Implementation intentions: helping people achieve their goals

Implementation intentions are challenging. I intended to write this blog weeks ago, but here I am days before the deadline frantically hitting the keyboard on my laptop.

It is not just blog writing that experiences a drift from intention to action; the adherence of medication, such as antidepressants (Chong, Aslani & Chen, 2011), completion of therapy homework (Katzantzis et al., 2006) and attendance to treatment are common areas where the gap between intention and action often occur.

This review focused specifically on goal striving (moving towards a goal) rather than goal setting and how the bridge between goal intentions and behaviour can be overcome.

The meta-analysis looked at the effect of if-then intentions on goal attainment on individuals with a clinical mental health diagnosis.

There’s often a chasm between our intentions and our actions, which can be especially problematic for people with poor mental health.

Methods

The review had four inclusion criteria:

Studies involved an experimental investigation of the effect of forming implementation intentions
Participants met the criteria for DSM-IV or ICD-10 diagnosis (this included dementia, mood and neurodevelopmental disorders) or participants who scored above a clinical cut off on a standardised clinical measure (e.g. The Hospital Anxiety and Depression Scale)
Studies had to report a measure of goal attainment (this could be task performance, changes in behaviour or other outcomes, e.g. levels of anxiety) following the manipulation of implementation intentions
Studies had to be in the English language and have been published (or available) between January 1980 and March 2014.

The authors searched Web of Science and ProQuest Dissertations and Theses. They examined reference lists of relevant papers using an ancestry approach. They examined records that cited relevant papers and contacted authors to request unpublished research or studies that were in press.

Analytic methods

The analysis strategy was to estimate the effect size (Cohen’s d) as a representation of standardised difference in outcomes between experimental and comparison conditions. To do this, the authors used the Lyons and Morris 2014 meta-analysis calculator
The authors used adjusted values and pooled effects sizes if studies reported multiple measures and weighted the estimate by sample size. If there was more than one experimental condition, the control condition was halved to avoid double counting
The studies compared had at least 35 participants in each arm. For those that had fewer, a random effects computation model was used.

Results

29 studies were identified for inclusion with a total of 1,652 participants
Studies included participants with a diagnosis of schizophrenia, schizoaffective disorder, anxiety, depression and addictions, as well as ADHD and brain damage
Most studies explored the experimental forming of intentions on goal attainment using if-then plans to support goals. However, some of the studies focused on the implementation of intentions for specialised interventions.
The sample weight average effect was d= 99 (95% CI: 0.40 to 1.60), this excluded an outlier with an effect size of d= 4.99. This indicated a large effect size of forming implementation intentions on goal attainment.
Seven possible moderators were assessed:
- There was no statistical difference between studies that recruited those with:
  - Mental health symptoms (d=0.96)
  - Developmental disability (d=0.35)
  - Brain injury (d=1.13)
- Forming intentions had similar effects on:
  - Action initiation (d=0.42)
  - Cognitive skills (d=1.22)
  - Emotional regulation (d=0.65)
It was found publication status did not moderate effect.

This meta-analysis suggests that people with mental health problems can benefit if they are prompted to form if-then plans, which specify when, where and how they will achieve their goals.

Conclusions

The authors concluded that if-then planning can be an effective technique in the promotion of goal attainment in mental health populations.

The overall effect is robust and if-then planning can be effective in attaining goals across a range of clinical problems.

The authors suggest that:

Encouraging people to specify when, where and how they will achieve their goals will be likely to improve outcomes.

The findings suggest that if-then planning has a large effect size on goal attainment and is effective in promoting a range of different goals, across a range of different mental health problems.

The paper includes guidance for researchers and practitioners in how to promote the formation of implementation intentions.

Strengths and limitations

The study has several strengths. The authors employed a number of strategies to identity papers and cast their web widely. They utilised some sensible methods for comparing outcomes by weighting effects by sample size and removing statistical outliers that could inflate effects. There also was a high level of rater agreement at each stage of identification and screening, so the authors were consistent.

However, the search itself used a limited number of databases, a minimal variation of search terms and was limited to English language only, which means that relevant research may have been missed. The included studies were not quality rated and give readers little idea of how robust the included studies methodologies and analysis were, making it difficult to know if the included studies represent high quality research. Finally, the inclusion of both those with a clinical mental health diagnosis and those with a neurodegenerative disease or brain injury appears to muddy the waters somewhat, as it is difficult to know if the studies are comparing apples to apples.

Discussion

This review focuses on a specific element of what could broadly be considered behaviour change. It highlights the importance of the gap between intention and action, which occurs across clinical practice. The ability to increase the likelihood of action undoubtedly will support individuals to move towards a multitude of goals.

However, the implementation of intentions is just one element of behaviour change, which is a complex and multifaceted process, as noted by Michie et al. (2011, 2013) in their behavioural change model and taxonomy. These findings should be considered within the wider context of individuals’ capability, motivation and access to opportunity.

Behaviour change is a complex and multifaceted process.

Links

Primary paper

Toli A, Webb TL, Hardy GE. (2016) Does forming implementation intentions help people with mental health problems to achieve goals? A meta-anaylsis of experimental studies with clinical and analogue samples. British Journal of Clinical Psychology, 55, 69-90. [PubMed abstract]

Other references

Chong WW, Aslani P, Chen TF. (2011) Effectiveness of interventions to improve antidepressant medication adherence: a systematic review. International Journal of Clinical Practice, 65 (9), 954-975. [DARE summary]

Kazantzis N, Deane FP, Ronan KR. (2006) Homework Assignments in Cognitive Behavioral Therapy: A Meta-Analysis. Clinical Psychology: Science and Practice, 7(2), 189-202. [Abstract]

Lyons LC, Morris WA. (2014) The meta-analysis calculator. Retrieved from www.lyonsmorris.com/ma1/

Michie S, van Stralen MM, West R. (2011) The behavioural change wheel: a new method for characterizing and designing behaviour change intervention. Implementation Science, 6,42.

Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane J, Wood CE. (2013) The Behavior Change Technique Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an International Consensus for the Reporting of Behavior Change Interventions. Annals of Behavioral Medicine, 46(1), pp. 81-95. doi: 10.1007/s12160-013-9486-6. [PubMed abstract]