. Of the sources, 20 of 62 argued for the importance of a standardized procedure, including standardized measurement, timing, and for some sources, the nature of the discussion about the data (e.g., topics discussed, length of discussion, tools used; e.g., Kearney et al., 2015; Law & Wolpert, 2014). Several sources emphasized how standardization facilitates comparison across cases and clinicians as a means of tracking outcomes at the clinician or agency level (Lambert et al., 2002; Ottenbacher & Cusick, 1990). While this is an attractive concept consistent with the noted ideal of accountability, standardization is also a means for promoting consistency, which is vital to successful goal pursuit. Very simply, how can someone meet their goals if they forget they set them or rarely revisit them? The interval length will depend on the clinical context, nature of the treatment, and agreement between therapist and client, but 18 of 62 sources noted a need for regular intervals for goal monitoring such as every session, monthly, or quarterly (Glasgow et al., 2006; Goodman et al., 2013; Wampold, 2015). Consistent with principles four and six, as well as the importance of standardization, a measure or set of measures are selected by the therapist and agreed upon with the client (10 of 62 sources). A number of sources suggested specific measures, including validated scales (e.g., Brief Addiction Monitor, Cacciola et al., 2013; Outcome Questioniare-45, Lambert et al., 2004; Outcome Rating Scale/Session Rating Scale, Miller et al., 2005; Treatment Outcome Package, Youn et al., 2012) and numeric tracking systems (e.g., Goal-based Outcomes, Law, 2013; Goal Attainment Scaling, Ottenbacher & Cusick, 1990) for a range of indicators such as goal achievement, symptoms, mechanisms of behavior change, and primary outcomes. However, the sources underscored the importance of careful selection based on validity, feasibility, and fit as well as a thorough understanding of the performance of the measure/s by the therapist, including its limitations (2 of 62; Prescott et al., 2017).

The next series of goal monitoring practices were related to the role of the process in treatment, or why, as well as the nature of the goal monitoring discussion, or how. The purpose of goal monitoring is to provide feedback to both therapist and client about the ongoing progress of treatment (Lewis et al., 2019); this process was highly salient in the data (23 of 62 sources). Sources noted that many clients may not tell their therapists about progress, positive or negative, if the importance of monitoring progress is not made explicit in the continuity of care (principle four; Lambert et al., 2002; Youn et al., 2012). To facilitate this, any number of tools can be used (13 of 62 sources) such as data collection and presentation tablets (Kearney et al., 2015), graphs and figures (Cooper, 2015), as well as decisional aids on evidence-based treatment options (Goodman et al., 2013). These practices relate to the key aspect of how goal monitoring occurs—via a discussion (principle three; 15 of 62 sources). Similar to the goals that are set, the data on progress made are always fed back to the client, and goal reformulation and negotiation subsequently occurs (Duncan & Sparks, 2017). Potential targets for feedback and discussion are numerous and can include feedback on the working relationship (principle two; Prescott et al., 2017) and should foster continued engagement in treatment by empowering clients to take an active role in their care (principle seven; Scott & Lewis, 2015; Lewis et al., 2018; 5 of 62 sources). Finally, sources argued that goal monitoring discussions include not only the noted renegotiation of goals and treatment plans, but also the reinforcement of progress to promote positive outcome expectancies (7 of 72 sources; Goodman et al., 2013) and transparency when progress is slow or when deterioration may be occurring (13 of 62 sources; Lambert et al., 2002).

3.2.3. Practices for attending to self-determination.

Sources yielded four practices consistent with the principle of attending to and capitalizing upon the client’s need for self-determination (principle seven). Consistent with principles five and seven, clients’ needs, preferences, and choice should be the priority at each step of the goal setting and monitoring process (22 of 62 sources; Carroll, 1998; Martino et al., 2006; Miller, 2002; SAMHSA, 2017; 2019; Wubbolding, 2000). Granted settings exist in which goals are partially determined by the service context (e.g., medication-assisted treatment) or clients’ capacity to select a goal is constrained or compromised (e.g., mandated treatment; cognitive impairment, respectively), but even in these circumstances opportunity for autonomy must be created (SAMHSA, 2017). As a result, goals, objectives, and procedures are, ideally, client-directed and always mutually agreed upon (15 of 62 sources; Cox & Klinger, 1999; Eubanks & Goldfried, 2019; Loyd et al., 2019). The client is treated as the expert in explicit and implicit ways (10 of 62 sources). Regarding the latter, the therapist should explore and defer to the client’s view of presenting concerns and solutions whenever possible (Karlin & Wenzel, 2013). Another means of structuring the encounter to promote and reinforce the client’s experience of agency is via the types of questions that therapists ask (12 of 62 sources). This could include asking permission prior to advising (Miller et al., 1992), asking clients what they know about their presenting conditions prior to providing information (Elwyn et al., 2012), and asking for a client’s ideas on courses of action prior to providing any recommendations (SAMHSA, 2019).

3.2.4. Practices for attending to motivation.

Sources yielded four practices consistent with the principle of attending to client motivation (principle eight). A number of sources (9 of 62) highlighted the role of the Transtheoretical Model of Change (Prochaska & DiClemente, 1984), and argued for the importance of matching treatment to a client’s stage of motivational readiness (SAMHSA, 2017; 2019; Vakharia & Little, 2016). Ten of 62 sources also highlighted exploring motives for change. This includes exploring values (Carroll, 1998; Elwyn et al., 2012); reasons for or against a particular outcome, goal, or objective (SAMHSA, 2012); and perceptions of others whose views matter to the client (Miller et al., 1992). Further, ambivalence is one aspect of fluctuating motivation in ongoing goal pursuit (7 of 62 sources); therefore, it should not be feared or vilified, but rather viewed as just another force in the natural momentum of change (Miller et al., 1992; Miller, 2002). A related concept is to roll with resistance, which is a phrase from brief motivational interventions such as, Motivational Interviewing (Miller & Rollnick, 2013), and speaks to the lack of effectiveness of confrontational methods or other control tactics, as these go directly against the client’s natural desire for self-determination (4 of 62 sources; SAMHSA, 2019).

3.2.5. Practices for attending to self-efficacy.

The final set of practices are related to attending to and enhancing clients’ self-efficacy (principle nine), and these practices are also important to and similarly described in our prior work on behavioral skills training (Magill et al., 2020). A therapist’s genuine optimism for the client’s successful goal and objective pursuit can be considered a pre-requisite for high quality, goal-directed therapeutic work (13 of 62 sources; Carroll, 1998; Nowinski et al., 1992). A number of sources also noted authentic, verbal affirmation of clients’ strengths, efforts, and progress as a key practice for promoting and reinforcing self-efficacy (23 of 62 sources; Kadden et al., 1992; Martino et al., 2006). One source of verbal (and intrinsic) reinforcement relates to progress over time. Thus, meeting each successive goal or objective is a source for reinforcement of a client’s capacity for change (13 of 62 sources; Monti et al., 2002) and sets the grounds for identifying the next goal or objective. Finally, questions can facilitate a client’s ability to recognize and reinforce their own strengths and self-efficacy (13 of 62 sources). Such questions might include direct self-assessment questions, past success experiences, and self-identified progress (SAMHSA, 2012). In this sense, a therapist can rely on the client’s own view of their strengths rather than being effusive in noting positive qualities in the client as a means of boosting their efficacy and esteem.

4. Discussion

Goal-directed behavior, goal formulation, and more recent considerations for progress monitoring are of interest across a range of academic and helping disciplines. In the current work, we drew heavily from sources outside the field of addictions to operationalize a process for goal setting and monitoring with AOD. Table 1 illustrates this, by providing 17 sample guidelines, models, or frameworks; five, or less than 30%, are derived from evidence-based addictions treatments, despite a clear preference for these types of sources in the literature search phase. The absence of this type of work could be due to a historic lack of focus on client autonomy in this population relative to other populations (e.g., a historic focus on abstinence-only goals). Thus, this overview offers a novel resource for guiding trainees, clinicians, and clinical supervisors in how to deliver what can be considered a key transtheoretical process in treatment for addictive behavior change. Altogether, 62 multi-disciplinary sources yielded 10 principles and 32 practices for goal setting and monitoring as defined as: collaborative processes where clinicians and clients identify and formulate therapeutic goals; actionable objectives; and revisit, measure, and renegotiate these plans via a standardized procedure over time. Some additional themes, arising from this work, are worthy of discussion.

4.1. Goal setting and monitoring are a lens for treatment

To have, pursue, and monitor goals in treatment are not ground-breaking concepts, but explicit and standardized integration into routine care may be less common than expected. For example, informed consent involves educating clients about the nature of their condition, the parameters of the treatment and treatment context, including treatment alternatives, and acts as a springboard for treatment planning. The process is part of standard medical ethics (Institute of Medicine, 2001) as well as ethical principles in fields such as clinical psychology (American Psychological Association, 2002) or social work (National Association of Social Workers, 1999). Informed consent not only meets standards of ethical care but also promotes client self-determination, ownership over the treatment process, and can help to build therapeutic rapport (Fisher & Oransky, 2008; Walker et al., 2005), which are all factors that this review highlights. Yet in a study of informed consent to research with community addictions clinicians, less than half of those surveyed understood central concepts involved in the process (Forman et al., 2002). Even in medicine, true informed consent to treatment may be an exception rather than a rule, occurring in 9% of patient encounters by some estimates (Braddock et al., 1999). In contrast, 87% of individuals receiving community-based alcohol treatment reported a preference for having and choosing their own goals (Sobell et al., 1992). The current review suggests that goal-directed therapeutic work connotes a shift toward a more accountable frame, or lens, for care characterized by certain ideals such as transparency, standardization, and openness to feedback. These ideals are consistent with both clinical ethnics and deeply held values across a number of helping disciplines.

4.2. Limitations to goal setting and monitoring exist

A portion of sources within this review appropriately noted the potential limitations of goal setting and monitoring. Concerns may exist about impaired decision-making due to intoxication or early withdrawal or a need to have pre-determined goals due to the nature of the service setting (SAMHSA, 2017). Some clients may also wish to engage in nondirective supportive therapy or may hold a view that argues for clinician-articulated goals. In all of these circumstances the lens of accountability, transparency, and openness to feedback can persist. For example, the therapeutic contract may be that the client would like a safe place to check-in about their weekly experiences; in other words, the contract does not contain a goal beyond obtaining nonspecific support from the clinician. In such cases, many of the principles and practices still apply, including that this contract should be explicit, identified via informed discussion, agreed upon, and monitored over time. Other circumstances could be issues of premature goals or moments where goals produce the potential for therapeutic rupture. Moreover, the literature on progress monitoring included concerns about valid and feasible assessment (Law & Wolpert, 2014; Prescott et al., 2017; Youn et al., 2012) and difficulties with implementation (Lewis et al., 2018; Wampold, 2015). Therefore, we do not argue that goal setting and monitoring are appropriate with all clients or under all clinical circumstances, but that the process is applicable and valuable in many cases, when done in a manner consistent with best principles and practices. Finally, the reader may have noted that this work is agnostic to the specific content of goals and outcome measures, as these are best decided by the specific therapeutic context.

4.3. Limitations and implications

This literature review and qualitative content analysis yielded 10 principles and 32 practices for goal setting and monitoring as a transtheoretical process of evidence-based addictions and other behavior change therapies. However, some limitations of this work exist that the reader should consider. First, the first author conducted the content analysis as a single rater. This method is an important limitation to keep in mind as rater bias could have affected the selection of code references and coding procedure. With that said, assessment of face validity and inter-rater reliability with an independent rater showed the data could be encoded with good agreement, and this suggests promise for future fidelity monitoring of the principles and practices described here. Second, we do not know whether additional sources would have yielded additional principles and/or practices. With these limitations in mind, this work contributes to future training and fidelity assessment of goal setting and monitoring, which have to date, evolved as two separate literatures. Combined with our previous work on skills training (Magill et al., 2020), psychoeducation (Magill et al., 2021), and future work on developing a working relationship and working with naturalistic support systems, a training model on common factor principles and practices of addictions therapies is emerging. This flexible, modular-based approach may be more favorable to clinicians than quality improvement efforts targeting the implementation of a specific, evidence-based therapy (e.g., Borntrager et al., 2009). In other words, this approach targets processes in which most providers are already engaged, while providing tools for quality assessment. Future work will include proof-of-concept research on training model efficacy.

Highlights.

• This systematic review and qualitative analysis operationalized the process of goal setting and goal monitoring.

• Sixty-two source documents and videos were examined.

• Ten principles and 32 practices were identified.

• Goal-directed therapeutic work characterizes a shift toward a more accountable frame for care.

• This work informs a fidelity-based approach to goal setting and monitoring.