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.
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.
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.
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.
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.
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:
defining the research question;
identifying relevant studies;
selecting studies;
extracting data; and
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:
Research questions:
We completed this review to answer the research questions:
What is the scope of goal-setting practices within the domain of mental health, especially in the context of OT?
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.
Author declaration, conflict of interest and funding: This work was supported by Grant-in-Aid for Scientific Research (B) [19H03875]. The authors declare that there are no conflicts of interests. The authors also declare that this work has not been presented or published elsewhere.
Since submission of this article, the following author has updated his affiliation: Takao Kaneko is at the Department of Rehabilitation, Yamagata Prefectural Central Hospital, Yamagata, Japan.
