Apathy, anhedonia, and social withdrawal constitute the motivational factor of negative symptoms (1, 2) and are evident in approximately 60% of people with psychotic disorders (3). Compared to positive symptoms and the expressivity factor of negative symptoms (i.e., alogia and blunted affect) motivational negative symptoms account for the reduced levels of long-term functioning (4, 5) and the low quality of life (6, 7). Consequently, both clinicians (8) and patients (9) consider motivational negative symptoms an important treatment target.
Several meta-analyses found that psychological approaches, such as cognitive behavior therapy (CBT), social skills training, and cognitive remediation, can alleviate motivational negative symptoms, however, with only small to moderate effect sizes (10–14). One reason for these rather unsatisfying effect sizes could be that the available interventions were either not derived from empirical knowledge about negative symptoms or that each intervention targets only single factors, e.g., social skills (15), beliefs (16), or goal pursuit (17, 18). Meanwhile, empirical research on psychological mechanisms of motivational negative symptoms has gained traction. This has considerably refined and extended our understanding of the factors that are likely to be relevant to the formation and maintenance of negative symptoms. This research now provides a comprehensive set of factors that can be, and in our view should be, addressed by psychosocial interventions. As we will outline in the following, these include suboptimal goal setting, altered reward processing, anticipatory anhedonia, demotivating beliefs as well as reduced social and problem-solving skills (for an overview see (19)).
Suboptimal goal setting. Even though people with negative symptoms are able to set personal life goals (20), they report difficulties initiating and maintaining behavior towards goal realization (21). More fine-grained analyses of the types of short-term goals in daily life indicate an association between negative symptoms and setting too many avoidance goals (22) which is likely to explain the reduced approach-oriented (23) and increased avoidance-oriented behavior (24). Thus, effective interventions aimed at optimizing goal pursuit need to encourage the setting of personal meaningful specific, measurable, attractive, realistic, and time-bound approach goals.
Altered reward processing. People with motivational negative symptoms have also been found to display problems in reinforcement learning (24–26), prediction of reward cues, generating, updating, and maintaining value-representations (27–30), exploratory behaviors with uncertain reward-outcomes (31), and unfavorable trade-offs in effort-value computations (5, 27, 28, 32). Intervention targets that can be derived from this research on reward processing include training patients to generate, maintain and update a mental representation of a reward and in supporting them in developing an accurate estimation of the effort necessary to achieve a goal.
Anticipatory anhedonia. Recent reviews point towards a reduced ability to anticipate pleasure for future events in people with negative symptoms (33, 34), despite intact ability to experience in-the-moment pleasure (35). This problem in anticipatory pleasure has been found to mediate the translation of goal intentions into goal-directed behavior (36). Research from basic neuroscience has found that the anticipation of positive future events draws strongly on the ability to recall pleasant episodic memories (37), however, this ability has also been found to be reduced in people with negative symptoms (38, 39). Taken together, this research indicates that improving anticipatory anhedonia could be a key to ameliorate motivational negative symptoms. This could be achieved by either supporting the recall of episodic memories about similar past pleasurable experiences (40) and by building on the intact ability to experience consummatory pleasure (41, 42).
Demotivating beliefs. Demotivating beliefs about self (self-defeating beliefs), others (social indifference beliefs) and the future (low expectancy of pleasure) (see (43–46)) have been found to account for one third of variance in amotivation (36, 46) and to impede the willingness to exert effort (47). Particular attention has been given to a specific aspect of self-defeating beliefs, namely, defeatist performance beliefs (e.g., “If you cannot do something well, there is little point in doing it at all.”) that are associated with a reduced level of functioning (48). It follows that identifying, challenging, and gradually modifying these specific beliefs could be another promising treatment approach.
Reduced interpersonal and problem-solving skills. Impaired social skills and social cognition, have long been associated with motivational negative symptoms (49, 50). Targeting social skills has been shown to improve negative symptoms (51–53). Similarly, difficulties in the ability to solve problems in an effective and timely manner have been repeatedly found to be associated with psychosis in general (54) and negative symptoms specifically (55). Training of problem-solving skills has also become a well-established approach for psychosis (56, 57). Accordingly, effective interventions for the reduction of negative symptoms would be advised to include these effective components.
We argue that each of these factors contributes to the observed difficulties of patients with negative symptoms in pursuing personally meaningful goals. It follows, that interventions that specifically target these factors are likely to be more successful in reducing motivational negative symptoms than the rather unspecific interventions such as behavioral activation and cognitive therapy. Given that each of these factors is associated with negative symptoms but none of them can fully account for negative symptoms, we also expect approaches addressing several of these factors to be superior to interventions that focus on a single factor. This expectation is corroborated by the fact that some of the novel approaches that have targeted several of these factors, such as by combining cognitive interventions with social skills training (58) or with interventions targeting anhedonia (59–61), tend to produce more promising effects. In addition, given the high heterogeneity between patients in regard to the factors that drive amotivation, we argue that intervention approaches will more likely be effective if their focus of intervention can be flexibly adjusted to the individual needs of a given patient (19). However, to our knowledge, there is no approach that addresses the full range of relevant mechanisms in a customizable manner.
On that account, we derived a comprehensive individualized cognitive behavioral intervention (“Goals in Focus”) that supports patients in specifying attainable personal goals and overcoming obstacles in goal pursuit. This is done by increasing the salience of rewards, training anticipatory pleasure, challenging demotivating beliefs, and strengthening social and problem-solving skills in respect to the patient’s individual goals.
With this feasibility trial, we aim to test the feasibility and acceptability of the therapy protocol and trial procedures as well as to obtain first estimates of the effect size that can be expected from “Goals in Focus” to inform the sample size calculation for a fully powered clinical trial.