Why involve patients in goal setting? A guide for speech and language therapists

Goals that come from the person, not just the therapist, give therapy a reason that matters to them. The research suggests that goal setting can build people's confidence in managing their own recovery. Yet truly shared goal setting is still uncommon, especially when someone has aphasia or another communication difficulty. This post looks at why it's worth the effort, and how to make it work in a busy caseload.

What does involving the person actually mean?

Involving someone in goal setting is more than asking "what would you like to work on?" at the end of an assessment. It means the person (and, where they want, their family) helps decide:

• what matters in their everyday life: the conversations, roles and activities they want back

• which goals come first, when there's more to work on than one block of care allows

• what success looks like, in words they recognise

• how progress is checked, and when goals change

The therapist still brings the clinical picture: what's realistic, what the assessment shows, and which approaches have evidence behind them. Shared goal setting brings the two together, rather than choosing one over the other.

What does the research say?

The honest answer: the evidence is promising but not yet strong, and it points most clearly to how people feel about their recovery.

• Confidence and quality of life. A Cochrane review by Levack and colleagues (2015) looked at goal setting for adults with acquired disability in rehabilitation. Compared with no goal setting, it may improve self-efficacy (people's belief they can manage their own recovery) and health-related quality of life or emotional status. The certainty of evidence was low to very low, and effects on activity were small.

• Patient-centred goals are rarely the norm. A systematic review of stroke rehabilitation by Rosewilliam, Roskell and Pandyan (2011) found patient-centred goal setting was "minimally adopted" because of various barriers, with some evidence of benefits for psychological outcomes.

• In aphasia, it's harder still. Hersh and colleagues (2012) drew on interviews with 50 people with aphasia, 48 family members and 34 speech pathologists. They found collaborative goal setting "remains uncommon" and is "particularly difficult to achieve for people with aphasia".

• Families are often left out. In interviews with 34 speech-language pathologists (Sherratt and colleagues, 2011), some clients had no goals set, "particularly for family members", often because of limited contact.

So the case for involving people rests on two things: a reasonable signal that it supports confidence and wellbeing, and the principle that therapy should serve the person's own life.

Why it's harder, and matters more, when communication is affected

Goal setting usually happens through conversation: open questions, abstract ideas like "independence", and a lot of talking. That is exactly what aphasia, dysarthria or cognitive-communication difficulties make hard.

The risk is that the goals quietly become the therapist's goals. They might be sensible, but they're not the person's. And a person who can't easily say "that's not what I care about" may simply go along with them.

That's why Hersh and colleagues suggest negotiating goals in a SMARTER way: Shared, Monitored, Accessible, Relevant, Transparent, Evolving and Relationship-centred. It doesn't replace SMART goals. It changes how you get to them.

Practical ways to involve people with communication difficulties

1. Start with life, not speech. Ask about family, home, going out, work and hobbies before you ask about communication. Goals often appear on their own.

2. Use pictures and written key words. Offer choices the person can point to, rather than open questions they have to answer in full.

3. Rate, don't explain. Simple scales (stars for "how important?", faces for "how is it now?") let people show priorities without long explanations.

4. Give it time. Goal setting can be a session in its own right. It's not a box to tick at the end of an assessment.

5. Bring in family, with the person's permission. Families have their own goals too, and they often know what matters at home.

6. Write goals in their words. Put "chat with my grandchildren at Sunday dinner" on the page, then add the measurable detail underneath.

7. Check back regularly. Goals evolve. Review them with the person, show progress visually, and change them when life changes.

When the person can't fully take part

Some people can't take part in goal setting fully, for example after a severe stroke or with advanced dementia. That doesn't mean their voice drops out.

• Support first. Make every reasonable effort to help the person communicate their wishes, with pictures, gesture, yes/no questions, time and a familiar person present.

• Follow your capacity law and professional guidance. Depending on where you work, decisions are guided by the person's will and preferences or by their best interests. Check your local legislation and service policy.

• Involve the people who know them. Family and carers can say what mattered to the person before, and what they seem to enjoy now.

• Record how you did it. Note how the person was involved, what supports you used, and who else contributed. That protects them, and you.

Making it easier: the goal brainstorm in Clinician HQ

We built a goal brainstorm into Clinician HQ to make this kind of session easier to run. You go through four short steps together: what matters, ideas, how important, and priorities. It uses big pictures, few words, stars and faces, and you can share a patient screen in the room or by telehealth.

The person's priorities then turn into goals, sessions and progress tracking. You also get a goal setting report drafted for you to check and edit. Patient information stays on your own device.

See Clinician HQ or join as a clinician.

• Levack WMM, Weatherall M, Hay-Smith EJC, Dean SG, McPherson K, Siegert RJ (2015). Goal setting and strategies to enhance goal pursuit for adults with acquired disability participating in rehabilitation. Cochrane Database of Systematic Reviews, CD009727.

• Rosewilliam S, Roskell C, Pandyan A (2011). A systematic review and synthesis of the quantitative and qualitative evidence behind patient-centred goal setting in stroke rehabilitation. Clinical Rehabilitation, 25(6), 501–514.

• Hersh D, Worrall L, Howe T, Sherratt S, Davidson B (2012). SMARTER goal setting in aphasia rehabilitation. Aphasiology, 26(2), 220–233.

• Sherratt S, Worrall L, Pearson C, Howe T, Hersh D, Davidson B (2011). "Well it has to be language-related": Speech-language pathologists' goals for people with aphasia and their families. International Journal of Speech-Language Pathology, 13(4), 317–328.