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Psychotherapy Research

ISSN: 1050-3307 (Print) 1468-4381 (Online) Journal homepage: http://www.tandfonline.com/loi/tpsr20

Goal setting in psychotherapy: The relevance


of approach and avoidance goals for treatment
outcome

Eileen Wollburg & Christoph Braukhaus

To cite this article: Eileen Wollburg & Christoph Braukhaus (2010) Goal setting in
psychotherapy: The relevance of approach and avoidance goals for treatment outcome,
Psychotherapy Research, 20:4, 488-494, DOI: 10.1080/10503301003796839

To link to this article: http://dx.doi.org/10.1080/10503301003796839

Published online: 27 Jul 2010.

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Psychotherapy Research, July 2010; 20(4): 488494

Goal setting in psychotherapy: The relevance of approach and


avoidance goals for treatment outcome

EILEEN WOLLBURG & CHRISTOPH BRAUKHAUS

Medical Psychosomatic Clinic Bad Bramstedt, Bad Bramstedt, Germany


(Received 6 August 2009; revised 10 February 2010; accepted 17 March 2010)

Abstract
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The present study is the first aimed at investigating the influence of goal definition on treatment outcome in a sample of
depressed patients. Data from 657 inpatients admitted to a psychosomatic clinic in Germany being treated in a cognitive
behavioral therapy program were analyzed. Treatment goals were identified as either approach or avoidance, and the sample
was classified accordingly. Patients who identified approach goals only were placed in the approach group, and those who
identified at least one avoidance goal were placed in the avoidance group. Results showed that framing goals using avoidance
terms was associated with less symptomatic improvement but did not affect goal attainment. Findings from this research
should be utilized in practice not only for process management such as individual treatment planning but also to control
outcome quality. Furthermore, goal definition should be considered as a control variable in research on depression.

Keywords: approach goal; avoidance goal; therapy outcome; depression; cognitive behavior therapy; mental health
services research; outcome research

Evaluation of therapy for mental disorders and toward or maintain the desired outcome. Avoidance
quantification of change during treatment are some goals, on the other hand, focus on negative end
of the most difficult issues in psychotherapy re- states and moving or staying away from them (Elliot
search. Treatment quality can be assessed by differ- & Sheldon, 1997). A positive end state is usually
entiating among certain general aspects. One such understood as what is ‘‘commonly considered nor-
distinction made is that between structural, process, mal, health-inducing’’ (Elliot & Friedman, 2005).
and outcome quality (Margraf, 2000). Setting treat- Early on, theorists have posited that goals are
ment goals is essential for quality assurance and has concrete concepts of more global motivational dis-
been a long tradition in order to direct the therapy positions (for a review, see Elliot & Church, 1997). In
process itself (i.e., increasing patient motivation and therapy, the same goal can be defined by approach or
compliance) and evaluate the outcome. Especially avoidance behavior. For instance, a patient might
cost-intensive inpatient treatments increasingly re- want to ‘‘improve his/her mood’’ or ‘‘be less de-
quire goal-oriented processes. If goal setting is pressed.’’ Both goals target the same underlying
considered as a therapeutic element, proper goal motive and, therefore, one could assume that the
definitions may lay the groundwork for a successful verbal representation should not be of interest.
cognitivebehavioral treatment. However, several researchers have posited systems
Over the years, different theoretical models and that underlie approach and avoidance strivings and
criteria have been suggested in order to enhance behavior, respectively (Davidson, 1998; Fowles,
patients’ motivation and possibly increase treatment 1988; Gray, 1982). Although these models differ,
effects. One basic conceptual distinction discerned they have in common neurophysiological systems that
long ago is that of approach (appetitive)avoidance underlie approach and avoidance processes. For
(aversive; e.g., Carver & Scheier, 1996; Coats, instance, Gray’s (1982) behavioral activation system
Janoff-Bulman, & Alpert, 1996; Higgins, 1996). is linked to signals of reward and feelings of happiness
Most researchers have defined approach as ‘‘being or hope; the behavioral inhibition system, on the other
focused on a positive end state.’’ Hence, it is linked hand, is linked to punishment, anxiety, and sadness.
to approach behavior, meaning trying to move In Carver and Scheier’s (1990) self-regulation

Correspondence concerning this article should be addressed to Eileen Wollburg, Medical Psychosomatic Clinic Bad Bramstedt, Bad
Bramstedt, Germany. Tel: +49(4192)504751 E-mail: EWollburg@schoen-kliniken.de

ISSN 1050-3307 print/ISSN 1468-4381 online # 2010 Society for Psychotherapy Research
DOI: 10.1080/10503301003796839
Approach and avoidance goals in psychotherapy 489

feedback model, perceived information is compared Deci, 1996), is associated with more physical
with an internal reference and if the discrepancy symptoms (Elliot & Sheldon, 1998), inhibits pro-
between both needs to be enlarged, avoidance beha- gress toward goal achievement (Elliot & Sheldon,
vior will follow and vice versa. The actions that need 1998), and is in general related to poorer psycho-
to take place to reach the goal may be the same, but logical outcome, such as lower positive moods,
the process differs. More recently, Grawe differen- more anxiety, lower self-esteem, or less life satisfac-
tiated between approach and avoidance motivational tion (Elliot & Friedman, 2005; Elliot & Sheldon,
goals. In his consistency theory (Grawe, 2007), he 1997; Elliot, Sheldon, & Church, 1997). Other
points out that strong avoidance motivational goals researchers describe similar interaction results of
are one source of incongruence because they require subjective well-being and avoidance goals when
constant control and distributed attention and hence investigating nonclinical populations (Coats et al.,
are associated with psychological problems. He 1996; Emmons, 1996; Gollwitzer & Moskowitz,
defines incongruence as a state that develops when
1996; Rooney, Higgins, & Shah, 1995). Students
goals (approach or avoidance) are not achieved. Just
in Rooney et al.’s (1995) study even performed
because the aversive state has been fought once does
worse during the semester when they framed their
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not mean it cannot possibly occur any minute again;


goals in avoidance terms.
therefore, avoidance motivational goals can never
Only few studies with clinical populations exist
fully be reached and lead to inefficient goal pursuit
and these involved mixed populations, which may
and attainment and a feeling of dissatisfaction.
Furthermore, several authors (Derryberry & Reed, confound findings and limit interpretation of re-
1994; Gomez & Gomez, 2002; Higgins & Tykocinski, sults. Elliot and Church (2002) investigated the
1992) point out that goal framing influences how proportion of avoidance and approach goals in
information is processed. Avoidance motivation students seeking outpatient psychotherapy. The
biases people toward negative cues and makes them higher the proportion of avoidance goals, the less
not only remember more negative information but improvement, measured as subjective well-being,
also recall positive or neutral information less posi- was seen during treatment. In another study,
tively (Strachman & Gable, 2006). One may even dysphoric adolescents not only generated more
suspect that certain metacognitions such as ‘‘the more avoidance than approach goals but were also in a
the better’’ influence goal formulation; hence, the ‘‘negative state of mind.’’ Patients thought of more
definition itself may already be the first step of a reasons for failure than success in pursuing the goals
successful therapy. and expected better achievement of avoidance goals
Although early theorists assumed that, regardless (Dickson & MacLeod, 2006). On the motivational
of the goal, satisfaction of needs in general leads to level, psychotherapy patients, compared with psy-
happiness (Srull & Wyer, 1985; Wilson, 1960), the chiatrically healthy controls, tend to pursue more
outlines given previously indicate that both ap- avoidance goals (Grosse Holtforth & Grawe, 2003)
proach and avoidance should lead to very different and achieve a better treatment outcome when
emotional states and, therefore, to different therapy avoidance motivation is reduced and approach
outcomes. Indeed, it was postulated two decades motivation is strengthened during therapy (Berking
ago that patients should focus on a positive wording et al., 2003).
of therapy goals, or knowing what to do instead of In sum, the studies discussed previously show
what not to do (Kanfer, Reinecker, & Schmelzer, that approach goals are positively related and
1991). However, few studies have investigated the avoidance goals negatively related to subjective
influence of goal definition on therapy outcome. well-being, although it is unclear whether avoid-
Some studies were done with mixed clinical popula- ance causes worse well-being or whether clients
tions (Berking, Grosse Holtforth, & Jacobi, 2003;
who are feeling poorly tend to pursue more
Dickson & MacLeod, 2006), but for the most part
avoidance behavior. In our study, we sought to
findings from basic research conducted with stu-
further examine the relationship between the defi-
dents were adopted to psychotherapy (e.g., Coats et
nition of therapy goals, regardless of goal content,
al., 1996; Dickson & MacLeod, 2006; Elliot &
and therapeutic outcome in depressed inpatients.
Sheldon, 1997; Emmons, 1986). Elliot et al.’s work
in numerous studies with undergraduate students On the basis of previous findings, we hypothesized
indicated that pursuing avoidance goals makes that, compared with solely identifying approach
people feel less competent in terms of goal achieve- goals, (a) pursuing at least one avoidance goal will
ment (Elliot & Church, 1997; Elliot & Sheldon, be associated with less symptomatic improvement
1997, 1998), undermines intrinsic motivation (Elliot and (b) avoidance goals will be achieved less than
& Harackiewicz, 1996; Ryan, Sheldon, Kasser, & approach goals.
490 E. Wollburg and C. Braukhaus

Method If a goal was not unambiguously classifiable, the


patient was omitted from the sample.1
Participants
The study sample consisted of 657 inpatients ad-
mitted to a psychosomatic clinic in Germany with a Procedure
primary diagnosis of depression. The mean age was Data from patients consecutively admitted to the
45.2 years, and approximately 68.5% were female clinic in 2008 were analyzed. All patients were
(n 458 female and n 199 male). The majority of treated with a multimodal cognitivebehavioral ther-
the sample was married (47.5%) and had at least apy program. Demographic and clinical data col-
some college or university education (70.8%). As is lected at pretreatment and posttreatment were taken
typical among German psychosomatic inpatient from archived patient files and rendered anonymous
clinics, race and ethnicity were not recorded. Pa- by hospital staff. Patients completed a battery of self-
tients must have met criteria for a current Interna- report questionnaires at both assessments, of which
tional Classification of Mental Disorders (Dilling, the BDI and goal achievement were used for the
Mombour, & Schmidt, 2005) diagnosis of either a present study (see prior discussion). Within the first
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single depressive episode (F32) or recurrent depres- week of the stay, therapy goals were formulated and
sive episodes (F33) and have had a total score on the achievement was rated at posttreatment. Patients
Beck Depression Inventory (BDI; German version: were asked to note three major goals. Goals were
Hautzinger, Bailer, Worrall, & Keller, 2000) of at
classified into approach or avoidance goals by two
least 18 at the beginning of therapy. Exclusion
trained raters. Both raters were graduate students
criteria were current alcohol or drug abuse or a
with a master’s degree in psychology and trained by
history of any psychotic disorder. The majority of the
the primary investigator by means of sample goals.
group was diagnosed with recurrent major depres-
First, raters independently coded each treatment
sion of moderate severity (45.3%). About 85% had
goal. After interrater reliabilities were computed,
an additional International Classification of Mental
disagreements were discussed with the principal
Disorders diagnosis. On average, patients stayed at
author and consensus rating was performed. Inter-
the clinic for 7 weeks (approach group, 48.7 days;
rater reliability (Cohen’s kappa) reached .89, which
avoidance group, 48.3 days). Ninety-three percent of
the sample was on medication; 35.5% of these took can be interpreted as ‘‘almost perfect agreement,’’ as
antidepressants only and 52.1% took antidepressants suggested by Landis and Koch (1977).
in combination with other medications (e.g., hypno-
tics or analgesics). There was no difference in Statistical Analysis
antidepressive medication between groups, x2(1,
N 657) 2.65, p .13. Computations were made using the Statistical Pack-
age for Social Sciences (version 17.0; SPSS Inc.).
For demographic and clinical measures, differences
Instruments in categorical variables were tested with the chi-
The questionnaire package included, among other square test, and continuous variables were investi-
measures, the BDI (Beck, Ward, Mendelson, Mock, gated with one-way analyses of variance (ANOVAs).
& Erbaugh, 1961; German version: Hautzinger et For analysis of the repeated psychological data
al., 2000). The questionnaire consists of 21 items collected during both assessments, general linear
rated on a 4-point Likert scale ranging from 0 to 3 models with the factors time (pre, post) and group
and one yesno question. The BDI was used to (APP, AVOID) were used. Interrater reliability was
operationalize symptomatic improvement. Further- calculated with Cohen’s kappa and judged according
more, the patients rated the achievement of each to Landis and Koch (1977). Therapist effects were
goal on a scale ranging from 0 to 10 at the end of tested with intraclass correlation coefficients on the
therapy. Approach was defined as trying to move BDI and goal achievement. Effect sizes were calcu-
forward or maintain a positively evaluated end state lated as Cohen’s (1988) d when appropriate. For
(e.g., ‘‘I want to experience more joy’’) and avoid- within- and between-group comparisons, the pre-
ance as trying to escape or stay away from a and posttreatment values and change scores, respec-
negatively evaluated end state (‘‘I want to reduce tively, were entered into Cohen’s equation (M1  M2/
my depression’’). The total sample was then split SDpooled). Statistical significance was set to p 5.05,
into two groups: The approach (APP) group in- two-tailed. For exploratory purposes, Pearson
cluded patients who identified only approach goals, productmoment correlations were performed to
and the avoidance (AVOID) group consisted of detect linear association between goal variables and
patients who identified at least one avoidance goal. questionnaire scores.
Approach and avoidance goals in psychotherapy 491

Results Number of goals


4.0
approach goals
Sample Characteristics avoidance goals
3.5
After classifying the goals and dividing the total
3.0
sample into two groups, 464 patients remained in
the APP group and 193 in the AVOID group. Both 2.5
groups’ mean ages (45.3 and 45.1 years, respec-

mean
2.0
tively), proportion of women (71.6% and 65.3%,
respectively), and mean BDI scores pretherapy were 1.5

similar, increasing comparability and, therefore, 1.0


interpretability of the findings (see Table I).
0.5
Primary diagnoses, x2(15, N 657) 13.5, p 
0.56, and number of comorbid diagnoses, F(1, 0.0
APP (N=464) AVOID (N=193)
0.38) 0.36, p .55, were similar for both groups.
Group
About half of the patients of each group were
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diagnosed with recurrent major depression (moder- Figure I. Mean number of approach and avoidance goals by group
(APP, approach group; AVOID, avoidance group).
ate severity), about 33% with a major depressive
episode (moderate severity), and 20% with recurrent
major depression (severe episode without psychotic
Change with Treatment
symptoms). Eighty-four percent of the sample had
comorbid diagnoses in addition to primary depres- The repeated measures ANOVA of the BDI resulted
sion (37.9% one comorbid diagnosis, 31.1% two, in significant main effects: group, F(1, 190.62)
11.3% three, 2.89% four, and 1.07% five). Investi- 4.44, p .04; time, F(1, 4323.91) 105, p .00;
gation of the frequency of comorbid diagnoses and interaction effects: Group Time, F(1,
revealed substantial differences between groups. 581.58) 4.66, p .03. At posttreatment, the BDI
Significantly more clients in the APP group suffered total score significantly decreased in both groups,
from burnout syndrome, x2(2, N657) 12.0, p B but more so in the APP group (see Figure II). The
.01, and more people in the AVOID group from overall group effect was caused by the difference at
comorbid eating disorder, x2(1, N 657) 6.65, posttherapy because pretherapy scores were compar-
p B.05. able. Between-group effect size for the BDI was
0.18, within-group effect sizes ranged from 1.16
(AVOID) to 1.51 (APP). Intraclass correlation
Pretreatment
ranged from .03 to .10 (rBDI .10, rgoal attainment
Table I displays the total scores for the question- overall .07).
naire. According to self-report, the two groups felt
equally depressed at pretherapy. On average, three
treatment goals were set (see Figure I); the AVOID
identified significantly more approach goals than Beck Depression Inventory
30
avoidance goals (2.22 vs. 1.29, respectively).
28

26
Table I. Demographic and Clinical Characteristics by Group
24
AVOID
0-64

Variable APP (n 464) (n 193) x2 or F p 22

20
Women 71.6% 65.3% x2 2.54 .07
Age (years) F0.02 .90 18
M 45.3 45.1 APP (N=464)
SD 11.7 11.3 16 AVOID (N=193)
BDI (064) F0.90 .73
14
M 28.3 28.9 10
50
SD 7.39 8.38 pre-therapy post-therapy
assessment points
Note. x2 from contingency tables; F values from one-way analysis
of variance. APP, approach group; AVOIDavoidance group; Figure II. Mean Beck Depression Inventory scores (9 SE) at pre-
BDIBeck Depression Inventory. treatment and posttreatment (APP, approach group; AVOID,
avoidance group).
492 E. Wollburg and C. Braukhaus
Table II. Mean Ratings of Goal Achievement by Group findings from other research groups. Berking et al.
Variable APP AVOID F p
(2003) showed that patients with less avoidance
motivation at the end of therapy benefited more
Approach goals from the treatment. Furthermore, as consistently
n 1,493 422 reported from research with individuals from the
M (SD) 5.38 (2.31) 5.09 (2.48) 1.97 .16
general population, pursuing avoidance goals is
Avoidance goals
n n/a 249 related to poorer psychological outcome (Elliot &
M (SD) 5.04 (3.04) n/a n/a Friedman, 2005; Elliot & Sheldon, 1997; Elliott et
Total al., 1997) and worse mood state (Gollwitzer &
N 1,493 671 Moskowitz, 1996). On the other hand, our results
M (SD) 5.38 (2.31) 5.02 (2.54) 3.01 .08
contradict previous findings of Sack, Lempa, Lam-
Note. F values from one-way analysis of variance. APP, approach precht, and Schmid-Ott (2003), who found no
group; AVOIDavoidance group. association between therapy goal achievement and
the degree of improvement and, therefore, con-
Posttreatment cluded that goals are suitable not for an evaluation
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Goal achievement was assessed for each individual of treatment outcome but only for process quality
goal (ratings ranged from 010); groups did not management.
differ (see Table II). Both groups achieved all of their The findings of this study show that in a sample of
goals, whether approach or avoidance, to approxi- depressed inpatients treatment outcome was related
mately 50%; the difference between groups failed to goal definition. From research with nonclinical
significance. and some mixed clinical samples, we know that
people who pursue avoidance goals appear to differ
in various ways from those with approach tenden-
Exploratory Analyses cies, and several authors have suggested explana-
Additional analyses included correlations between tions. Approach is much simpler and requires less
change scores on the BDI (pre minus post) and complex cognitive processes than avoidance because
attainment ratings of goals to explore whether group one pathway can be followed to reach a positive
assignment or improvement during therapy might be outcome instead of preventing all possible ways of
related to other variables. Results showed that the being confronted with a negative end state. There-
BDI change score was not correlated with the fore, information might be processed differently, as
number of avoidance goals (rBDI .073, p .06). shown before (e.g., Derryberry & Reed, 1994;
However, improvement on the BDI was positively Strachman & Gable, 2006). The AVOID group
related to the average rating of attaining approach might have focused instead on negative cues, such
(r .404, p .00) as well as avoidance goals (r  as one’s weaknesses or difficulties during the day
.273, p .00). instead of positive experiences and strengths and,
therefore, experienced less positive emotions
throughout therapy and were inhibited in their
Discussion improvement. Dickson and McLeod (2006) called
In this study we investigated whether goal definition this effect being in a ‘‘negative state of mind,’’ which
in psychotherapy is related to therapeutic outcome in may furthermore inhibit self-regulatory efforts.
a sample of depressed inpatients. We suspected that In addition, we found that a diagnosis of burnout
avoidance goals would diminish improvement and be was more frequent among the APP group members
more difficult to attain than approach goals. and otherwise eating disorders more frequent in the
We were able to support our first hypothesis that AVOID group. One may say that people who are
pursuing avoidance goals is related to less sympto- primarily solution oriented tend to pursue approach
matic improvement. Overall, large effect sizes were rather than avoidance goals, which appears to be
reached with the hospital treatment for within-group advantageous for treatment outcome. On the other
changes and a small but noteworthy effect for hand, people who have a general tendency to avoid
between-group changes. Both groups started out may identify related goals.
with the same level of depression, but patients who Contrary to our expectations, attainment of
defined at least one avoidance goal improved sig- avoidance and approach goals was comparable
nificantly less and felt more depressed at the end of (Hypothesis 2). Both groups reached their goals
therapy than those who focused solely on approach equally well, to about 50%. In contrast to the results
goals. Correlation analysis showed significant rela- of Rooney et al. (1995), who found that the
tionships between the attainment of both type of performance of students worsened when goals were
goals and change of depression. Our results support framed in avoidance terms, our results do not
Approach and avoidance goals in psychotherapy 493

suggest that the actual pursuit and attainment of utilized in the therapy process. Future studies could
goals were affected. Hence, we do not assume that go in two directions. On the one hand, they could
motivational processes played a central role. We have purposefully manipulate goal definition (e.g., refor-
also tested for therapist effects and found no mulating avoidance goals in approach terms) and
systematic differences between them in terms of aim for comparing multiple clinical populations,
goal achievement or change of depression. possibly identifying subgroups who may profit
Even though on average twice as many approach more or less from the approachavoidance distinc-
goals than avoidance goals were defined and the tion. We would expect patients suffering from
attainment of approach goals correlated more depression to profit more from focusing on the
strongly with the change of depression than avoid- approach system, because cognitive processing in
ance goals, the latter still appears to have had a favor of negative cues is a key symptom in that
greater impact on the outcome. This supports the population. On the other hand, diagnostic comor-
results from others. Several authors have found bidities should be investigated more closely and
evidence that people with avoidance tendencies possibly compared in terms of initial goal definition.
have more reactive avoidance systems (Grawe, There is evidence that certain diagnoses may be
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2007; Tomarken & Keener, 1998; Watson, Wiese, more inclined toward approach and avoidance,
Vaidya, & Tellegen, 1999), which could explain why respectively. Underlying metacognitions that may
defining only a few avoidance goals has had a large influence goal definition should be explored and
impact on improvement. possibly considered as elements of the therapeutic
In sum, this study replicates others’ results in- process that are in place, ready to be activated,
dicating that pursuing avoidance goals is related to before specific goals have even been set. In research,
poorer psychological outcome even in short-term goal definition in depressive patients should be
therapy. To our knowledge, the present study is the controlled for in outcome studies.
first to investigate a sample of patients primarily Furthermore, future research should link therapy
suffering from depression; and even though those goals and Grawe’s motivational goals more closely
patients may in general experience the cognitive and investigate the interaction of approach therapy
impairments mentioned previously, we were able to goals with an underlying avoidance motivation and
show that goal definition has differential effects on vice versa. We hypothesize that, regardless of the
emotional well-being. However, this study has some motivational goal, framing of the therapy goal is what
limitations, which suggest cautious interpretation of will affect treatment outcome. Finally, long-term
findings. Although the clinical inpatient setting effects of goal framing in clinical populations need to
increases external validity of the study, inferences be investigated.
have to be made with caution because we cannot be Overall, the present findings indicate that framing
certain that all possible variables were controlled for. goals in avoidance terms does not influence attain-
As of now, results should only be generalized to ment of therapy goals but is related to symptomatic
European patients with a diagnosis of depression, improvement. Hence, goal definition is important
because there are indications that different ethni- not only for process management but also to control
cities in general may be more or less inclined toward outcome quality. Therapists should emphasize the
avoidance (Sheu & Sedlacek, 2004). It needs to be importance of approach goal definition in therapy
noted that a rather large number of therapists (N and attempt to activate the approach system as often
95) were included in the study, many of whom as possible to increase treatment success.
treated only one patient. However, as mentioned
previously, systematic therapist effects cannot be
Note
assumed, but we would encourage future experi-
1
mental studies to include more patients per therapist A total of 28 patients defined one or more ambiguous goals.
to confirm our analyses. Furthermore, differing
methods of assessing approachavoidance may lead References
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