Goal setting in mental health: a scoping review to inform occupational therapy practice

Abstract

Purpose

Goal setting is a crucial aspect of client-centered practice in occupational therapy (OT) for mental health conditions. However, it remains to be seen how goal-setting has been delivered in mental health, particularly the OT process. The purpose of this scoping review was to explore the nature and extent of goal setting delivered in mental health and informed OT practice.

Design/methodology/approach

The authors followed the guidelines of Arksey and O’Malley (2005) and searched three databases using key search terms: “mental disorder,” “goal setting,” and “occupational therapy” and their synonyms.

Findings

After excluding duplicate records, the authors initially screened 883 records and resulted in 20 records in total after the screening process. Most of the identified articles used goal-setting delivered by both a health professional and a client (n = 14), and focused on people with schizophrenia or schizoaffective disorder (n = 13), but three interventions were delivered by occupational therapists. Further research needs on goal-setting in mental health OT, exploring the reliability and validity of different goal-setting strategies and investigating the effectiveness of goal-setting for promoting behavior change and client engagement across various mental health conditions and settings.

Research limitations/implications

The scoping review has some limitations, such as not investigating the validity and reliability of goal-setting strategies identified, and excluding conference papers and non-English articles.

Originality/value

This scoping review presents a mapping of how goal-setting has been delivered in mental health and informed OT practice. The findings suggest limited research in OT and highlight the need for more studies to address the evidence gap in individualized client-centered OT.

Citation

Okita, Y., Kaneko, T., Imai, H., Nair, M. and Tomori, K. (2024), "Goal setting in mental health: a scoping review to inform occupational therapy practice", Irish Journal of Occupational Therapy, Vol. 52 No. 1, pp. 3-20. https://doi.org/10.1108/IJOT-03-2023-0007

Introduction

Occupational therapy (OT) has traditionally played a pivotal role in mental health practice. Occupational therapists are skilled in assessing an individual’s ability to manage daily activities, provide access to the community and engage in tasks that are productive, meaningful and enjoyable (Hardaker et al., 2007). Recent literature indicates that contemporary OT interventions in mental health primarily target areas such as employment, education, psychoeducation, creative occupations/activities, time use/occupational balance, skills/habit development, group/family approaches and animal-assisted therapy (Kirsh et al., 2019). Some systematic reviews focus on specific interventions and populations. For example, the systemic review of OT interventions for employment and education for adults with serious mental illness by Arbesman and Logsdon (2011) concluded that supported employment programs could improve employment and education through goal-setting, skill development and cognitive training. A recent systematic review of OT for everyday life activities in adults with depression found strong evidence of the effectiveness of OT return-to-work interventions but also highlighted the gap in individualized client-centered OT (Christie et al., 2020).

Central to the therapeutic journey is the establishment of rehabilitation goals, which refer to “the desired future state to be achieved by a person with a disability as a result of rehabilitation activities” (Levack et al., 2015). Setting client-centered goals can enhance client engagement and motivation, potentially fostering quicker recovery and improved health outcomes (Sugavanam et al., 2012). Client-centered goal setting is an essential process in delivering quality mental health care. It helps identify service recipients’ functional outcomes and needs in rehabilitation and enables clients to work toward their needs and wants, leading to self-management (Lloyd et al., 2002; Weisz et al., 2011). Further, it also enables clients to reflect on their progress and understand their recovery needs (Andresen et al., 2003; Lenzen et al., 2017). Although some clinicians may consider goal setting straightforward, growing evidence shows it is a complicated procedure requiring appropriate methods and tools for individual needs (Rose and Smith, 2018). Notably, a study across seven rehabilitation wards revealed that nearly 80% of goals established by occupational therapists did not align with the clients’ perceived objectives, thus underscoring the intricate nature and challenges of the goal-setting process (Saito et al., 2019).

Occupational therapists often use client-centered outcome measures, such as the Canadian Occupational Performance Measure (COPM), to identify occupational performance issues and understand the client’s perspective on different activities (Doig et al., 2015). However, some systematic reviews indicate that even with such tools, clinicians face difficulties in identifying client’s issues and needs due to client factors such as impaired cognitive and communication skills, limited recognition of the rehabilitation process, limited awareness of disability impact and possible outcomes and low motivation in setting goals (Leach et al., 2009; Plant et al., 2016).

As the emphasis on evidence-based approaches in mental health intensifies (Kirsh et al., 2019), the significance of client-centered goal-setting becomes ever more apparent, while the details of how the goal-setting has been delivered remain unclear (Christie et al., 2020). In response, we selected a scoping review approach, where the existing evidence can be mapped to explore the extent, range and nature of the evidence on a topic (Arksey and O’Malley (2005). A scoping review not only outlines existing knowledge but also identifies the evidence gap and highlights further research needs. Our review’s primary aim is to thoroughly investigate goal-setting practices in mental health, with a particular focus on their application within OT settings. As our preliminary PubMed search conducted before initiating this scoping review revealed a scarcity of studies specifically dedicated to OT, we have also included studies that address goal-setting within broader mental health contexts. These broader studies may offer insights that are potentially applicable to OT settings.

Methods

The review followed the guidelines of Arksey and O’Malley (2005) and consisted of five steps:

1. defining the research question;

2. identifying relevant studies;

3. selecting studies;

4. extracting data; and

5. summarizing and reporting the results.

Further, we used Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram (Page et al., 2021) for representing the process and reporting purposes:

1. Research questions:

We completed this review to answer the research questions:

RQ1.

What is the scope of goal-setting practices within the domain of mental health, especially in the context of OT?

RQ2.

What is the range of practices relevant to mental health that could be potentially applicable to OT?

• 2 Inclusion and exclusion criteria:

  • The scoping review included articles that met the following inclusion criteria.

  • Articles published in English that address goal-setting in mental health practice.

  • Focus on individuals over the age of adolescence diagnosed with a mental disorder or those that describe health-care professionals within a mental health setting.

• 3 Exclusion criteria is as follows:

  • manuscripts not in English;

  • articles that do not mention goal-setting;

  • studies targeting pediatric populations; and

  • specific article types: conference papers, study protocols and review papers.

The methodological quality of articles was not a deciding factor during the screening process, in line with the guidance that it is not a requisite step in scoping review (Peters et al., 2021). This study considered mental disorder as “a clinically recognizable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions” (Whitfield, 1993). Examples include anxiety disorders; bipolar disorders; dissociative disorders; feeding and eating disorders; personality disorders; somatoform disorders; substance-related disorders; depressive disorders; schizophrenia; trauma and stressor-related disorders. These examples were included in the search terms. Furthermore, we have distinguished between Serious Mental Illness, an umbrella term encompassing a range of mental health conditions, and its subtypes, such as schizophrenia, considering the nature of mental health literature, as some sources do not adequately explain what Serious Mental Illness entails.

Search strategy

For this scoping review, we used the databases including PubMed, Scopus, Web of Science and CINAHL. Our search used key search terms such as “mental disorder,” “goal setting,” and “occupational therapy,” as well as their synonyms. Rather than solely relying on the general term “mental disorder,” we also incorporated specific mental disorder names to ensure a comprehensive search. While our primary aim was to explore the scope of the goal-setting process within the OT settings, we expanded our scope based on discussions among the authors. As a result, our search also encompassed articles that, while not exclusively set within an OT context, presented findings potentially applicable to this domain. The detailed search strategy for each database can be found in Appendix.

Screening process

More than two authors reviewed titles and abstracts to eliminate duplicates and irrelevant studies that did not pertain to “goal setting in occupational therapy for mental health” or “goal setting practices pertinent to mental health that could be applicable to occupational therapy.” The full-text screening was conducted after agreement on inclusion criteria. A third person resolved any discrepancies to determine whether the article met the inclusion criteria.

Charting process

The full text of each included article was read, and data describing goal-setting in mental health were extracted. The authors (TK and KT) developed and refined the charting template after discussion with other authors. Each author extracted data equally, with reliability checked by either YO or KT. Discrepant information was reviewed and agreed upon through discussion between authors. The following information was collected and classified into three categories: Reference, Demographic data including its intervention and main findings and Goal setting. Under “Goal setting,” the following data were gathered to investigate the goal-setting process in each article: goal-setting framework, types of goals, decision-making style, goal-setting tool, who participated in goal-setting, strategy for goal-setting and any additional information as needed. Further, all data were stored in an Excel spreadsheet.

Results

Study selection and characteristics

We conducted the search on the four databases on August 18, 2023, and included articles published up to that date. This initial search yielded 883 records after removing the duplicated articles. Based on the title and abstract, we excluded 851 records first, then excluded an additional twelve articles on full-text screening, which resulted in 20 records in total. Reasons for excluding the 851 records through the title and abstract screening were as follows: not related to OT for mental health; no description of goal setting; non-English study; study protocol; conference paper; review paper. The reasons for excluding the twelve articles through the full-text screening are described in Figure 1.

Table 1 shows all the identified study characteristics including its target population, study setting, intervention, how the goal setting was delivered, type of the goal, decision-making, who participated in the goal setting and characteristics of the goal setting. The included articles were published in the following years: before 2004 (n = 3); between 2005 and 2010 (n = 5); between 2011 and 2016 (n = 8); and between 2017 and 2021, (n = 4). The largest number of studies appeared from the USA (n = 8), whereas only a small number of studies appeared from the following countries: the Netherlands (n = 3); the UK (n = 2); Canada (n = 2); Belgium (n = 1); Denmark (n = 1); Hong Kong (n = 1); Israel (n = 1); and Italy (n = 1). The following study types appeared: observational study, pre-post design, non-random design, feasibility study (n = 9); qualitative study (n = 4); case study (n = 2); randomized controlled trial (RCT) including sub-analysis (n = 4); and descriptive study (n = 1). Over a half of the studies (n = 11) included a sample size of over 50. A large number of studies were conducted in community settings (n = 15). The following number of articles targeted the following mental health diagnosis of target subjects: schizophrenia or schizoaffective disorder (n = 13); serious mental illness (n = 4); bipolar (n = 4); substance use disorder (n = 2); depression (n = 1); and post-traumatic stress disorder (n = 1).

Intervention and main findings

Only three interventions, including occupational goal intervention (Katz and Keren, 2011), specific intervention programs based on each participant’s goals identified during the COPM administration (Richard and Knis-Matthews, 2010), and Goal Attainment Program (Bacon and Hector, 2000) were delivered specifically by occupational therapists. Each of this study used different outcome measures to evaluate the intervention outcome as follows: Wisconsin Card Sorting Tests, Wechsler Adult Intelligence Scale-Digit Span Forward and Backward, Routine Task Inventory–Expanded, Activity Card Sort, Reintegration to Normal Living Index from (Katz and Keren, 2011); COPM and interview data (Richard and Knis-Matthews, 2010); and Goal Attainment Scale, Goal Attainment Scale for Psychiatric In-patients, Validated Goal Attainment Scale for Psychiatric In-patients (Bacon and Hector, 2000).

Characteristics of approaches to goal setting in mental health

A large number of the identified articles used goal-setting delivered by both a health professional and a participant (n = 14). Only two studies had a client-selected goal-setting without a clinician’s involvement (Bell, Lysaker and Bryson, 2003; Casaletto et al., 2016). Nearly half of the identified goals were related to “Activity and Participation” (n = 9), such as improving social, education and leisure activities participation. Other identified goals include specific work performance (n = 1); cognitive, functional competence and vocational domains (n = 1); and Social skills such as improving social skills or gaining self-confidence in social situations (n = 1).

Ten goal-setting tools or strategies were used to help set clients’ goals. Each tool or strategy only appeared in a single study with the exceptions of the following approaches that were used across multiple studies: Boston University approach to psychiatric (BPR) rehabilitation approach (Sanches et al., 2018; Swildens et al., 2011); dialogue (Dalum et al., 2015; Rudnick, 2002); Goal Attainment Scaling (GAS) (Tabak et al., 2015; Vogel et al., 2019).

Goal setting tools or strategies in randomized controlled trials

Among the included articles, four RCTs, including two sub-analysis, assessed the effectiveness of structured or semi-structured goal-setting approaches (Bitter et al., 2017; Sanches et al., 2018; Swildens et al., 2011; Tabak et al., 2015). Two of the included RCTs used the BPR approach (Sanches et al., 2018; Swildens et al., 2011), and the remaining two studies used the GAS and CARe methodology for delivering goal setting (Bitter et al., 2017; Tabak et al., 2015). Primary outcome measures of the RCTs included: informally asking about goal attainment during the interview (n = 2); GAS (n = 1); Working alliance measured with the Working Alliance Inventory (WAI) (n = 1); quality of life measured with World Health Organization Quality of Life questionnaire (WHOQOL-BREF) (n = 1); Psychiatric symptoms measured with Brief Psychiatric Rating Scale (BPRS) (n = 1); Quality of life measured with Manchester Short Appraisal (MANSA) (n = 1); Social functioning measured with Social Functioning Scale (SFS); personal recovery measured with Mental Health Recovery Measure (MHRM).

Two RCTs investigated the effectiveness of BPR, comparing a structured goal-setting approach and a non-structured goal-setting. Swildens et al.’s (2011) study shows that the goal attainment rate was substantially higher for the group using the BPR, where structured goal setting was conducted among people with severe mental illnesses, including schizophrenia, bipolar, depression, personality, addiction and cognitive disorders. This approach also appeared to be a practical approach for improving social participation. However, another RCT used the BPR approach and concluded that only having a good relationship between a client and clinician is not enough to induce successful rehabilitation outcomes, but discussion of clients’ wishes and ambitions and deciding goals together is vital for successful rehabilitation (Sanches et al., 2018). Another RCT from (Tabak et al., 2015) investigated the feasibility of GAS to set goals and measure goal attainment by facilitating collaborative goal setting. This study concluded that GAS is a reliable and sensitive tool to facilitate goal setting and track and measure goal achievement. Furthermore, GAS appeared to facilitate collaborative goal-setting between clinicians and clients (Tabak et al., 2015). Bitter et al.’s (2017) cluster RCT investigated the effectiveness of the CARe methodology in delivering a semi-structured collaborative goal-setting process compared with a control group without this process. Although all clients’ quality of life improved after goal setting with the CARe methodology, a significant difference was not obtained in this study.

Discussion

The present scoping review aimed to explore the scope of goal-setting practices within the domain of mental health, particularly in the context of OT. However, only three of the identified articles were specific to OT settings, highlighting a need for further research in this area. Furthermore, the absence of identified RCTs delivered by occupational therapists suggests a potential limitation of high-quality evidence in mental health goal-setting within OT. These results raise questions about whether mental health OT services are being delivered effectively. Previous research has suggested that goal-setting is included in supported employment programs for generating positive outcomes for adults with serious mental illness (Arbesman and Logsdon, 2011). As our findings highlight a need for more research on goal-setting in mental health OT, further studies should investigate the optimal way to set goals and maximize outcomes in mental health services. Moreover, individualized goal-setting is integral to delivering client-centered OT, and recent research has identified a gap in this area in the context of OT for everyday life activities in adults with depression (Christie et al., 2020), aligning with our findings that highlight limited research on goal-setting in mental health OT. Despite the increasing attention paid to evidence-based practice research (Sultana et al., 2020; Tucker et al., 2021), the steady publishing rate of articles on goal-setting in mental health suggests that more attention is needed. Considering the limited evidence available to guide a client-centered approach and goal-setting in OT, more research in this field is necessary.

This review aimed to encompass goal-setting processes within mental health that could be pertinent and transferable to OT practice. Most of the included articles in our review delivered goal-setting in an interview setting involving both a health professional and a client. This predominance of the interview approach could be associated with the nature of the client’s mental health conditions, where communication and cognitive skills are often affected, limiting the clients’ ability to express their needs without receiving prompts or encouragement from others (Green, 2006; Weickert and Goldberg, 2005). Despite the importance of facilitating the client’s involvement in the goal-setting process (Weiste et al., 2022), none of our identified studies investigated the quality of the interview-based goal-setting process. This prompts the question: Is the prevailing goal-setting process in mental health truly aligned with best practices for client-centered care? A recent study spotlighted an intriguing discrepancy: although a majority of occupational therapists and their clients believed they collaboratively set goals, only 21% of the goals genuinely reflected mutual agreement. This finding emphasizes a palpable gap in shared decision-making, despite perceived participation in goal-setting (Saito et al., 2019). To our knowledge, there is no study that investigated quality of goal setting process within mental health available yet. While tools such as the Client-Centeredness of Goal-Setting (C-COGS) scale exist (Doig et al., 2015), their application and appropriateness in the context of mental health, especially within OT, remain unexplored. Moving forward, research should not only assess the quality of goal-setting within OT services in mental health but also examine the feasibility of current evaluation tools, ensuring that the goal-setting process maintains a high standard of quality.

Interestingly, nearly half of the goals outlined in the articles we reviewed were centered on activity and participation. This prompts questions about the current priorities within OT practices in mental health. Earlier qualitative research that examined narratives from nine mental health occupational therapists highlighted the challenges they faced when oscillating between occupation-centric and psychology-centric approaches. This study emphasized the pressures some therapists experienced, feeling inclined to adopt psychological frameworks over occupation-focused models in their mental health practices (Ashby et al., 2016). Yet, our study did not pinpoint goal-setting that explicitly followed a psychological frame of reference. This gap leaves us pondering the expected methodologies of goal-setting in contemporary mental health OT. The Occupational Therapy Practice Guidelines for Adults Living with Serious Mental Illness, published in 2018 based on systematic review findings, provides some insights. Following this, Lannigan and Noyes (2019) elaborated in their article on how this systematic review’s evidence could inform and steer clinical decisions. Notably, their research advocated for the COPM as a pivotal tool for goal-setting, thereby establishing a foundation for devising OT intervention strategies. Considering the clinical guidelines and the ongoing discussions among mental health occupational therapists about the optimal model for their practice, there is an evident need for deeper research. Such endeavors would offer clarity on the roles and responsibilities of occupational therapists navigating the evolving realm of mental health care.

Regarding the outcomes used in the four included RCTs, most of the studies measured the effectiveness of the intervention for goal attainment and/or quality of life. This is despite the recognized importance of assessing motivation and engagement, critical elements in delivering a client-cantered practice within OT. Goal-setting is not just a procedural step; it plays an instrumental role in amplifying a client’s motivation and instigating behavioral change. Consequently, this boosts the overall efficacy of rehabilitation services and the positive outcomes they yield (Siegert and Levack, 2015; Wade, 2009). Despite this, none of the included RCTs measured the effectiveness of goal-setting for behavior change or the client’s motivation or engagement level. Furthermore, although we used specific search terms to identify mental health disorders such as eating disorders, personality disorders and trauma-related disorders, our results did not include any studies targeting these populations. Considering these two factors, future research needs to measure the effectiveness of goal setting for behavior change and their motivation and engagement level in populations with a broader range of mental health disorders.

Study limitations

This scoping review followed the guidelines of Arksey and O’Malley (2005), but several limitations were identified. One major limitation is that the study did not investigate the reliability and validity of each identified goal-setting strategy. Therefore, the validity and reliability of each goal-setting strategy remain unclear. While this omission can be considered a significant limitation, this scoping review was successful in mapping the existing evidence in goal-setting strategies for OT in mental health by addressing the research questions according to the scoping review guidelines.

Another limitation is that we excluded protocol papers and conference papers, and it is possible that we have missed unpublished information on the most recent goal-setting strategies for mental disorders. Additionally, this review only included articles published in English, which raises questions about whether there is more evidence available in this area in other languages.

The limited number of included articles and the exclusion of gray literature might also have led to potential bias in our findings. Additionally, we did not perform a meta-analysis or other statistical analysis to quantitatively synthesize the data. However, given the heterogeneity of the identified articles in terms of methodology, participant characteristics and intervention strategies, a quantitative synthesis would not have been appropriate.

Finally, this scoping review did not assess the risk of bias of the included studies, which could be considered a limitation. Future research in this area should consider conducting a systematic review or meta-analysis to more thoroughly assess the quality and risk of bias of the included studies.

Conclusion

In summary, this scoping review has revealed a need for further research on goal-setting in mental health OT (see Table 2). While most of the identified studies involved a collaborative goal-setting process between a health professional and a client, the evidence base is limited in terms of its quality and scope, with only a few studies specifically focusing on OT settings. These findings raise questions about the effectiveness of current mental health OT services and highlight a need for more targeted and individualized approaches that better reflect clients’ needs and goals. Given the limitations of the current evidence base, future research should investigate the reliability and validity of different goal-setting strategies and explore the effectiveness of goal-setting for promoting behavior change and client engagement across a range of mental health conditions and settings. To achieve this, it is essential to prioritize research in OT and identify research needs and gaps in this area, as well as to encourage the use of standardized assessments and interventions in practice. Ultimately, addressing these issues will help to optimize the delivery of client-centered OT in mental health settings and ensure that clients receive the best possible care and support.

Key points

• Most of the identified articles used goal-setting delivered by both a health professional and a client, and focused on people with schizophrenia or schizoaffective disorder.

• More research is required to understand how goal-setting should be delivered specifically in OT sessions.

Figures

Figure 1

 Literature searching and screening process

Figure A1

 Literature searching and screening process

Table 1

Summary of study characteristics, analysis and findings

Reference	Published country	Study design	Target population, study setting	Intervention	Findings
Bell et al. (2003)	The USA	Observational study	N = 63 Schizophrenia or Schizoaffective disorder, Community	BI	Results showed that those receiving the BI had significantly greater improvement on the WBI subscales overall and specifically on social skills, personal presentation and cooperativeness. Those in BI also worked significantly longer, 36% more hours and 22% more weeks. Additionally, those in BI showed a trend toward greater improvements on measures of motivation, sense of purpose and enjoyment in life. Results indicate that BI can improve work performance, particularly for interpersonal behaviors that are less likely to be addressed by work supervisors, increase job retention and may enhance feelings of motivation, sense of purpose and enjoyment in life
Bitter et al. (2017)	The Netherlands	RCT	N = 263 severe mental health, community	CARe	All clients improved in quality of life. However, no significant differences were found between the clients of the both conditions on any outcome measure. Possible explanations of these results are: the difficulty to implement rehabilitation-supporting practice, the content of the methodology and the difficulty to improve the lives of a group of people with longstanding and severe impairments in a relatively short period. More research is needed on how to improve effects of rehabilitation trainings in practice and on outcome level
Bowie et al. (2017)	Canada	Observational study	N = 50 serious mental illness, vocational rehabilitation	tCR and ABCR	Compared with a traditional CR program that relied on the same computerized training but with only group discussion of strategies and generalization, ABCR produced larger effects on functional capacity and work outcomes. This suggest that establishing an active training environment with more direct therapist involvement and supportive guidance can yield functional improvements that are more robust than traditional CR. Collectively, these findings suggest that a distinction between cognitive training and cognitive remediation is the latter’s focus on restoring everyday functioning, yet it need not be at the expense of targeting neuroplasticity
Casaletto et al. (2016)	The USA	Observational study	N = 90 HIV + SUD, 30 received GMT, 30 received GMT + metacognitive training and 30 control, unclear setting	GMT or GMT and metacognitive training	Results showed that GMT and GMT + Metacognitive training groups demonstrated small benefits compared to the control group but did not differ from one another. When GMT groups were combined, there were significant medium effect size benefits in Everyday MT performance and metacognitive task appraisals as compared to the control condition. Among participants who underwent GMT, benefits were most prominent in persons with poorer pre-training dual-tasking ability, depression and methamphetamine use disorders
Dalum et al. (2015)	Denmark	Qualitative study	N = 16 HCPs	No information	Three themes emerged from the HCPs’ reflections on changes in attitudes and practices: “Hopeful Attitude” captures a change in the HCPs’ attitude toward a more positive view on the future for clients’ living with mental illness; “A New Focus in the Dialogue With Clients” thematizes how the HCPs focus more on the individual’s own goal for recovery rather than disease-induced goals in the dialog with clients; “A Person-Centered Role” comprises a shift in the professional role whereby the HCPs value the client’s own ideas in addition to the professional’s standards
Fakhoury et al. (2005)	UK	Qualitative study	N = 41 schizophrenia or related psychotic disorder, and staff of supported houses, community	No information	Clients’ most frequently reported goal was moving to independent housing, followed by staying healthy and increasing living skills. A comparison of goals reported by clients and staff showed poor or no agreement between them. Cluster analyses identified two clusters of clients. Cluster A contained those with no stated goals (or with the aim of staying healthy), lower quality of life and more psychopathology; cluster B included those with an aim to move to independent housing, better quality of life and less psychopathology. In the United Kingdom, more staff training may be needed to identify and achieve the goals of the “new” long-stay clients
Ferguson et al. (2009)	UK	Observational study	N = 14 schizophrenia, paranoid schizophrenia and bipolar disorder, community (forensic care)	Well-being interventions (a new, empirically derived, well-being intervention)	There was a significant effect of treatment on well-being and symptoms of mental illness. By the end of treatment (and maintained at two-month follow-up), participants reported reduced hopelessness and negative affect and increased positive future thinking. They were also rated as presenting with fewer negative symptoms of psychosis. Participants also reported higher levels of satisfaction with life two months post-intervention compared to pre intervention. The results support the view that developing goal setting and planning skills in mentally disordered offenders enhances well-being and impacts on symptoms of mental illness
Godley et al. (2008)	The USA	Descriptive study – extracted from charts completed by each participant	N = 86 adolescents with substance use disorders, community	Different types of continuing care interventions	The most popular goal area from which activities were chosen was social/recreational. Ninety-eight percent of participants chose at least one activity from this category. The most often chosen activities included completing the Adolescent Leisure Questionnaire, watching movies, going shopping and participating in a sports activity. Verification for these activities included the completed Adolescent Leisure Questionnaire, movie ticket stubs, retail store receipts, gym logs and a written description of the sports activity. In total, 933 social/recreational activities were selected, and 64% were completed and verified by the case manager
Katz and Keren (2011)	Israel	Observational study	N = 18, adult participants ages 20–38 with schizophrenia, community	OGI	No significant differences were found among the groups on pre-test to post-test change; however, significant differences were found within groups before and after intervention and moderate to high effect sizes. The OGI group showed relative improvement on all measures of executive functioning and activity and participation. Results provide initial support for the OGI’s effectiveness for clients with schizophrenia
Levaux et al. (2012)	Belgium	Case study	N = 1 schizophrenia, community	modified version of GMT	The results revealed improvement in planning and on trained laboratory and meal preparation tasks and a generalization of GMT effects on nontrained laboratory and everyday tasks. Self-esteem also improved. Finally, a two-year follow-up indicated the durability of the beneficial effects
Magliano et al. (2016)	Italy	Observational study	N = 96, residents diagnosed with schizophrenia, schizoaffective disorders or a personality disorder, N = 55 CIGI, N = 41 TAU, Community	CIGI	Findings showed a significant interaction effect between users’ functioning at baseline and follow-up assessments, and the intervention. In particular, change in global functioning was higher in the 55 CIGI users than in the 44 TAU users. These results suggest that CIGI can be successfully introduced in residential facilities and may be useful to improve functioning in users with severe mental disorders
McGuire et al. (2015)	The USA	Qualitative study	N = 21 veterans with schizophrenia spectrum disorder, depression, bipolar disorder or PTSD, Community	No information	Themes indicate people with differing self-experiences differ in how they form goals and the barriers they face in this process. This study finding suggests that the differences in ontological status and threat to ontology seen among the four dialogical self-types have important implications for the goal-setting process
Bacon and Hector, 2000)	Hong Kong	Pre-post design	N = 25 patients diagnosed with schizophrenia with length of stay of over one year, hospital	Goal attainment program	The overall results of this study verified the effectiveness of the Goal Attainment Program in instilling hope in chronic patients with schizophrenia and the use of the Goal Attainment Scale in documenting patients’ progress
Richard and Knis-Matthews (2010)	The USA	Observational study	N = 7 Schizophrenia, Community	Specific intervention programs based on each participant’s goals identified during the COPM administration	In a client-centered, community residence program for people diagnosed with mental illness, programming would be driven by goals identified by the client in collaboration with the occupational therapist. In this case, the occupational therapist, working in the residence, had a therapeutic relationship with each of the client participants for a minimum of one year. During that time the occupational therapist developed and implemented programming based on what she perceived as the client goals. On analysis of the COPM, however, convergence between the clients’ perceived goals and those that the occupational therapist identifies for those same clients was not evident
Rudnick (2002)	Canada	Case study	N = 1 schizophrenia, community	No information	The result may be that C and her clinician set the goal of homelessness for her psychiatric rehabilitation, if they come to agree that her well-being would benefit most from that. Alternatively, they may agree to disagree on the appropriate living goal for her psychiatric rehabilitation, in which case the process of psychiatric rehabilitation for that goal may be put on hold, without necessarily disrupting the therapeutic alliance
Sanches et al. (2018)	The Netherlands	RCT-sub analysis	N = 156 Serious Mental illness, Hospital	BPR	A good bond between client and practitioner is not enough to attain successful rehabilitation outcomes Findings suggest that it is important to discuss clients’ wishes and ambitions and form an agreement on goals. Attaining rehabilitation goals directly influenced the subjective quality of life of individuals with serious mental illness, which underscores the importance of investing in these forms of client support
Stackert and Bursik (2006)	The USA	Qualitative study	N = 136 schizophrenia, schizoaffective disorder or bipolar disorder, community	No information	Rehabilitation goals were more prevalent at lower stages of ego development, while goals such as enhancing one’s personal relationships, and gaining increased insight emerged at higher stages
Swildens et al. (2011)	The USA	RCT	N = 156 Severe Mental Illness, Community	BPR	The rate of goal attainment was substantially higher in BPR at 24 months. The approach was also more effective in the area of societal participation but not in the other secondary outcome measures. BPR is effective in supporting patients with Severe Mental Illness to reach self-formulated rehabilitation goals and in enhancing societal participation, although no effects were found on the measures of functioning, need for care and quality of life
Tabak et al. (2015)	The USA	RCT-sub analysis	N = 55 schizophrenia and schizoaffective disorder, community	CBSST or GFSC	The most common goal chosen by consumers was establishing or re-establishing relationships, followed by self-care, employment, leisure activities, housing, school, independent transportation, recovery from addictions and money management. Results indicated a significant increase in mean goal attainment corresponding to “talks to support person about goal,” “actively engages in goal activity = behavior at least once” at end of treatment. This preliminary evidence suggests the GAS measure is sensitive to change in a clinical trial. GAS is a promising recovery-oriented therapeutic tool and functional outcome measure for consumers with Severe Mental Illness
Vogel et al. (2019)	The Netherlands	Feasibility study	N = 9 schizophrenia, bipolar disorder or schizoaffective disorder, multiple settings (patient’s house, hospital, community)	The HY intervention	In personal interviews participants reported positive effects on social support, loneliness and self-esteem. Nurses reported that participants became more independent during the intervention. Participants were satisfied with the HY-intervention. All were able to organize a dinner for their peers with practical support from a nurse. Pre and post -intervention measures did not show important improvements. The HY intervention was well received by participants and nurses. Participants were motivated to work on personal goals. Also, positive changes in personal recovery topics were reported by participants

Notes:

Action-based cognitive remediation – ABCR; behavioral intervention – BI; Boston Psychiatric Rehabilitation – BPR; Canadian Occupational Performance Measure – COPM; cognitive behavioral social skills training – CBSST; combined individual and group intervention – CIGI; comprehensive approach to rehabilitation – CARe; goal attainment scaling – GAS; goal focused supportive contact – GFSC; goal management training – GMT; health-care professionals - HCPs; multitasking test – MT; occupational goal intervention – OGI; post-traumatic stress disorder – PTSD; substance use disorder – SUD; the hospitality – HY; traditional cognitive remediation – tCR; treatment as usual – TAU; well-being inventory – WBI

Source: Authors’ own work

Table 2

Summary of goal setting explained in each reference

Reference	How the goal setting was delivered	Type of the goal	Decision-making	Who participated in the goal setting	Characteristics of the goal setting
Bell et al. (2003)	No tools but wrote the goal on a time sheet	A specific work performance goal	Participant only	Participant only	After discussion and group problem-solving, a specific work performance goal was set for the next two-week period. The worker wrote the goal on a time sheet that the worker kept for recording daily work hours. At each group meeting, the worker was asked about efforts toward meeting the goal. When that goal was met, the worker would set a new goal. In this manner, WBI feedback was fully used to promote specific work performance changes and to recognize improvement
Bitter et al. (2017)	No information	Unclear	SDM	HCPs (rehabilitation practitioners had backgrounds in social work, nursing or vocational rehabilitation)	Goal setting was delivered as a part of CARe methodology Theoretical principles of the CARe methodology: recovery, presence, strengths oriented working, social participation and using environmental resources CARe follows: Building a partnership with a client and the basic principles of supporting clients Connecting to the recovery process of a client Inventorying the client’s wishes and strengths and seeing possibilities to realize these Formulating concrete goals with the client Draw up plans: a personal plan for the client and a support plan for the professional Introduction to the CARe Toolkit with specific tools for specific cases, for example an instrument to map a client’s social network
Bowie et al. (2017)	ABCR	Cognitive, functional competence and vocational domains	SDM	Participant and therapist	ABCR was used for goal setting and behavioral activation procedures at baseline and every five sessions to help participants identify their work-related goals as well as small steps they could take to reach those goals. The activities used in session were reviewed in the context of how the cognitive abilities and work skills were related to their individual goals. Therapists helped participants identify, document and plan how they could engage in challenging and cognitively stimulating everyday activities to build on the computerized training tasks
Casaletto et al. (2016)	GMT	Unclear	Participant only	Participant only	As a part of GMT As such, GMT is divided into five goal monitoring stages: Stop (before beginning a new task); Define (the task goal); List (the steps needed to complete that task); Learn (how you will complete the steps); and Check (ensure behaviors are goal directed/on task)
Dalum et al. (2015)	Dialogue	Activity and participation	SDM	HCPs and clients	The professional and the client are frequently talking about the client’s goals, dreams and hopes. This focus has become an integrated part of the overall practice for many of the interviewed health-care professionals
Fakhoury et al. (2005)	No information	Unclear	No information	Unclear	No information
Ferguson et al. (2009)	GAP	Unclear	No information	Unclear	GAP for use in a forensic setting, for example, consideration was given to patients’ current concerns and they were offered choice about the goals they wished to pursue, which is consistent with GAP. The goals selected were specific, realistic, of value to the individual and achievable within a relatively short time period
Godley et al. (2008)	Adolescent Leisure Questionnaire	Activity and participation	SDM	HCPs and participant	To help adolescents identify new prosocial activities to try, during the first session, all adolescents were asked to consider completing the Adolescent Leisure Questionnaire, which was based on the Leisure Questionnaire and Rosenthal and Rosenthal. This questionnaire has 150 potential activities in 10 categories and was tailored to appeal to the interests of adolescents. The categories were education, employment, family/friends, health, legal, personal improvement, sobriety, social/recreational/household and other. Participants were asked to check whether each activity (e.g., keeping a diary, completing a job application, sunbathing) interested them very much, much, a little or not at all. They were also asked to identify which five activities they were most interested in completing. Alternatively, they could list other activities if they did not find ones that interested them in the existing list. Clinicians used the completed leisure checklist to encourage adolescents to engage in activities they might enjoy without substance use, and in turn, earning the opportunity to draw for prizes
Katz and Keren (2011)	OGI	Activity and participation	SDM	OT and participants	The OGI program focuses on strategy learning using activities and everyday tasks. The steps of the program followed with a focus at the beginning on the individual choice of meaningful activities and at the end on debriefing of the activity performance. In the stage of OGI program, the specific goals were selected and defined. The treatment process emphasized the use of functional activities in three main domains: food preparation; money management; and reading, writing and using computers for information seeking. However, the functional domain was adapted to each client’s choices and needs when the client preferred to work on other activity domains
Levaux et al. (2012)	GMT	Activity and participation	SDM	HCPs and participants	As a part of GMT process - GMT process follows stop: orient awareness toward the actual state of the situation; define: the goal of the task; list: the task into sub-steps; learn: the steps; and check: if the result of an action corresponds to the stated goal
Magliano et al. (2016)	GP form	Unclear	SDM	HCPs and participants	As a part of VAOD approach or The Falloon’s psychoeducation approach – The GP form issued to develop written plans for the attainment of specific goals developed in the 28 domains examined by the Functional Assessment interview
McGuire et al. (2015)	No information	unclear	No information	No information	No information
Bacon and Hector, 2000)	The validated ten-item version of the GAS for Psychiatric	Activity and participation	SDM	HCPs and participants	The individualized four-stage cyclical model Goal Attainment Program was structured in a logical development sequence from affirming personal worth, imaging the future, establishing a sense of control to setting goals for the future
Richard and Knis-Matthews (2010)	COPM	Unclear	SDM	HCPs and participants	Each student researcher was responsible for interviewing three or four of the seven participants about his or her goals and then they also interviewed the occupational therapist about her perception of the client goals using COPM
Rudnick (2002)	Dialogue	Unclear	SDM	HCPs	Dialogue was guided by sound procedures of discussion that are agreed upon by the parties involved. This enabled both clients and clinicians to reflect on their set goals and underlying values and therefore to change them in accordance with sound arguments
Sanches et al. (2018)	BPR	Activity and participation	SDM	HCPs (rehabilitation practitioners had backgrounds in social work, nursing or vocational rehabilitation)	This approach is designed to support individuals with serious mental illness in all life domains (housing, education, work and social contacts). In BPR, individuals are aided in exploring their options and in choosing and realizing clearly defined goals. Support is aimed at increasing personal skills as well as learning to make use of other potential sources of help. BPR consists of four phases: exploring, choosing, getting and keeping rehabilitation goals. Each phase is accompanied by techniques that can be used by BPR practitioners to optimally support individuals in attaining their goals. Key to BPR is that the pace and direction of the process are directed by the individual. The practitioner facilitates the process and supports when necessary
Stackert and Bursik (2006)	No information	Unclear	Unclear	No information	No information
Swildens et al. (2011)	BPR	Activity and participation	SDM	HCPs and participants	As part of BPR process: The approach has 3 clearly described phases: setting a goal, that is, helping patients gain insight into their goals in the rehabilitation areas of work or study, social contacts and living environment and into the skills and resources needed to attain these goals; planning, that is, describing necessary interventions (skill training, support) to achieve these goals, and carrying out these interventions
Tabak et al. (2015)	GFSC and GAS	Activity and participation	SDM	Therapists and participants	Both treatments included 36 weekly 2-h group therapy sessions focused on recovery goal attainment, and both included individual goal setting, tracking sessions every three months using GAS
Vogel et al. (2019)	GAS and SMART formulated goals	Varied: organizing and preparing group meals, cooking and hosting a group of people to cooking healthy, dealing with budget or grocery shopping, having more social contact with others, social skills or gaining self-confidence in social situation and having peer contact specifically about diagnosis-related subjects	SDM	Nurse and participants	The nurse and participant meet for the first time, preferably at the participant’s home. The intervention is explained. Goals and wishes of the participant are explored with a semi structured interview using GAS for setting SMART goals

Notes:

Action-based cognitive remediation – ABCR; Boston Psychiatric Rehabilitation – BPR; Canadian Occupational Performance Measure – COPM; adapted goal setting and planning – GAP; goal attainment scaling – GAS; goal focused supportive contact – GFSC; goal management training – GMT; goal planning – GP; health-care professionals – HCPs; occupational goal intervention – OGI; shared decision-making – SDM; specific, measurable, achievable, relevant, time bounded – SMART; Valutazione di Abilità e Definizione di Obiettivi; in English, skills assessment and definition of goals – VAOD; well-being inventory – WBI

Source: Authors’ own work