International Journal of Mental Health Promotion

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DOI: 10.32604/ijmhp.2022.020090

ARTICLE

“Goals Give You Hope”: An Exploration of Goal Setting in Young People Experiencing Mental Health Challenges

Jamie Penno*, Sarah Hetrick and Grant Christie

Department of Psychological Medicine, The University of Auckland, Auckland, 0626, New Zealand
*Corresponding Author: Jamie Penno. Email: jpen174@aucklanduni.ac.nz
Received: 03 November 2021; Accepted: 29 June 2022

1  Introduction

New Zealand, although often perceived as having an enviable quality of life, has some of the worst rates of youth suicide, self-harm, anxiety and depression worldwide [1]. Anxiety and depression are not only risk factors for suicide [2,3], but are also associated with poorer overall health, decreased quality of life, and increased risk of developing additional disorders [4,5]. Initial analysis of the national Youth’19 survey, a cross-sectional community epidemiological study, suggests that the mental health of our young people is not only severely lacking, but is also actively deteriorating [6].

Current recommended first-line psychotherapies for youth with mood and anxiety disorders include Cognitive Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) [7,8], with treatment studies reporting improvements in depression and anxiety symptomatology for each [9,10]. CBT is also a recommended treatment for youth addictive disorders [11]. There is limited evidence for the efficacy of treatments targeting self-harm in young people in particular, but CBT, Mentalisation-based therapy (MBT), and Dialectical behaviour therapy (DBT) may be beneficial [12,13]. Acceptance and Commitment Therapy (ACT) also shows promising results for a range of mental health disorders [14].

A therapeutic element seldom studied but common to each of these psychotherapies is goal setting. Goal setting has a role in the delivery, and possibly the efficacy, of a multitude of mainstream therapies. Defined by Latham as ‘the aim of an action’, the purpose of which is to move an intention from thought into action steps [15], the practice of goal setting brings with it an array of benefits including enhanced interest in the activity involved and increased self-efficacy, as well as the practical outcomes of the goals themselves [15].

As Marks reflects in his article The Maturing of Therapy, “therapy is coming of age regarding efficacy for anxiety and depression, but is only a toddler regarding the scientific principles to explain its effects” [16]. The prevalence of goal setting in current mental health treatments, as well as its efficacy as a health behaviour change technique in non-psychiatric populations [17], suggests that it may play a pivotal role in psychotherapy. For example, within CBT, goal setting is used for setting cognitive and behaviour change targets and promotion of behavioural activation [18]. In DBT and ACT, patients are explicitly encouraged to set goals [19,20], while therapies such as IPT and MBT use goal setting indirectly as patients are encouraged to work towards therapeutic targets [21].

Goal setting’s efficacy as a behaviour change technique also proves pertinent in light of the evidence showing the positive impacts of certain lifestyle factors on mental health, such as physical activity [22], diet [23], and sleep habits and mindfulness [24].

A fuller understanding of goal setting’s usefulness and efficacy, as perceived by youth, may aid in the development and deployment of more effective interventions, providing a small stepping-stone on the path towards addressing our current mental health crisis. This becomes critical, as the health of our young people plays a crucial role in the health of our society, with mental and substance use disorders forming the majority of the disease burden for youth in high-income countries [25], and current unmet youth mental health needs becoming future adult population health deficits.

In this study we aim to explore young people’s lived experiences with goal setting as a therapeutic technique. Through a series of interviews we strive to create a nuanced understanding of young people’s perception and use of goal setting, and its potential significance in the realm of professional therapy.

2  Method

A qualitative research design involving semi-structured one-on-one interviews was used, with recruitment taking place in mid-late 2019. Young people who had previously participated in focus groups for a related project were approached, as well as young people sourced through a psychiatrist, a practicing clinical psychologist, and a LGBT youth support worker. Competent young people aged 12 to 25 years who had personal experience with mental health challenges were given information on the study and consented for participation. Purposive sampling [26] was used, and it was ensured that the sample contained both males and females, and those who self-identified as Pākehā (New Zealand European) as well as Māori.

Interview questions were developed based on goal setting theory and self-efficacy literature, and were designed to be open-ended with a focus on the participant’s subjective experience of mental health and goal setting (see Appendix A). Nine one-on-one semi-structured interviews were conducted at sites chosen by participants. Interviews were audio-recorded on site and later transcribed verbatim. Analysis was conducted using Braun & Clarke’s six-phase process of thematic analysis [27].

This study was given ethics approval by the New Zealand Health and Disability Ethics Committee (18/STH/30).

3  Results

Nine participants aged 16–24 years were interviewed. Our sample included six females, two males, and one gender queer individual. Ethnicity was not formally recorded, but the sample was known to contain both Māori and NZ European (self-identified) youth. The majority had a formal diagnosis of either depression or anxiety, with many also having co-existing mental disorders.

Six key themes emerged which are discussed below. Relationships between each of these themes can be found in Fig. 1.

Figure 1: Relationships between themes and subthemes found in the data

3.1 Motivation for Goal Setting and Goal Achieving

Several subthemes emerged as sources of motivation for young people’s goal setting including self-drive, alignment with personal values, having a sense of control, and one participant mentioning rewards. Many participants expressed the need for self-drive.

“The motivation has to come from yourself” (P9)

“It was really important to me and I had no one to motivate me apart from myself” (P7)

The majority of participants reported being more likely to succeed at goals that aligned with their personal values or desires.

“I think it’s really important it depends on your values and what’s important to you. If they line up with that then you will want to do them (P9)

“It’s not what you want everyone else to see, it’s the specific stuff to you” (P1)

While one participant observed a lack of motivation for goals that did not align with their personal values.

“I just won’t do it because it’s not important to me” (P7)

Several participants also linked their experience of setting goals to the feeling of being in control.

“I actually felt like I had my own control over my own life” (P4)

One participant emphasised the importance of feeling in control for recovery.

“Control is very important when you are trying to get better” (P3)

Only one participant mentioned rewards as a source of external motivation.

“You can do little rewards or something like that, because then you actually want to” (P6)

Another participant cited the goals themselves as a form of external motivation.

“[The goals] are something that can give you a bit of motivation. They’re little drivers” (P4)

3.2 Barriers to Goal Setting and Achieving

Participants reported multiple factors that hindered their goal setting and striving. Many of our participants expressed fear and other negative emotions in response to the idea of large goals or failure.

“If the goal is too big it can feel too daunting, and that’s when you start thinking like I’ll never achieve this” (P4)

“When you put big goals in front of people who are struggling it can be really overwhelming” (P7)

This fear often proved to be a deterrent to the initial setting of the goals themselves.

“I wanted these things but I was scared to try and get them because I was too scared of failing” (P5)

Failure to reach a goal was often perceived by participants as being a personal failure.

“It’s really important that I accomplish it, otherwise I feel really like a bit of a failure” (P7)

“The biggest downside is if you end up feeling like I’m a failure, I’ll never reach this goal. It can be a really bad hole to get into” (P4)

Experience of failure was also strongly associated with other negative emotions.

“I’m just mad at like everything. Like more mad at myself, but mad at everything and anyone” (P8)

“If I make those big goals and I don’t get them I feel sad” (P5)

Several participants recognised that mental illness symptomatology and negative states of mind made goal setting more difficult.

“That’s kind of the thing about being depressed, every little thing feels so much more difficult than it should” (P7)

“The mental health side of things is it’s hard to get out of bed, and it’s hard to put a lot of energy into things” (P1)

Some participants adjusted for this with the type of goals they set.

“When I’m really sad my goals are like get up and shower and brush my teeth” (P7)

Others continued to compare their goal setting ability to that of healthy individuals.

“It was like putting myself down because I wasn’t doing what a normal person should be doing” (P1)

One participant reported a decrease in motivation as their mental health worsened.

“When it got bad it was like I just didn’t really… I had goals but I just didn’t really go for them” (P5)

Another participant maintained motivation but shifted their focus to harmful goals such as calorie restrictions or self-harm.

“I still have the same motivation to achieve goals when I’m in a bad place, they’re just bad goals” (P9)

3.3 Strategies for Goal Achievement

Many of the young people in our study reported techniques to optimise their goal setting and success. This included having self-compassion and flexibility around goals, particularly with regards to countering negative emotions.

“So in case the goal doesn’t work out, you can go well look this thing happened… and that kind of dampens down the negative feeling” (P4)

“Compassion is a very important thing that you need to have for yourself. You need to have control but you also need to have enough control to know when to let it up” (P3)

Setting realistic expectations and working in small steps were also seen to be beneficial.

“I would prefer functional to normal” (P3)

“That’s why I find it so important to have those interim goals, like oh it’s small enough that it doesn’t seem daunting and I’ll move forwards to it” (P4)

This ‘small steps’ strategy seemed to be especially useful for those who expressed anxiety around large goals.

“I just want to work on one step at a time… it would be overwhelming to think of all the things that you have to do” (P5)

“I’m the type of person who like has to chip away at something rather than have this massive goal that just feels really unachievable” (P7)

One participant commented that interim goals helped them to work towards larger goals gradually.

“It feels achievable and even if you don’t have the means right now, you can make other goals that will make it so you do have the means” (P4)

Using goals to provide structure or a detailed action plan was another important strategy reported by participants who had difficulty taking steps toward recovery.

“That’s a lot of what mental health is, we just need structure” (P1)

“It’s almost a prerequisite to be meticulous about everything… make lists about every tiny little thing” (P3)

3.4 The Role of Self-Efficacy

Nearly every participant interviewed indirectly mentioned the impact that self-efficacy had on their goal setting, frequently using terms such as “confidence” and perceived “ability”. Some participants expressed awareness of an increase in their goal setting capacity during periods of improved mental health.

“I would be like I want to do this, and I would do it” (P5)

“I guess the happier I get, the bigger and harder the goals get because I can handle it” (P7)

A negative mental space was reported to have the converse affect.

“I didn’t feel like I could” (P7)

“I never really saw myself achieving them when I was in a bad place” (P9)

“They might not happen just out of lack of confidence” (P4)

One participant showed awareness of the negative impact that their mental health was having on their self-efficacy.

“I should be able to feel like I can do so much more” (P7)

Participants also reported experiencing an increase in self-belief or motivation when a goal was achieved successfully.

“I think it was just seeing that I could stop… even if it didn’t feel like I could” (P6)

“How far am I actually going to be able to go? And that being a small push of motivation to keep tracking along” (P4)

3.5 The Role of Support

Young people expressed diverse views on the usefulness and acceptability of support within the realm of goal setting. Some participants expressed that having a support person would be beneficial for motivation.

“If I have help… then I’ll be able to do it” (P1)

“Personally I find it easier to set goals while talking to another person” (P4)

One participant with explicit previous experience of goal setting within therapy said that goals need to be used “actively” (P4) and referred back to.

“A rock that we come back to in therapy” (P4)

Having support with goal setting was also considered to be a helpful technique for identifying factors that the individual may otherwise miss.

“Being able to discuss goal setting with a person enables you to consider other factors that could hinder or help that goal” (P4)

“Sometimes [I] get stuck in the thought pattern of thinking a goal can only be achieved one way” (P9)

Maintaining autonomy in the support process remained crucial for all participants.

“It’s really important to have a goal that’s important to you rather than necessarily what someone else, or a therapist, thinks is the best idea” (P7)

“They’re the things that I reflect on myself and I write them, no one tells me that I have to set a goal otherwise I’d be like no I’m not setting a goal” (P5)

Participants reported that goal setting should be presented by a support person as a personal, self-directed choice, expressing a negative response to the idea of being ‘told’ to set goals.

“I feel like I’m just going to make up a whole bunch of stuff just to make you happy” (P8)

“Its delivery is the important thing about whether or not its effective” (P4)

Some young people found that accountability was helpful as a motivator for achieving goals.

“I like being accountable to someone” (P6)

Other participants preferred their support person to take a more passive role.

“Basically just having someone to check in” (P1)

Interestingly, the participant who spoke most favourably of accountability within therapy also indicated that their motivation stemmed from avoidance of guilt.

“That was more of a mechanism of setting accountability for me so I actually had to go tell someone… kind of shaming myself into it” (P4)

3.6 Benefits of Goal Setting

Participants reported an array of significant benefits as a result of goal setting. Many participants reported experiencing positive emotions in response to goal attainment.

“[It] gives you a sense of achievement” (P9)

“I can feel great” (P8)

“It did make me feel good” (P1)

“I can feel more accomplished” (P7)

Interestingly, this positive emotional response didn’t seem to be impacted by goal size.

“I feel good when I do those, those small achievable ones” (P1)

One participant reported that the process of writing out goals itself was therapeutic.

“It just gives me peace of mind” (P1)

Goals were also seen to increase productivity.

“It helps you do something, because sitting around doing nothing all day is no way to live” (P9)

Perhaps most poignantly, goals were seen to improve individuals’ perceptions of their futures.

“In a way it’s just like I have a future” (P1)

“It was helpful because it made me realise… there is going to be a future” (P8)

One participant articulated this very clearly:

“[An] upside is that goals give you hope” (P6)

Individuals also expressed that goals helped give meaning to their lives, and helped them cope with periods of poor mental health.

“They give you a purpose” (P9)

“Finding something meaningful to do that didn’t seem like the end of the tracks” (P4)

“I personally found [goals] have helped me push through the darker times, harder times” (P4)

One participant set a goal exclusively focussed on survival.

“I’ve just got to make a goal to get me through to twenty-twenty…to make it to my niece’s first birthday… like I know nothing else will work” (P8)

4  Discussion

Based on our exploration of young peoples’ lived experiences with goal setting (using one-on-one interviews), we found goal setting to be perceived by young people as being both useful and effective when implemented well, with benefits including positive affect, productivity, and most poignantly: the sparking of a sense of hope and an improved view of the future. The concept of hope is a salient one in the context of mental health, with existing research showing that hope can aid personal resilience, and act as a buffer against suicidal ideation [28]. With no known existing research into goal setting in our target population, the observation that goal setting could be a potential mechanism of fostering hope represents a novel new finding with substantial clinical significance.

We also found that barriers such as fear of failure, negative state of mind, mental illness symptomatology and low self-efficacy deter young people from setting and striving for goals. Studies on fear of failure in other populations show that individuals often express maladaptive coping strategies such as use of avoidance goals and shame [29], or disengage completely from their goal [30], both of which were seen in our participants.

The primary motivators for goal setting in our participants included self-drive, perception of being in control, and having goals aligned with personal values. These findings strengthen existing literature showing that adolescents place strong value on autonomy, self-determination, and personal values, and find goals more motivating when these factors are incorporated [31–33].

Strategies reported to increase goal setting success in our study included use of small goals, setting realistic expectations, and having flexibility and self-compassion. Previous studies have found that use of smaller interim goals increases participant motivation, self-efficacy, and leads to an increased capacity for achieving larger goals in future [34,35]. Goal flexibility has similarly been found to be effective at promoting goal success and minimising negative emotions [30,36], and self-compassion is effective at promoting successful self-regulation of health behaviours [37].

The majority of our participants expressed awareness of the impact that self-efficacy had on their goal setting and reported a decrease in confidence as mental health or mental state worsened. Existing research has found links between low self-efficacy and depression or negative affect [38], with our results suggesting that this relationship may be bidirectional.

Several of our participants reported that support would be useful during times in which goal setting felt daunting or overwhelming, providing the individuals maintained autonomy. Existing research has found that the use of a support person can aid in the facilitation of goal setting, increase adherence to health interventions, and ultimately improve health outcomes [39].

While none of our participants explicitly mentioned the role of broader structural factors, we feel it is important to acknowledge that all therapeutic techniques, including goal setting, occur against a backdrop of wider social, cultural, political and economic contexts, each of which may play a part in a young person’s capacity to engage with the given therapeutic technique. Inquiry into the exact impact of these factors would prove an interesting and important area for future research.

A key strength of the current study is the depth of insight able to be generated through semi-structured one-on-one interviews. Limitations include the relatively small study sample, that few sample characteristics were recorded at baseline, and that participants were each engaged with different types and stages of therapy. One of our interview recordings failed, however the content of the interview was immediately transcribed from memory and checked with the participant. One participant spoke very extensively, and few scheduled questions were able to be asked as a result.

In conclusion, this study found that when used appropriately, goal setting is viewed as being a useful and effective tool by young people experiencing mental health challenges. Goal setting is common to a number of psychotherapies, and may significantly contribute to their mechanism of action. Our results suggest that support with goal setting in the context of youth mental health therapy may be advantageous when navigated appropriately. Further research into ways in which young people can foster effective strategies and mitigate barriers to goal setting is recommended.

Availability of Data and Materials: Data from this project, beyond the excerpts included in this article, is unavailable to protect participant confidentiality.

Funding Statement: The authors received no specific funding for this study.

Conflicts of Interest: The authors declare that they have no conflicts of interest to report regarding the present study.

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Appendix A. Interview schedule

Interview schedule for adolescents

Experience of Mental Wellbeing

•   Tell me about your experience of mental wellbeing? (prompts; have you experienced tough times? When did this happen and how did it start? how has it changed?)

•   What do you think causes distress and self-harm in young people?

•   How do/did you think mental wellbeing will work out for you? (expectations)

•   what has helped you feel better? (what support did/do you think would help?)

Experience of Goal Setting

•   How would you describe goal setting

•   Have you used goal setting (if yes, in what way; what was it like; did it work; what was difficult, what worked well, what were the upsides/downsides, did you have support, what influenced your motivation to achieve your goals, what happened when you did/didn’t achieve your goals)

•   Do you think this could be a good approach for helping young people with their mental health and wellbeing (or to stop self-harming or substances, or overcoming depression, anxiety etc…)

•   How do you think it could be useful

•   What things would make it easier to do/more fun/more achievable

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