Shirah Vollmer MD

The Musings of Dr. Vollmer

Goal Setting: A Rant

Posted by Dr. Vollmer on January 23, 2014

Lolly, twenty-five, female, said, after a recent flirtation with suicide, “I know I need to have goals,” leading me to feel she is parroting the mantra that goals give folks like Lolly a means to engage in life. “I think you need to work on your relationships, and in so doing, you will then want to accomplish your goals,” I say, highlighting the priority that attaching to others is the critical aspect of good mental health. Once again, I am struck by the inversion of so many treatment interventions, where the emphasis is on the concrete, and not on the emotional connection. Weight loss, for example, may be a goal, but the larger issue is wanting to be healthy so that one can enjoy the people who give their life meaning. Goals, outside of the context of relationships, are shallow, and short-lived, without a deeper connection, which involves deep feelings for others. Yet, in our age of metrics, goals can be measured, whereas relationships cannot be, and hence goals are often documented and discussed, at the expense of less linear activities. “What kind of therapy does Lolly need?” A student asks me. “She needs to develop agency over her life, where she designs a way of being in the world that has sense and meaning for her,” I say, emphasizing that being the author of one’s narrative is the “goal” but this “goal” is not easily seen or documented, and hence it is invisible to those who want to have “evidence” of improvement. So, should therapy intervene in a way that allows measurement to prove its usefulness or, should therapy be about developing narratives, which is, by definition, is more art than science? My opinion is clear and definite. Measuring improvement is antithetical to helping people make their way in the world. Each person has a different path, and so therapy helps in this individual, and hence not measurable way. This rant never gets old for me. Lolly’s life depends on it.

14 Responses to “Goal Setting: A Rant”

  1. Shelly said

    Who measures the improvement you write about, the therapists or the patient? If Lolly works on developing relationships and begins to have friends, meaning she feels secure about herself and that she “matters to someone,” will that help in ending her wish to end her life? Perhaps the frustration of not meeting the goals that she sets out to meet can be the trigger to make her try suicide again. There are all sorts of reasons people wish to stop living. Have you explored Lolly’s? Sometimes people lack direction, others have financial disasters, and still others just want freedom from terrible physical or emotional pain. Goal-setting may not be the simple answer you seek.

    • Yes, the point of this post is that in this current age of mental health care, goals are the holy grail, rather than fostering relationships, since goals can be measured and relationships cannot be. This need for measurement robs the field of the value of human connection, which, if Lolly could come to understand that, would likely do enormous good in terms of helping re-vitalize her. Goals are empty without connection. Thanks.

  2. Jon said

    Goals do not have to be quantitative. The can be qualitative to help set a direction. They can be somewhat amorphous, as it may not be quite clear where one wants, or needs, to be going. They can be dynamic, changing with the circumstances.

    Lolly’s goal could be as simple as “Staying Alive.” They could be as shapeless as making new, or deepening existing friendships. They could be changing as she understands more what could bring joy into her life.

    Goals qua goals are not bad. Arbitrary, or unnecessarily numeric goal, however, are at best silly.

    • Yes, Jon. As I said to Shelly, there is tremendous pressure to quantify our work, and as such, I imagine that the mental health professionals of the next generation will have a good laugh, at the expense of a lot of human suffering. Thanks.

  3. Ashana M said

    Goals can help provide a sense of confidence and mastery–although weight loss is probably a poor choice, as it’s usually so difficult. Those positive feelings can improve the relationship with the self as well as with the world, which can also affect feed into better relationships with others. I’m afraid I’m on the other end of the pole from you in this: measurable goals support less tangible ways of improving one’s life. At the same time, without measurable goals there is never any evidence that anything you are doing is either successful or unsuccessful, so it’s easy to continue to engage in work that isn’t productive and avoid ever having to acknowledge that it isn’t, so avoiding concrete measures lends itself very naturally to a form of denial. Evading measurement is a way of evading evaluation and scrutiny.

    • Thank you, Ashana, for offering a different point of view. This is the “argument” that we need to keep going, as I think there is merit to both sides. Thanks Again.

  4. Eleanor said

    I’ve had to give this topic time to “sink into my brain a bit” so to speak…there are so many aspects which have to be considered…so many directions the mind can wander….(at least mine 🙂 . At gut level I would have to say that in my experience both with myself in my work area, and many years as a close bystander in the medical arena, I’ve seen too many people set goals, reach the “top” of their chosen work or profession and end up “empty” inside, not seeming to have a clue just who the heck they are on deeper levels. I’ve seen power and money and social standing, among other things, become poor substitutes for relationships . So to me, I lean toward the premise that first, and foremost, one must have a deeper relationship with themselves , family, friends ..these things just can’t be measured or put on a chart. To find one’s true “work or goal(s)”, passion and talents, one must have a pretty good idea about “who they really are at base levels”. With this said however, I believe that this process hopefully continues …that we explore ourselves, grow, and modify goals and interests for the rest of our lives.

    • Yes, Eleanor, the emptiness of goals, independent of how they are integrated into relationships, is an important issue for me, as with the beginning of electronic medical records, comes with a sense of measuring everything. In the Internal Medicine world, this makes sense. Following glucose levels, cholesterol levels and blood pressure, gives a good marker to the health and health care of the individual. These metrics make sense, but in the mental health world, we do not have clear metrics and we, as professionals, need to scream about this. Patients also need to protest, as their care will be severely compromised by the pressure to meet “goals” rather than a more nebulous feeling of “fulfillment”. On the one hand, insurance companies are pressured by parity to make sure that mental health care is on the same level as medical health care, but on the other hand, this parity is false, in that the metrics for mental health care simply do not make sense. Thank you for thinking about this post and chiming in.

      • Eleanor said

        Speaking of insurance, recently I was having a rather lively discussion with an extended family member who is in the medical insurance business. I was complaining about the lack of parity concerning mental health therapeutic treatments as opposed to “traditional”, “real” medicine (being sarcastic here). My family member “explained” to me that to have reimbursement they must “see” measurable proof, whether it be lab results, MRI or Xray or surgical reports, hospital records…whatever. They need “concrete evidence”.

        Many many years ago when my daughter was young, struggling with severe physical disabilities she was born with, I applied for insurance reimbursement for her psychotherapy for two years in a row. After the second request, not only did the insurance company cancel any coverage for our daughter but cancelled my husbands whole medical office practice insurance for not only our family but the other physicians and office staff that were covered under the policy. Not until we agreed we would never include either myself or my daughter in the policy would they re instate the insurance for the medical office. I had been explaining this never to be forgotten insurance dilemma to my family member and he said once again….but we need “proof on paper” to pay. It’s a sad state of affairs.

        • Wow, Eleanor, I am so saddened, but understanding, of your story. Our health care system is broken. We cannot be like cars, where an accident increases premiums. We need to measure things we can, and not measure things we cannot, and for now, mental health outcomes are, for the most part, not measurable.This is my rant. I will never tire of repeating this. Thanks.

          • Sunflower said

            This thread has special relevance and importance to me. Just last week, my healthcare provider decided after interviewing my psychoanalyst twice over the past few weeks (and also after viewing my LinkedIn page–yes, you read that right) that they cannot justify continued weekly coverage of analysis, but would cut me back to every other week. They had some sort of checklist of questions for my therapist, and because I (1.) have a job, (2.) am in a relationship, and (3.) apparently am not currently in danger of suicide, I no longer really need or deserve weekly coverage. Getting a long letter from the insurer in which their “clinician” explained to me how well I’m doing in all these areas, was nothing short of bizarre. In an entirely unexpected turn of events, within the first “skipped week” of therapy last week, I nosedived into my MDD symptoms, became suicidal and have put myself back on SSRI’s–something I swore I would never do again and believed my regular weekly talk-therapy would allow me to avoid. So now, thanks to this erroneous judgment from the giant insurance company about how I’m doing, I’m getting numbed out again (SSRI’s), further removed from the likelihood of moving forward with my deep and difficult work in analysis (it took the past 3.5 yrs for me to decide I could trust anyone/my therapist enough to get into the “the real stuff” we just started to touch upon–it now feels like there is someone else in the room with us)…and will have to make regular visits ($$) to my primary (medical) care doc to keep the pills (that I hate being on again) flowing my way, and will be utilizing the insurance coverage ($$) toward the prescriptions…. It’s just so damn “bass ackwards,” it’s hard to fathom this is the way it’s all going down.
            So yes, this is all the result of my perceived progress. Beware of posting online a CV that infers any level of “success” if you want to have continued mental health coverage.
            As my Tdoc said of the clinician who made this judgment on my file, “It takes a special kind of therapist to end up in that job.”

            • There is absolutely a third person in the room. There is no question about that. Thank you for sharing your experience, as what you went through is exactly my point. The checklists seem to trump the idea of prevention, or maintaining the progress that you have achieved. The use of the internet to support their conclusion is even more appalling. I love technology, but like everything else, it can be used for good or evil. Thanks Again and welcome to my blog.

            • Sunflower said

              I think you can tell, I am thoroughly enjoying your blog! (Sorry for a million “like” notifications all at once; I just came back to WordPress and got acquainted with your page yesterday…and frankly, am having a hard time with stopping my reading!)

              I wanted to mention–beyond feeling that the insurance rep is in the room with us, I honest to God have a nervous feeling even writing about this here on your blog. I realize this fear is (mostly? somewhat?) not based in reality, but it doesn’t change that it’s there. I feel like I’m in an Orwellian scene and my thoughts are being recorded. No, I’m not schizophrenic…but this has left a very bad feeling in me of being monitored and watched. I never thought any of this would factor into my very private work in psychoanalysis.

              Can I avoid this trap? Sure, once I win the lottery and stop using insurance coverage for my therapy. Unfortunately, I don’t buy lottery tickets.

  5. Hello Sunflower!
    I enjoyed your enthusiasm for my posts. Thank You. I can understand that you feel that privacy has evaporated, both, at large, and specifically in psychotherapy. The presence of a third-party payor changes the relationship. Electronic communication has changed the access to information such that things that used to be hard to find out are now easily obtainable. I don’t think you can avoid the trap, but understanding that the “trap” is there will help you. Knowledge is power, even if it is very unpleasant and unsettling.

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