Tanner, C., 2002. Target Problems: The Focus in a CAT Therapy. Reformulation, ACAT News Summer, p.x.
CAT is practised as a brief time-limited therapy and its purpose is to enable clients to recognise maladaptive procedures and then revise these procedures. The setting for this process is the therapeutic relationship and the tasks that enable clients to change is the jointly created tools with the therapist, of reformulation embodied in the reformulation letter, Target Problem Procedures (TPPS), Reciprocal Role Procedures (RRPs) and the Sequential Diagrammatic Reformulation (SDR). Using these tools in the recognition and revision of procedures happens through the employment of a variety of techniques, particularly keeping in mind that promoting awareness of re-enactment of the procedures both within therapy sessions and between sessions is a primary function of the therapist in CAT.
Maladaptive procedures serve as not very useful coping devices for clients. They are familiar (known), and it is perhaps frightening to give these coping devices up. It is very important for therapists to acknowledge the ambivalence, resistance and even hostility that may be evoked when clients embark on changing their procedures.
Why then would anyone wish to change? What is the motivation for undertaking therapy and changing the way one copes with life? What motivates people to undertake therapy is that the problems they are experiencing feel difficult enough to drive/cause them to seek help in finding a way of feeling better. These are Target Problems. The refinement with careful negotiation with the client on what the client’s problems are is the motivation to undertake the work of therapy. Perhaps to face the discomfort and fear that change can produce. Without this clarification, of shared, created, named Target Problems, the therapist and client may often find themselves at cross-purposes as the goals of therapy can then differ between them. Uncertainty quickly takes its place.
In order to recruit the client into the process of recognition and revision of procedures, identifying problems from the client’s point of view is a necessary step to promote motivation to change. Symptoms that cause distress can be named and focused on as Target Problems and then clarified with linked procedures. Subtly looking at deeper issues that cause problems for the client is necessary. They need to be clarified and refined to continue to engage the client in the process of recognition and revision.
How the client views him or her self in the world may be named as a Target Problem. This may become the focus of what the client would like to change. Broad statements about the client’s sense of self, such as lacking confidence, may not be helpful. Again, clarification on what the problem is for the client about lacking confidence would be more helpful as a motivation towards change. So a Target Problem such as " I lack confidence as I must be 100% right" is clear and focussed and helps the client to change the sense of 100%. Linking this to a specific procedure ensures that both the therapist and the client are working together towards the same goal, changing the ‘100% right’ to a lower (%) percentage.
Problems concerning how a client experiences others in a relationship are very important to explore and clarify as this will enable both client and therapist to acknowledge (what might be the RRP between them) the possible RRP between them. So that if the client has a problem, for example, always feeling put upon in relationships, this might mean that he/she will feel put upon by the therapist during the course of the CAT. If this problem is named as a TP and agreed as a focus of work in the therapy, the client’s cooperation is recruited.
Thus, clarifying Target Problems in these broad categories; presenting symptoms, the client’s sense of his or her self in the world, and the client in the relationship, and naming them as what the problem is from the client’s point of view, helps motivate the client to recognise and revise the procedures. Without this specific contract between the client and the therapist on the nature of the client’s problems, then change is uncertain, vague and often absent in the CAT therapy. Uncertain and unspecified contracts between client and therapist on the problems the therapy is undertaking to resolve means those problems may not be resolved or even known. The client may then have no motivation to recognise and revise procedures.
The issue of the ease of agreement between client and therapist on the Target Problems is central to the establishment of a therapeutic alliance. There are many issues that are perceived by the therapist as a problem for (about) the client, but are not perceived by the client as a problem. Eating disorders, substance mis-use, negative relationships, all are clearly issues that require change, but the client may not wish to change. Perhaps then it is the client’s difficulty in changing these behaviours that is the Target Problem, not the behaviour that needs linking to a procedure. The contract is then clearer and the client’s motivation to explore the difference is engaged rather than there being a conflict of goals.
Expectations that the client has of the therapist might be named as a Target Problem if these expectations are unrealistic or something the therapist cannot meet. If clients expect therapists to provide solutions, provide unreasonable amounts of care, provide rescue etc., and these cannot be provided by the therapist, then there is a Target Problem linked to a procedure that can be worked on in the therapy. Equally, if the client finds the expectations of the therapist in the CAT therapy unreasonable then this can be named as a focus for therapy. Motivation to change this expectation might be recruited if the client is faced with the named problem, the named problem of the disappointment of expectations and the distress that that (and the) causes for the client. The problem is then put into the area/arena of what is difficult for the client (not the therapist) and the client may be more willing to recognise and revise procedures linked to unrealistic expectations.
Therapists often jump into working on recognition of procedures without doing the work of establishing the problems that will engage the client in the process of recognition and revision. Thus there is no clear contract between the client and the therapist. There may not be shared goals in the therapy and the client and therapist are left with the question why are we meeting together? Procedures get re enacted, rather than recognised and revised.
The very useful tool of the establishment and negotiation of Target Problems exists in CAT to enable therapists to form clearly and jointly a therapeutic contract with a client. Motivation to engage in the work of therapy and the motivation to change is explored through the negotiation of Target Problems. Giving time and attention to Target Problems will highlight how motivated a client is, what their expectations of therapy are and how willing they are to engage in therapy. Doing the work of establishing Target Problems can help present discouragement in both client and therapist, prevent collusion with RRPs and conflict of goals which leads to a non-collaborative CAT where recognition and revision do not take place. Leapfrogging over Target Problems straight to procedures seems potentially very unhelpful. Both client and therapist can only operate on their assumptions about one another, and the usefulness of accurately naming procedures is lost.
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