Psychotherapy Research

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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

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 Psychotherapy Research, July 2010; 20(4): 488
494

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
Downloaded by [NUS National University of Singapore] at 02:44 06 November 2015

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
quantification of change during treatment are some
of the most difficult issues in psychotherapy re-
search. Treatment quality can be assessed by differ-
entiating among certain general aspects. One such
distinction made is that between structural, process,
and outcome quality (Margraf, 2000). Setting treat-
ment goals is essential for quality assurance and has
been a long tradition in order to direct the therapy
process itself (i.e., increasing patient motivation and
compliance) and evaluate the outcome. Especially
cost-intensive inpatient treatments increasingly re-
quire goal-oriented processes. If goal setting is
considered as a therapeutic element, proper goal
definitions may lay the groundwork for a successful
cognitive
behavioral treatment.
Over the years, different theoretical models and
criteria have been suggested in order to enhance
patients’ motivation and possibly increase treatment
effects. One basic conceptual distinction discerned
long ago is that of approach (appetitive)
avoidance
(aversive; e.g., Carver & Scheier, 1996; Coats,
Janoff-Bulman, & Alpert, 1996; Higgins, 1996).
Most researchers have defined approach as ‘‘being
focused on a positive end state.’’ Hence, it is linked
to approach behavior, meaning trying to move
toward or maintain the desired outcome. Avoidance
goals, on the other hand, focus on negative end
states and moving or staying away from them (Elliot
& Sheldon, 1997). A positive end state is usually
understood as what is ‘‘commonly considered nor-
mal, health-inducing’’ (Elliot & Friedman, 2005).
Early on, theorists have posited that goals are
concrete concepts of more global motivational dis-
positions (for a review, see Elliot & Church, 1997). In
therapy, the same goal can be defined by approach or
avoidance behavior. For instance, a patient might
want to ‘‘improve his/her mood’’ or ‘‘be less de-
pressed.’’ Both goals target the same underlying
motive and, therefore, one could assume that the
verbal representation should not be of interest.
However, several researchers have posited systems
that underlie approach and avoidance strivings and
behavior, respectively (Davidson, 1998; Fowles,
1988; Gray, 1982). Although these models differ,
they have in common neurophysiological systems that
underlie approach and avoidance processes. For
instance, Gray’s (1982) behavioral activation system
is linked to signals of reward and feelings of happiness
or hope; the behavioral inhibition system, on the other
hand, is linked to punishment, anxiety, and sadness.
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)504
751 E-mail: EWollburg@schoen-kliniken.de

ISSN 1050-3307 print/ISSN 1468-4381 online # 2010 Society for Psychotherapy Research
DOI: 10.1080/10503301003796839

feedback model, perceived information is compared
with an internal reference and if the discrepancy
between both needs to be enlarged, avoidance beha-
vior will follow and vice versa. The actions that need
to take place to reach the goal may be the same, but
the process differs. More recently, Grawe differen-
tiated between approach and avoidance motivational
goals. In his consistency theory (Grawe, 2007), he
points out that strong avoidance motivational goals
are one source of incongruence because they require
constant control and distributed attention and hence
are associated with psychological problems. He
defines incongruence as a state that develops when
goals (approach or avoidance) are not achieved. Just
because the aversive state has been fought once does
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not mean it cannot possibly occur any minute again;
therefore, avoidance motivational goals can never
fully be reached and lead to inefficient goal pursuit
and attainment and a feeling of dissatisfaction.
Furthermore, several authors (Derryberry & Reed,
1994; Gomez & Gomez, 2002; Higgins & Tykocinski,
1992) point out that goal framing influences how
information is processed. Avoidance motivation
biases people toward negative cues and makes them
not only remember more negative information but
also recall positive or neutral information less posi-
tively (Strachman & Gable, 2006). One may even
suspect that certain metacognitions such as ‘‘the more
the better’’ influence goal formulation; hence, the
definition itself may already be the first step of a
successful therapy.
Although early theorists assumed that, regardless
of the goal, satisfaction of needs in general leads to
happiness (Srull & Wyer, 1985; Wilson, 1960), the
outlines given previously indicate that both ap-
proach and avoidance should lead to very different
emotional states and, therefore, to different therapy
outcomes. Indeed, it was postulated two decades
ago that patients should focus on a positive wording
of therapy goals, or knowing what to do instead of
what not to do (Kanfer, Reinecker, & Schmelzer,
1991). However, few studies have investigated the
influence of goal definition on therapy outcome.
Some studies were done with mixed clinical popula-
tions (Berking, Grosse Holtforth, & Jacobi, 2003;
Dickson & MacLeod, 2006), but for the most part
findings from basic research conducted with stu-
dents were adopted to psychotherapy (e.g., Coats et
al., 1996; Dickson & MacLeod, 2006; Elliot &
Sheldon, 1997; Emmons, 1986). Elliot et al.’s work
in numerous studies with undergraduate students
indicated that pursuing avoidance goals makes
people feel less competent in terms of goal achieve-
ment (Elliot & Church, 1997; Elliot & Sheldon,
1997, 1998), undermines intrinsic motivation (Elliot
& Harackiewicz, 1996; Ryan, Sheldon, Kasser, &
Approach and avoidance goals in psychotherapy 489
Deci, 1996), is associated with more physical
symptoms (Elliot & Sheldon, 1998), inhibits pro-
gress toward goal achievement (Elliot & Sheldon,
1998), and is in general related to poorer psycho-
logical outcome, such as lower positive moods,
more anxiety, lower self-esteem, or less life satisfac-
tion (Elliot & Friedman, 2005; Elliot & Sheldon,
1997; Elliot, Sheldon, & Church, 1997). Other
researchers describe similar interaction results of
subjective well-being and avoidance goals when
investigating nonclinical populations (Coats et al.,
1996; Emmons, 1996; Gollwitzer & Moskowitz,
1996; Rooney, Higgins, & Shah, 1995). Students
in Rooney et al.’s (1995) study even performed
worse during the semester when they framed their
goals in avoidance terms.
Only few studies with clinical populations exist
and these involved mixed populations, which may
confound findings and limit interpretation of re-
sults. Elliot and Church (2002) investigated the
proportion of avoidance and approach goals in
students seeking outpatient psychotherapy. The
higher the proportion of avoidance goals, the less
improvement, measured as subjective well-being,
was seen during treatment. In another study,
dysphoric adolescents not only generated more
avoidance than approach goals but were also in a
‘‘negative state of mind.’’ Patients thought of more
reasons for failure than success in pursuing the goals
and expected better achievement of avoidance goals
(Dickson & MacLeod, 2006). On the motivational
level, psychotherapy patients, compared with psy-
chiatrically healthy controls, tend to pursue more
avoidance goals (Grosse Holtforth & Grawe, 2003)
and achieve a better treatment outcome when
avoidance motivation is reduced and approach
motivation is strengthened during therapy (Berking
et al., 2003).
In sum, the studies discussed previously show
that approach goals are positively related and
avoidance goals negatively related to subjective
well-being, although it is unclear whether avoid-
ance causes worse well-being or whether clients
who are feeling poorly tend to pursue more
avoidance behavior. In our study, we sought to
further examine the relationship between the defi-
nition of therapy goals, regardless of goal content,
and therapeutic outcome in depressed inpatients.
On the basis of previous findings, we hypothesized
that, compared with solely identifying approach
goals, (a) pursuing at least one avoidance goal will
be associated with less symptomatic improvement
and (b) avoidance goals will be achieved less than
approach goals.
 490 E. Wollburg and C. Braukhaus
Method
Participants
The study sample consisted of 657 inpatients ad-
mitted to a psychosomatic clinic in Germany with a
primary diagnosis of depression. The mean age was
45.2 years, and approximately 68.5% were female
(n 458 female and n 199 male). The majority of
the sample was married (47.5%) and had at least
some college or university education (70.8%). As is
typical among German psychosomatic inpatient
clinics, race and ethnicity were not recorded. Pa-
tients must have met criteria for a current Interna-
tional Classification of Mental Disorders (Dilling,
Mombour, & Schmidt, 2005) diagnosis of either a
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single depressive episode (F32) or recurrent depres-
sive episodes (F33) and have had a total score on the
Beck Depression Inventory (BDI; German version:
Hautzinger, Bailer, Worrall, & Keller, 2000) of at
least 18 at the beginning of therapy. Exclusion
criteria were current alcohol or drug abuse or a
history of any psychotic disorder. The majority of the
group was diagnosed with recurrent major depres-
sion of moderate severity (45.3%). About 85% had
an additional International Classification of Mental
Disorders diagnosis. On average, patients stayed at
the clinic for 7 weeks (approach group, 48.7 days;
avoidance group, 48.3 days). Ninety-three percent of
the sample was on medication; 35.5% of these took
antidepressants only and 52.1% took antidepressants
in combination with other medications (e.g., hypno-
tics or analgesics). There was no difference in
antidepressive medication between groups, x2(1,
N 657) 2.65, p .13.
Instruments
The questionnaire package included, among other
measures, the BDI (Beck, Ward, Mendelson, Mock,
& Erbaugh, 1961; German version: Hautzinger et
al., 2000). The questionnaire consists of 21 items
rated on a 4-point Likert scale ranging from 0 to 3
and one yes
no question. The BDI was used to
operationalize symptomatic improvement. Further-
more, the patients rated the achievement of each
goal on a scale ranging from 0 to 10 at the end of
therapy. Approach was defined as trying to move
forward or maintain a positively evaluated end state
(e.g., ‘‘I want to experience more joy’’) and avoid-
ance as trying to escape or stay away from a
negatively evaluated end state (‘‘I want to reduce
my depression’’). The total sample was then split
into two groups: The approach (APP) group in-
cluded patients who identified only approach goals,
and the avoidance (AVOID) group consisted of
patients who identified at least one avoidance goal.
If a goal was not unambiguously classifiable, the
patient was omitted from the sample.1
Procedure
Data from patients consecutively admitted to the
clinic in 2008 were analyzed. All patients were
treated with a multimodal cognitive
behavioral ther-
apy program. Demographic and clinical data col-
lected at pretreatment and posttreatment were taken
from archived patient files and rendered anonymous
by hospital staff. Patients completed a battery of self-
report questionnaires at both assessments, of which
the BDI and goal achievement were used for the
present study (see prior discussion). Within the first
week of the stay, therapy goals were formulated and
achievement was rated at posttreatment. Patients
were asked to note three major goals. Goals were
classified into approach or avoidance goals by two
trained raters. Both raters were graduate students
with a master’s degree in psychology and trained by
the primary investigator by means of sample goals.
First, raters independently coded each treatment
goal. After interrater reliabilities were computed,
disagreements were discussed with the principal
author and consensus rating was performed. Inter-
rater reliability (Cohen’s kappa) reached .89, which
can be interpreted as ‘‘almost perfect agreement,’’ as
suggested by Landis and Koch (1977).
Statistical Analysis
Computations were made using the Statistical Pack-
age for Social Sciences (version 17.0; SPSS Inc.).
For demographic and clinical measures, differences
in categorical variables were tested with the chi-
square test, and continuous variables were investi-
gated with one-way analyses of variance (ANOVAs).
For analysis of the repeated psychological data
collected during both assessments, general linear
models with the factors time (pre, post) and group
(APP, AVOID) were used. Interrater reliability was
calculated with Cohen’s kappa and judged according
to Landis and Koch (1977). Therapist effects were
tested with intraclass correlation coefficients on the
BDI and goal achievement. Effect sizes were calcu-
lated as Cohen’s (1988) d when appropriate. For
within- and between-group comparisons, the pre-
and posttreatment values and change scores, respec-
tively, were entered into Cohen’s equation (M1
M2/
SDpooled). Statistical significance was set to p 5.05,
two-tailed. For exploratory purposes, Pearson
product
moment correlations were performed to
detect linear association between goal variables and
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-
ate severity), about 33% with a major depressive
episode (moderate severity), and 20% with recurrent
major depression (severe episode without psychotic
symptoms). Eighty-four percent of the sample had
comorbid diagnoses in addition to primary depres-
sion (37.9% one comorbid diagnosis, 31.1% two,
11.3% three, 2.89% four, and 1.07% five). Investi-
gation of the frequency of comorbid diagnoses
revealed substantial differences between groups.
Significantly more clients in the APP group suffered
from burnout syndrome, x2(2, N657) 12.0, p B
.01, and more people in the AVOID group from
comorbid eating disorder, x2(1, N 657) 6.65,
p B.05.
Pretreatment
Table I displays the total scores for the question-
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
avoidance goals (2.22 vs. 1.29, respectively).
Figure I. Mean number of approach and avoidance goals by group
(APP, approach group; AVOID, avoidance group).
Change with Treatment
The repeated measures ANOVA of the BDI resulted
in significant main effects: group, F(1, 190.62)
4.44, p .04; time, F(1, 4323.91) 105, p .00;
and interaction effects: Group Time, F(1,
581.58) 4.66, p .03. At posttreatment, the BDI
total score significantly decreased in both groups,
but more so in the APP group (see Figure II). The
overall group effect was caused by the difference at
posttherapy because pretherapy scores were compar-
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
ranged from .03 to .10 (rBDI .10, rgoal attainment
overall .07).
Beck Depression Inventory
30
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 (0
64) 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
Variable APP AVOID F p
Approach goals
n 1,493 422
M (SD) 5.38 (2.31) 5.09 (2.48) 1.97
Avoidance goals
n n/a 249
M (SD) 5.04 (3.04) n/a n/a
Total
N 1,493 671
M (SD) 5.38 (2.31) 5.02 (2.54) 3.01
Note. F values from one-way analysis of variance. APP, approach
group; AVOIDavoidance group.
Posttreatment
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Goal achievement was assessed for each individual
goal (ratings ranged from 0
10); groups did not
differ (see Table II). Both groups achieved all of their
goals, whether approach or avoidance, to approxi-
mately 50%; the difference between groups failed
significance.
Exploratory Analyses
Additional analyses included correlations between
change scores on the BDI (pre minus post) and
attainment ratings of goals to explore whether group
assignment or improvement during therapy might be
related to other variables. Results showed that the
BDI change score was not correlated with the
number of avoidance goals (rBDI .073, p .06).
However, improvement on the BDI was positively
related to the average rating of attaining approach
(r .404, p .00) as well as avoidance goals (r  as one’s weaknesses or difficulties during the day
.273, p .00).
Discussion
In this study we investigated whether goal definition
in psychotherapy is related to therapeutic outcome in
a sample of depressed inpatients. We suspected that
avoidance goals would diminish improvement and be
more difficult to attain than approach goals.
We were able to support our first hypothesis that
pursuing avoidance goals is related to less sympto-
matic improvement. Overall, large effect sizes were
reached with the hospital treatment for within-group
changes and a small but noteworthy effect for
between-group changes. Both groups started out
with the same level of depression, but patients who
defined at least one avoidance goal improved sig-
nificantly less and felt more depressed at the end of
therapy than those who focused solely on approach
goals. Correlation analysis showed significant rela-
tionships between the attainment of both type of
goals and change of depression. Our results support
findings from other research groups. Berking et al.
(2003) showed that patients with less avoidance
motivation at the end of therapy benefited more
from the treatment. Furthermore, as consistently
reported from research with individuals from the
.16
general population, pursuing avoidance goals is
related to poorer psychological outcome (Elliot &
Friedman, 2005; Elliot & Sheldon, 1997; Elliott et
al., 1997) and worse mood state (Gollwitzer &
Moskowitz, 1996). On the other hand, our results
.08
contradict previous findings of Sack, Lempa, Lam-
precht, and Schmid-Ott (2003), who found no
association between therapy goal achievement and
the degree of improvement and, therefore, con-
cluded that goals are suitable not for an evaluation
of treatment outcome but only for process quality
management.
The findings of this study show that in a sample of
depressed inpatients treatment outcome was related
to goal definition. From research with nonclinical
and some mixed clinical samples, we know that
people who pursue avoidance goals appear to differ
in various ways from those with approach tenden-
cies, and several authors have suggested explana-
tions. Approach is much simpler and requires less
complex cognitive processes than avoidance because
one pathway can be followed to reach a positive
outcome instead of preventing all possible ways of
being confronted with a negative end state. There-
fore, information might be processed differently, as
shown before (e.g., Derryberry & Reed, 1994;
Strachman & Gable, 2006). The AVOID group
might have focused instead on negative cues, such
instead of positive experiences and strengths and,
therefore, experienced less positive emotions
throughout therapy and were inhibited in their
improvement. Dickson and McLeod (2006) called
this effect being in a ‘‘negative state of mind,’’ which
may furthermore inhibit self-regulatory efforts.
In addition, we found that a diagnosis of burnout
was more frequent among the APP group members
and otherwise eating disorders more frequent in the
AVOID group. One may say that people who are
primarily solution oriented tend to pursue approach
rather than avoidance goals, which appears to be
advantageous for treatment outcome. On the other
hand, people who have a general tendency to avoid
may identify related goals.
Contrary to our expectations, attainment of
avoidance and approach goals was comparable
(Hypothesis 2). Both groups reached their goals
equally well, to about 50%. In contrast to the results
of Rooney et al. (1995), who found that the
performance of students worsened when goals were
framed in avoidance terms, our results do not

suggest that the actual pursuit and attainment of
goals were affected. Hence, we do not assume that
motivational processes played a central role. We have
also tested for therapist effects and found no
systematic differences between them in terms of
goal achievement or change of depression.
Even though on average twice as many approach
goals than avoidance goals were defined and the
attainment of approach goals correlated more
strongly with the change of depression than avoid-
ance goals, the latter still appears to have had a
greater impact on the outcome. This supports the
results from others. Several authors have found
evidence that people with avoidance tendencies
have more reactive avoidance systems (Grawe,
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2007; Tomarken & Keener, 1998; Watson, Wiese,
Vaidya, & Tellegen, 1999), which could explain why
defining only a few avoidance goals has had a large
impact on improvement.
In sum, this study replicates others’ results in-
dicating that pursuing avoidance goals is related to
poorer psychological outcome even in short-term
therapy. To our knowledge, the present study is the
first to investigate a sample of patients primarily
suffering from depression; and even though those
patients may in general experience the cognitive
impairments mentioned previously, we were able to
show that goal definition has differential effects on
emotional well-being. However, this study has some
limitations, which suggest cautious interpretation of
findings. Although the clinical inpatient setting
increases external validity of the study, inferences
have to be made with caution because we cannot be
certain that all possible variables were controlled for.
As of now, results should only be generalized to
European patients with a diagnosis of depression,
because there are indications that different ethni-
cities in general may be more or less inclined toward
avoidance (Sheu & Sedlacek, 2004). It needs to be
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
treated only one patient. However, as mentioned
previously, systematic therapist effects cannot be
assumed, but we would encourage future experi-
mental studies to include more patients per therapist
to confirm our analyses. Furthermore, differing
methods of assessing approach
avoidance may lead
to other findings. Additionally, we did not test other
goal characteristics, such as realistic formulation,
that may have (partially) accounted for the differ-
ences we found. Finally, one could wonder whether
the differentiation between single depressive epi-
sodes and recurrent episodes and their interaction
with goal definition may affect the results.
Notwithstanding these limitations, the findings of
this research provide useful information that can be
Approach and avoidance goals in psychotherapy 493
utilized in the therapy process. Future studies could
go in two directions. On the one hand, they could
purposefully manipulate goal definition (e.g., refor-
mulating avoidance goals in approach terms) and
aim for comparing multiple clinical populations,
possibly identifying subgroups who may profit
more or less from the approach
avoidance distinc-
tion. We would expect patients suffering from
depression to profit more from focusing on the
approach system, because cognitive processing in
favor of negative cues is a key symptom in that
population. On the other hand, diagnostic comor-
bidities should be investigated more closely and
possibly compared in terms of initial goal definition.
There is evidence that certain diagnoses may be
more inclined toward approach and avoidance,
respectively. Underlying metacognitions that may
influence goal definition should be explored and
possibly considered as elements of the therapeutic
process that are in place, ready to be activated,
before specific goals have even been set. In research,
goal definition in depressive patients should be
controlled for in outcome studies.
Furthermore, future research should link therapy
goals and Grawe’s motivational goals more closely
and investigate the interaction of approach therapy
goals with an underlying avoidance motivation and
vice versa. We hypothesize that, regardless of the
motivational goal, framing of the therapy goal is what
will affect treatment outcome. Finally, long-term
effects of goal framing in clinical populations need to
be investigated.
Overall, the present findings indicate that framing
goals in avoidance terms does not influence attain-
ment of therapy goals but is related to symptomatic
improvement. Hence, goal definition is important
not only for process management but also to control
outcome quality. Therapists should emphasize the
importance of approach goal definition in therapy
as possible to increase treatment success.
Note
1
A total of 28 patients defined one or more ambiguous goals.
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