Improving goal striving and resilience in older adults through a personalized metacognitive self-help intervention: a protocol paper

Resilience and behavioral adaptability as critical element

Older adults’ mental well-being and quality of life (QoL) may be jeopardized by various age-related challenges and transitions (e.g., loss of spouse or functional abilities) if these are not adequately managed and controlled [1, 2]. Accordingly, successful aging is often linked to an individual’s ability to demonstrate resilience: successful adaptation in the face of challenges [3,4,5,6,7]. Resilience can be conceptualized as the maintenance and/or quick recovery of functional ability, (mental) well-being and QoL despite losses or adversity [1, 2, 8, 9], and has been considered a defense mechanism against mental health problems (but also [10,11,12] for their perspectives on resilience).

Although much emphasis is generally put on the importance of psychological adaptability (e.g., exhibiting adaptive coping styles and self-management abilities, or having an optimistic and positive frame of mind; [9]), behavioral adaptability also constitutes a critical element of resilience. It refers to the adaptive changes in behavior in accordance with internal or external demands [13, 14]. In later life, the (impending) loss of a spouse or good friend may, for instance, require adjustments in daily life behaviors to increase opportunities for other social contacts to diminish or prevent feelings of loneliness. Similarly, to delay physical decline or to alleviate depressive symptoms, older adults may scale up the number of hours spent on (physical) activities [15,16,17,18]. Age-related degradation of executive functions can, however, lead to volition problems that compromise flexible, goal-directed adjustment of behavior (e.g., failing to get started; [19,20,21,22,23,24]). These may be exacerbated by mental health problems, including depression or apathy, which is defined as a quantitative reduction in goal-directed, non-routine behaviors due to as loss of effort/initiative, interest and/or emotional reactivity [25,26,27]. In contrast, however, the reliance on efficient habitual control has been shown to remain relatively intact in later life [20, 28], and may therefore provide an expedient route to goal attainment among older adults [29].

In the current study, we examine whether a metacognitive self-help intervention (MCSI), aimed at facilitating goal striving through the gradual automatization of efficient routines, could effectively support behavioral adaptability in favor of resilience among older adults with and without (sub-clinical) mental health problems. This MCSI is based on insights from health & social psychology and clinical psychology and adopts an integrated approach by combining components of existing behavioral change/activation interventions from both fields. The idea is that individuals learn a strategy that can help them to set and strive for self-identified goals. To accommodate for the large individual differences that exist among aging individuals, a personalized framework is used to tailor the intervention to personal needs and challenges.

Improving behavioral adaptability through habit formation

When a specific action is consistently performed in response to a situational cue, an associative link between the situation and that action (i.e., stimulus–response link) is formed [30]. This process is known as habit formation and enables individuals to automate behaviors without the need for conscious planning. Habit formation as a potential mechanism to foster behavioral adaptability has received widespread attention, particularly for samples with volition problems [31]. A particularly prevalent volition problem among older individuals pertains to action initiation [32]. It has been hypothesized that this is due to the stability of older adults’ lives and the regularity with which they encounter situational cues, making it harder to initiate an intended change [32, 33]. For instance, increasing exercise behavior in daily life likely requires one to adjust some deep-seated routines (e.g., taking the stairs, rather than the elevator; after lunch going for a walk first, instead of putting on the TV immediately). Therefore, it may be particularly challenging for older adults to initiate new target behaviors that compete with existing habits. On the other hand, once the target behavior has been initiated, the stability of older adults’ lives may help to automatize and maintain this new behavior [32].

A useful strategy to overcome difficulties with action initiation and facilitate automatized goal striving is by forming so-called ‘implementation intentions’ (IIs; [21]): if–then plans that specify a behavior to be performed in response to an anticipated cue (‘If situation Y arises, then I will initiate behavior X’; [34, 35]). Such plans are thought to operate by heightening the cognitive accessibility of a situation cue (or opportunity to act) and by forging a mental association with a desired behavior, such that this is automatically elicited when the situation is subsequently encountered [34,35,36,37]. For instance, after formulating the following plan: “If I enter my building, then I will take the stairs to my floor”, entering the building becomes a trigger for walking up the stairs, and one does not have to deliberate about when or how to act. This increases the likelihood of consistent repetition [21, 38], and thereby facilitates habit formation [39, 40].

IIs have been widely applied in health psychology, and have been shown to facilitate goal attainment among the general population, as well as specific subgroups [21]. Interestingly, IIs are considered to be particularly helpful for individuals whose self-regulatory skills are compromised [21], thereby serving as a compensatory strategy for those in strongest need of assistance. This has been supported by a number of studies showing that IIs can help to overcome ego-depletion [41], and promote goal attainment among those suffering brain damage or drug addiction [42, 43], as well as improve prospective memory performance among those with low executive functioning [44, 45] or fluid mechanics (i.e., those cognitive functions that tend to decline with age; [46]). Accordingly, IIs have been suggested as a means to compensate for age-related decline in prospective memory [47]. Indeed, several studies have already provided promising results among older adults [48,49,50,51], showing that IIs can foster new sets of actions in favor of resilience in later life (e.g., improve physical activity; [51]).

Using implementation intentions to support mental health

Another group that may particularly benefit from IIs and automatization of adaptive behaviors are those with underlying mental health problems. Previous research has emphasized how mental health problems may exacerbate goal striving challenges (e.g., see [27, 52, 53]). This may be especially the case in many aging individuals, who already experience a natural degradation of their (goal-directed) self-regulatory processes. This is a critical issue, as goal striving and adaptive behavior change (e.g., engaging in social/physical activities) can effectively break or even reverse the downward spiral to mental health problems that is most prevalent among older adults (e.g., apathy, depression, loneliness; [16, 17, 52, 54,55,56,57,58,59]).

In clinical practice, promoting adaptive routines is part of behavioral activation treatment, which is built on the premise that engaging in behaviors that connect people to sources of positive reinforcement can improve mental health (e.g., alleviating depressive symptoms, increasing social connectedness; [16, 17, 58]; based on Lewinsohn’s theory of depression [60]). Specifically, behavioral activation encourages individuals to engage in pleasurable, mood-independent, pre-planned activities, and therefore overlaps largely with our primary goal of using IIs to support behavioral adaptability in favor of resilience. Behavioral activation is often incorporated in cognitive behavioral treatment (e.g., Beck’s Cognitive Therapy; [61]), and may be an important driving force behind its efficacy [62, 63].

A critical element of behavioral activation treatment is monitoring of daily activities and mood, followed by identifying adaptive behaviors that could restore an adequate schedule of positive reinforcement (e.g., calling daughter; going for a walk every day; see [16] for manual). Such a personalized (reward-driven) framework may also provide a useful tool for improving the efficiency of IIs, especially when applied more broadly, in a metacognitive way. Reversely, IIs have also been suggested to boost behavioral activation by stimulating the actual execution of the personally identified activities [53]. That is, while behavioral activation treatment encourages to include the identified activities in their daily schedule (e.g., ‘at 9 a.m. on Monday’), they are not instructed to link this to a specific situation, pre-existing routine or other consistent opportunity to act (e.g., ‘If I have finished my breakfast’; [53, 64]; and also see [16]), which may result in lower than desired enactment. Hence, by incorporating these behavioral activation principles (i.e., monitoring of daily activities and mood, and encouragement of engagement in rewarding, personally relevant activities that match with intrinsic values) into an II intervention, the formation of persistent habits may be accelerated and behavioral adaptability in favor of resilience, and consequently better mental well-being, QoL and mental health, may be more effectively supported in the older population.

Importantly, IIs have been found to be effective among clinical populations. In previous studies, IIs were either targeted at reducing behaviors that were part of the symptomatology (e.g., [65, 66]) or, most commonly, focusing on improving adaptive behaviors that could accelerate recovery and treatment of symptoms (e.g., psychotherapy attendance, increasing social/physical activities, relaxation under stressful circumstances; [53, 67,68,69,70], as well as the prevent relapse (e.g., [71, 72]). A meta-analysis of Toli and colleagues [27] demonstrated that IIs effectively support goal attainment among clinical samples, with the effect size being larger than has been found for non-clinical populations [21]. Interestingly, IIs have been suggested to be particularly beneficial for mental disorders that are characterized by low levels of executive functioning [63], lending support for the idea that older adults with (sub-clinical) mental health problems may also be a subgroup that can largely benefit from IIs. Yet, how mental health problems at an advanced age influence the effectiveness of IIs has not been established.

Strategic planning of adaptive behaviors

The formulation of a personalized II involves multiple steps. Firstly, as IIs are only effective when underpinned by strong intentions to change behavior [34,35,36], one should define a clear goal intention (GI; e.g., ‘My goal is to engage in more social/physical activities’) that aligns with the motivation to do so (‘I want to engage in more social/physical activities’). Importantly, this GI should be somewhat challenging, as forming IIs does not provide additional benefit when the goal is relatively easy to achieve [73], or is performed frequently already [74]. Secondly, one should decide what goal-directed behavior would be appropriate to achieve the goal. This behavior should be realistic, concrete and not overly complicated (e.g., ‘walking for at least 15 min on a daily basis’, or ‘going to a local community center’). This overlaps with the SMART criteria for goal setting in the context of cognitive behavioral therapy (specific, measurable, achievable, relevant and time-bound; [75]). Thirdly, this action should be linked to a specific cue that provides a good opportunity to act on the behavior. Selecting an appropriate cue for the if-portion entails deciding which of the many possible (consistent) opportunities is most useful and effective to achieve one’s goal. It has been recommended to select an event-based cue (i.e., situational), rather than a time-based cue (e.g.,’after breakfast’ instead of’at 9 am’) as these are more salient and do not involve active monitoring of the time of day and thus reduce the likelihood of missing the critical situation, especially among older adults [76]. The likelihood of cue encounter and plan enactment may also be enhanced by choosing a cue that takes place on a daily, rather than weekly, basis (e.g., after breakfast, after lunch, after dinner; [51]).

Metacognitive use of implementation intentions in the older population

Typically, in previous studies, participants were guided through the II formulation process, after which they were encouraged to work with a specific plan for a number of weeks to test its effectiveness. In this way, one may learn how to form an II to strive for one specific goal. However, to promote resilience and independent functioning in older age, it is critical that older adults can use this self-regulation strategy independently, as a metacognitive (self-help) intervention (MCSI), to set and strive for any self-identified goal and thereby tackle a multitude of challenges in different domains [77,78,79]. This necessitates a multi-pronged approach, in which individuals are encouraged to monitor opportunities for behavioral change in their daily life, and supported in forming effective IIs. In addition, the wide application of IIs to everyday life behaviors likely requires a certain extent of plan evaluation in terms of its effectiveness. That is, while a plan may be effective at the start, circumstances or personal needs may change over time, such that it could lose its feasibility and effectivity. For instance, the situational cue may no longer provide a good opportunity to act (e.g., not very consistent, easily missed). Alternatively, the goal-directed behavior may become excessively costly or impossible to carry out, or no longer align with one’s intention, such that encountering the situational cue will probably not elicit the desired response [36]. The concreteness and consequently inflexibility that is inherently linked to implementation intentions may then even provide a disadvantage, rendering individuals less inclined to adjust their behavior when the situation calls for this [80, 81]. By encouraging individuals to evaluate their progress, reflect upon their plan to determine whether it is still relevant, and formulate a new, more suitable plan when necessary, both the effectiveness and wide applicability of IIs can be enhanced [78, 82]. Importantly, it is expected to increase the volitional nature of their plans and the experienced autonomy [74, 83].

To prompt and support individuals to use monitoring, planning and plan evaluation principles both during and after the intervention period, a comprehensive and logically structured manual is provided as part of the MCSI. This manual emphasizes the importance of being able to adequately adjust one’s behavior to internal and external demands in later life, and includes a detailed description on how IIs can provide an easy tool to accomplish this. In addition, it explains how monitoring of new opportunities for behavioral change is integrated in the intervention (i.e., by answering daily questions about one’s satisfaction with several lifestyle domains, mood and experienced daily events), and describes the most relevant questions one can ask oneself to carefully evaluate the effectiveness and usefulness of their II.

Current scope: early intervention for non-clinical and sub-clinical samples

The potential of using II as a key element of a MCSI has been suggested in previous literature [78, 84, 85]. Yet, it remains to be established whether it supports behavioral adaptability (as critical element of resilience) among older adults. As this intervention is intended to support self-management of daily life behaviors that support functional ability, well-being and QoL, it may provide a promising tool for the prevention or alleviation of emerging mental health problems. Early treatment of symptoms of depression or loneliness can potentially prevent their escalation [55, 86,87,88]. Importantly, it may also reduce the need for intensive therapy among clinical samples, which usually involves professional clinical supervision. In this way, an effective MCSI may help to alleviate pressure on existing systems of care ([89]; also see [90]) and provide an efficient route towards better public health.

In the current study, we focus on non-clinical and sub-clinical older adults, who do not (yet) require help of a trained clinician, to examine the potential of the metacognitive (IIs) self-help intervention as an early intervention.

Current study: aims

In the current study, we train older adults to use our MCSI to facilitate striving of a pre-determined goal (i.e., walking for at least 15 min on a daily basis; training phase), after which they are prompted to deploy the same strategy for another (personal) everyday life challenge (test phase). In this way, we intend to coach older adults in how to manage current, as well as future demands and challenges that may cross their path by tailoring this strategy to their personal goals and obstacles. The intervention combines several behavior change principles, from social & health psychology [35] and clinical practice, focusing on some of the techniques that are described in the behavioral activation treatment for depression manual of Lejuez and colleagues [16] (also see [58] for modification example). We strive for a short, but comprehensive and effective intervention with IIs as the central ingredient, inspired by elements of behavioral activation. In some cases, these elements have a more general character, since we do not focus on depression specifically, but on mental well-being, QoL and alleviation of mental health problems in general. The effectiveness of the intervention will be assessed by comparing an experimental metacognitive strategy group with a group that solely formulates a goal intention to support goal enactment (i.e., the control group; see Fig. 1).

Fig. 1

Experimental design. The key elements of the study are shown in the top diagrams, with the experimental metacognitive strategy and control group in the left and right panel, respectively. When these key elements are included within the program, is shown in the bottom section

The central aim of this study is to test the effectiveness of the MCSI and determine whether it can indeed effectively support goal striving in favor of resilience among older adults. To this end, we examine whether the MCSI can effectively support behavioral adaptability (aim 1a) and whether mental well-being, QoL are thereby improved, and mental health problems reduced (aim 1b). Thus, we evaluate one’s level of resilience by looking at several outcome variables, referred to as outcome based resilience [2, 91, 92]. We assume that those who are more equipped to adjust their behavior in accordance to personal goals and challenges, are more resilient, and thus report more favorable levels of these outcome variables. Aim 1a will be established by evaluating changes in both phase-dependent (e.g., training or test) and phase-independent variables. Phase dependent variables include the frequency of the target behavior, temporal regularity of the performance and the perceived automaticity, whereas phase independent variables comprise self-efficacy (i.e., the belief that one can successfully execute the behaviors required to produce an outcome; [93]), self-management ability, the tendency to engage in if–then planning and lifestyle satisfaction [94, 95]. We hypothesize that individuals in the strategy group will show a higher (and more consistent) frequency of behavior, as well as better improvement in perceived automaticity during both the training and test phase. Moreover, self-efficacy, self-management ability, the tendency to engage in if–then planning and lifestyle satisfaction are expected to show a larger improvement for this group.

Aim 1b will be determined by examining the direct impact of the intervention on mental well-being and QoL, and several outcome variables that tap onto different kinds of mental health problems, including depressive symptomatology, loneliness, and apathy. We expect that the strategy group will show more beneficial effects of the intervention (after the test phase) than the control group, as reflected in a larger reduction in depressive symptomatology, loneliness, and apathy, and a greater increase in mental well-being and QoL. In addition, we will also quantify the extent to which the behavioral adaptability variables (except for regularity) act as intermediate variables and therefore explain the potential change in mental well-being, QoL and mental health outcomes. These phase-dependent behavioral adaptability variables either reflect competencies or inclinations that are associated with higher self-sustainability and adaptability (self-efficacy, self-management ability, and if–then planning) or imply success experiences (lifestyle satisfaction, performance of behavior and perceived automaticity). We hypothesize that frequency, perceived automaticity, and all phase- independent variables mediate the effects on the health outcome variables. Altogether, this allows us to identify the mechanisms that putatively underlie the intervention effects on mental well-being, QoL and mental health problems, and it can help us to determine ways to further improve the intervention, especially when mediating variables are not affected.

In addition, we will examine whether mental health problems (assessed prior to the intervention) moderate the effectiveness of the MCSI (Aim 2). A previous meta-analysis suggest that the effects of IIs are larger for those with underlying mental health problems than for non-clinical samples [21, 27]. We will for the first time directly assess the modulating effect of underlying mental health problems on the effectiveness of IIs, in combination with other behavior change components. Because of the scarcity of previous research, we will assess the role of underlying mental health problems in an exploratory fashion, without strong a priori hypotheses.

We also aim to shed light on the extent to which a certain level of cognitive functioning may be necessary for the effectiveness of this MCSI (Aim 3). Indeed, as elaborated previously, IIs are generally considered to be particularly helpful for individuals whose self-regulatory skills are compromised [21]. Nonetheless, a certain level of cognitive resources may also be necessary to effectively deploy IIs, especially when applied in a metacognitive way. Evidence for this comes from a study of Burkard and colleagues [96], who showed that IIs were only efficient among older individuals with relatively high working memory capacity. This could explain why some studies have found beneficial II effects for the young-old, but not the old-old (e.g., [97]). This suggests that when cognitive resources are extensively compromised, this may form a boundary condition for the effectiveness of the metacognitive use of IIs. In the current study, we will address this matter by evaluating the relation between working memory capacity and the effectiveness of the MCSI, where we test two competing hypotheses: (1) that the MCSI will be more effective at facilitating behavioral adaptability in favor of resilience (as reflected in better QoL, mental well-being/health) for those with high working memory capacity, in line with the position that (some level of) working memory is essential for such a self-help strategy to be effective, and (2) that this MCSI will be more effective for those low in working memory capacity, in line with the contention that such a self-help strategy can serve as a compensatory strategy for those with low.

Additional aims

By teaching individuals how to effectively use the MCSI to manage demands and challenges that cross their path (i.e., supporting behavioral adaptability as critical element of resilience), they may also develop a general buffer against stressful events or perturbations, thereby fostering resilience to daily stressors (i.e., tapping onto the psychological adatability element of resilience). Firstly, once healthy and efficient routines are formed, these behaviors will be relatively insensitive to stress [29, 98], thereby maintaining the provisions for good mental well-being/health in the face of adversity, even when self-control processes might be compromised. Secondly, if individuals feel more in control of their behavior and experience elevated levels of self-efficacy, they may more easily adapt to (or even prevent) such events, also promoting good mental well-being/health. To this end, we will also examine whether mastering the MCSI may alleviate the effects that daily stressors/hassles on psychological distress and daily mood. Daily stressors refer to experiences and conditions of daily living that are appraised as salient, harmful or threatening to an individual’s well-being” [99]. One’s level of psychological distress refers to a state of emotional and psychological discomfort or disturbance that is characterized by non-specific symptoms of anxiety and depression, which can persist for a longer period of time; daily mood pertains to the transient emotional states or feelings that individuals experience on a day-to-day basis.. We hypothesize that the MCSI will indeed alleviate the effects that stressors/hassles can have on individuals’ psychological distress and daily mood. To better interpret potential changes in one’s ability to deal with such stressors/hassles, we will also consider the impact of one’s baseline resilience level (i.e., how well one was dealing with stressors prior to the intervention) and scores on two psychological appraisal style constructs. When encountering a stressor, several thoughts and thinking processes can occur [92, 100], and these likely have a great impact on how well individuals may be able to show resilience against daily stressors/hassles. We expect that more positive thinking processes (PASSp, process focused) and thoughts (PASSc, content focused) are associated with better stressor-coping.

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