Writing Realistic Goals from Delusional or Unrealistic Client Statements: A Guide for PACT Providers

Writing Realistic Goals from Delusional or Unrealistic Client Statements: A Guide for PACT Providers

By: JH - MHP

Clients with severe mental illness often express goals or desires that reflect their delusions, misunderstandings, or coping strategies. These may not be achievable or safe in their current form—but they still reveal important needs and motivations. Translating these into concrete, therapeutic goals helps promote engagement, stability, and recovery.

Here’s how to reframe delusional or unrealistic goals into meaningful treatment objectives.

Why Reframe Goals?

  • To align client motivation with realistic, achievable steps

  • To address the underlying emotional or cognitive needs

  • To promote stability, skill-building, and quality of life

  • To foster collaboration and trust in treatment

Examples of Delusional/Unrealistic Client Goals and Therapeutic Alternatives

Client’s Original Goal/Statement Why It Matters (Therapeutic Reflection) Reframed Goal (Actionable, Clinical)
“I want to find my lost millions/buried treasure.” Desire for financial security, control, and self-worth. Client will engage in structured budgeting and money management tasks weekly to build financial stability and realistic planning.
“I want to keep using drugs but find a way to function in society.” Ambivalence about substance use; seeking balance without full abstinence. Client will participate in harm reduction counseling weekly to increase awareness of substance effects and identify strategies to minimize risk.
“I want to get cleaner and have a clean apartment.” Desire for control, reducing anxiety/paranoia by managing environment. Client will work on organizing living space 1x/week to create a calming environment that supports mental wellness and reduces triggers.
“I want to prove the government is spying on me and expose the conspiracy.” Experiencing paranoia and mistrust; need for safety and validation. Client will engage in reality testing exercises and develop coping strategies for anxiety related to paranoia during therapy sessions.
“I am going to be a millionaire and take over the world.” Grandiosity and impaired insight; need for purpose and identity. Client will participate in vocational skill-building and goal setting to explore realistic career or volunteer opportunities.
“I need to stay isolated to keep safe from people trying to harm me.” Social withdrawal from paranoia and fear; need for safety and connection. Client will gradually increase social engagement with supportive peers or staff to build trust and reduce isolation.
“I want to talk to dead relatives who visit me every night.” Processing grief or trauma through hallucinations; emotional distress. Client will participate in coping skill development and trauma-informed therapy to address grief and distressing experiences.
“I don’t need my medications because I’m already cured.” Poor insight and medication adherence issues. Client will attend medication education sessions and medication monitoring appointments to improve insight and adherence.
“I want to stay up all night because the voices tell me to.” Sleep disturbance worsening symptoms; need for regulation. Client will develop and follow a sleep hygiene routine to improve rest and reduce symptom exacerbation.
“I want to control my neighbors through telepathy.” Delusional thinking with impaired reality testing. Client will work on cognitive behavioral strategies to recognize and challenge delusional beliefs and improve reality orientation.

Tips for Writing Reframed Goals

  • Always link the goal to the client’s underlying needs or emotions (safety, control, stability, social connection, insight, etc.)

  • Use clear, measurable, and time-specific objectives

  • Avoid confrontational or judgmental language

  • Keep goals client-centered but within therapeutic scope

  • Make goals flexible to allow gradual progress

Handling “I Don’t Know,” “I Don’t Care,” and Limited Client Engagement

Clients in PACT often struggle with motivation, insight, or are difficult to engage due to their symptoms. It’s common to hear responses like:

  • “I don’t know.”

  • “I don’t care.”

  • “Why do I need to do this?”

  • Or, you may be unable to make contact despite repeated attempts.

These situations pose clinical and documentation challenges. How do you honor the client’s experience, maintain therapeutic rapport, and still meet documentation standards—especially when reporting to insurers or oversight bodies?

Clinical Approach

1. Validate and Explore
Instead of pushing, start by validating their feelings:
“It sounds like this feels frustrating or overwhelming right now.”
Gently explore the meaning behind “I don’t care” or “I don’t know.” This often reflects emotional exhaustion, hopelessness, or cognitive difficulties, not mere resistance.

2. Use Motivational Interviewing Techniques
Help clients explore ambivalence by asking open-ended questions:
“What do you hope could be different?”
“What worries you about making changes?”
Even small reflections can spark motivation.

3. Break Tasks into Tiny Steps
If clients express overwhelm or disinterest, offer very small, achievable actions, such as:
“Would you be willing to talk for 5 minutes today?”
“Let’s just focus on one thing you feel okay about trying.”

4. Build Rapport Over Time
Sometimes the best progress is consistent engagement rather than immediate change. Being present, reliable, and nonjudgmental can increase willingness over weeks or months.

5. Document Your Efforts

When clients are disengaged or unavailable, document all attempts to engage, contacts made, and responses received—even if minimal.

Documentation Tips for These Situations

Insurance and clinical audits want to see that you have:

  • Made reasonable efforts to engage the client, including dates/times of contacts

  • Documented client statements verbatim, e.g., Client stated, “I don’t know.”

  • Reflected clinical observations, e.g., Client appeared withdrawn and unresponsive.

  • Noted your clinical interventions, e.g., Attempted motivational interviewing to explore ambivalence.

  • Set realistic next steps or plans, e.g., Will attempt follow-up visit next week; encourage client to identify goals when ready.

Sample Documentation Language

  • “Multiple attempts were made to contact client by phone and in-person on [dates]. Client was unavailable/no response.”

  • “During session, client stated, ‘I don’t care,’ and was unable to identify goals. Therapist validated client’s feelings and explored ambivalence with motivational interviewing techniques.”

  • “Client expressed uncertainty about the need for treatment, stating, ‘Why do I need to do this?’ Therapist provided psychoeducation on benefits of treatment and safety planning.”

  • “Client was passive during session but agreed to discuss goals in future visits.”

  • “Despite limited engagement, the clinician maintained rapport and planned ongoing outreach.”

Why This Matters

  • Demonstrates clinical judgment and diligence

  • Supports ongoing eligibility for services and funding

  • Protects your team and client by showing documented efforts

  • Provides a foundation for continued care and eventual engagement

Bonus: Sample Goal Formats

  • “Client will… [behavior] … at least X times per week/month to improve/maintain… [therapeutic reason].”

  • “Client will participate in [therapy type/activity] to develop skills in… [area related to delusion or symptom].”

  • “Client will identify and practice coping strategies for… [symptom/trigger].”

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