Formulating Needs and Goals Steve Wood, Lecturer

“Well, my main problem is that meeting people makes me anxious.” “In terms of your mental health, how would you describe your main problem at the moment?” “My main problem is my feelings of anxiety and images of making a fool of myself, accompanied by sweating, muscle tension and nausea and an urge to run away whenever I have to meet unfamiliar people. The anxiety and physical symptoms are quite severe and it occurs at least twice each week. This is affecting my employment, as I have to deal with personal enquiries by members of the public; I have stopped going out socially and my friends have started not to invite me; and it is causing rows between myself and my partner.” Into something like this… You have helped the client convert this…

Reframing problems as needs Having a clear idea of the problem, we want to help the client move towards solutions. It is not easy to move straight from Problems to Goals – we need an intermediate step. This is the process of converting problem statements into statements that form the basis of problem solving activities. You can use it with individual clients (or family members if carrying out family work) as part of the process of forming individual goals.

“Well, if I didn’t have to meet unfamiliar people.” “Well, I suppose I wouldn’t be doing the job I do now.” “Yes, well, if I felt I was at least able to keep the sweating and nausea under control.” “I suppose so.” “Okay, I’ll give it a go.” “So, you need to know a way of keeping those body symptoms under control when you have to meet unfamiliar people. Does that sound right?” “There are simple techniques you can learn to do that. Does it sound like something that we might be able to work on?” “Okay, but you’ve told me that it’s an essential part of your job, and your job’s very important to you.” An example… “So what would that look like?” “So, your main problem is your feelings of anxiety and images of making a fool of yourself, accompanied by sweating, muscle tension and nausea and an urge to run away whenever you have to meet unfamiliar people. What would need to be different for that to no longer be a problem?”

“In terms of your mental health, how would you describe your main problem at the moment?” I worry about my heart. You have helped the client convert this…

My problem is that I worry excessively about my physical health, particularly about my heart. Whenever I need to do anything that involves exertion I start to worry that it will cause a heart attack. I constantly tune in to my heart, take my pulse, and read everything I can about heart attacks and how to avoid them. My body is constantly tense and I tend to get headaches, which I put down to high blood pressure and this makes me worry even more, in case it’s damaging my heart. I never exert myself – never run for a bus, run with the children, try to avoid sex and so on. It’s getting so bad that some days I hardly get out of the house. It’s affecting life at home, because I don’t do anything around the house; social life, as I avoid doing sport and other things I used to do; it’s causing rows with my partner and affecting my relationship with the kids. Let’s have a go at the skill. Half the group role play this client. Other half use the steps of the skill to assist the client to reframe the problem as a need. Into something like this…

So, your main problem is that you’re preoccupied with thoughts that exerting yourself will bring on a heart attack and that these are leading to you constantly checking your pulse and avoiding exertion. What would need to be different for that to no longer be a problem?

“In terms of your mental health, how would you describe your main problem at the moment?” I’m so depressed since I lost my job. You have helped the client convert this…

My main problem is my low mood which has come on over the past 2 months since I lost my job. I’ve got no energy, get tired out easily, I’ve lost my appetite and can’t sleep. I find myself crying for no reason, and sometimes I’ve gone shopping and spent more than I could afford to try and cheer myself up. I’ve stopped seeing friends and lost interest in my hobbies. Into something like this… Let’s have another go. Swap roles. Use the steps of the skill to assist the client to reframe the problem as a need.

“So, your main problem is your low mood. You’ve no energy, get tired easily, you’ve lost your appetite and can’t sleep. You cry for no reason, and sometimes shop and spend more than you can afford to cheer yourself up. You’ve stopped seeing friends and lost interest in your hobbies. What would need to be different for that to no longer be a problem?”

In a family situation, this may be more complicated… Consider the following example – Jo, 22, finds it difficult to get out of bed in the morning. Brian, Jo’s father, thinks Jo is lazy and that it would be much better if Jo went out and got a job. Mary, Jo’s mother, is anxious about placing too many demands on Jo. One morning, Jo is still in bed at 10am. Brian has been up since 8am and is about to take Mary to the supermarket. Just before they leave, Brian calls out “Isn’t it about time you were up? You said you were going job-hunting today.” Jo yells “You’re always on at me. Why don’t you leave me alone?”

GROUP 1 Using the steps of the skill – assist Brian to reframe this problem as a need. GROUP 2 Using the steps of the skill – assist Mary to reframe this problem as a need. GROUP 3 Using the steps of the skill – assist Jo to reframe this problem as a need.

A cognitive behavioural ABC analysis of this illustrates how any issue giving rise to stress within the family is likely to be perceived differently by individual family members, with varying emotional and behavioural consequences. AntecedentBeliefConsequences EmotionalBehavioural 10 am, Jo is still in bed Brian –J’s being lazy J should be up by now AngryCriticises J Nags at J to get out of bed (May reflect underlying beliefs about roles, duty, etc.) Mary -B shouldn’t shout at J I should protect J Angry at B Anxious about J Guilty about herself Tells B to stop Reassures J (May reflect underlying beliefs about maternal role.) Jo -B doesn’t understand me B shouldn’t treat me like a child ResentfulShouts at B “Why don’t you leave me alone” Stays in bed Together, synthesize the needs you formulated individually so that you can offer the family something they can all sign up to work on.