Sailer et al.

BMC Psychiatry (2015) 15:211

DOI 10.1186/s12888-015-0513-y

RESEARCH ARTICLE Open Access

A brief intervention to improve exercising in

patients with schizophrenia: a controlled pilot
study with mental contrasting and implementation
intentions (MCII)
Pascal Sailer1, Frank Wieber1, Karl Pröpster1,2, Steffen Stoewer3, Daniel Nischk2, Franz Volk2
and Michael Odenwald1,2*

Abstract
Background: Regular exercise can have positive effects on both the physical and mental health of individuals with
schizophrenia. However, deficits in cognition, perception, affect, and volition make it especially difficult for people
with schizophrenia to plan and follow through with their exercising intentions, as indicated by poor attendance and high
drop-out rates in prior studies. Mental Contrasting and Implementation Intentions (MCII) is a well-established strategy to
support the enactment of intended actions. This pilot study tests whether MCII helps people with schizophrenia in highly
structured or autonomy-focused clinical hospital settings to translate their exercising intentions into action.
Methods: Thirty-six inpatients (eleven women) with a mean age of 30.89 years (SD = 11.41) diagnosed with schizophrenia
spectrum disorders from specialized highly structured or autonomy-focused wards were randomly assigned to
two intervention groups. In the equal contact goal intention control condition, patients read an informative
text about physical activity; they then set and wrote down the goal to attend jogging sessions. In the MCII
experimental condition, patients read the same informative text and then worked through the MCII strategy. We
hypothesized that MCII would increase attendance and persistence relative to the control condition over the course
of four weeks and this will be especially be the case when applied in an autonomy-focused setting compared to when
applied in a highly structured setting.
Results: When applied in autonomy-focused settings, MCII increased attendance and persistence in jogging group
sessions relative to the control condition. In the highly structured setting, no differences between conditions were
found, most likely due to a ceiling effect. These results remained even when adjusting for group differences in the
pre-intervention scores for the control variables depression (BDI), physical activity (IPAQ), weight (BMI), age, and
education. Whereas commitment and physical activity apart from the jogging sessions remained stable over the
course of the treatment, depression and negative symptoms were reduced. There were no differences in pre-post
treatment changes between intervention groups.
Conclusions: The intervention in the present study provides initial support for the hypothesis that MCII helps patients to
translate their exercising intentions into real-life behavior even in autonomously-focused settings without social control.
Trial registration: ClinicalTrials.gov ID; URL: NCT01547026 Registered 3 March 2012.
Keywords: Exercise, Implementation intentions, Mental contrasting, Physical activity, Schizophrenia, Self-regulation

* Correspondence: [email protected]
1
Department of Psychology, University of Konstanz, Universitätsstrasse 10,
78464 Konstanz, Germany
2
Center for Psychiatry, Feursteinstrasse 55, 78479 Reichenau, Germany
Full list of author information is available at the end of the article

© 2015 Sailer et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
Sailer et al. BMC Psychiatry (2015) 15:211 Page 2 of 12

Background easily applicable self-regulation strategy to address typical

Schizophrenia is one of the most debilitating psychiatric problems of goal striving, such as getting started with an
disorders; it is frequently linked to long-term disability intended behavior or staying on track despite obstacles
and a high burden on individuals, families, and societies (overviews by [40, 41, 44]).
[63]. The common, persistent, and disabling negative With MCII, participants first identify a personal wish or
symptoms of schizophrenia include affective flattening, goal (e.g., being physically fit), identify and imagine the most
alogia, and avolition [3]. As a result of these symp- positive future outcomes of goal attainment (e.g., being
toms and other barriers (such as cardio-metabolic healthier), and mentally contrast the most positive future out-
morbidity and the side-effects of antipsychotic come with the primary personal obstacle currently impeding
drugs), individuals with schizophrenia spend signifi- their goal attainment (e.g., feeling too tired to exercise). Next,
cantly more time sleeping and sedentary than the they search for instrumental means to overcome the obstacle
general population [28, 48, 60, 61]. Schizophrenia- and form implementation intentions specifying when, where,
related metabolic factors and the weight gain produced by and how they want to strive for their personal goal in an
antipsychotic drugs are also important contributors to if-then format (e.g., “If I feel too tired to exercise, then I
the higher risk of medical illness in people with will tell myself ‘You can do it!’ and go for a quick run.”).
schizophrenia [13]. The MCII strategy has been found to support goal attain-
Exercising has been found to be an effective way to ment through non-conscious cognitive and motivational
combat these health risks, with a positive effect on the processes. The approach increases the accessibility of the
physical and mental health of individuals with schizo- mental representations of the critical situations as well as
phrenia (reviews by [46, 49, 25, 57]; see also [16]). How- the strength of the implicit associations between the
ever, a positive attitude towards physical activity and the personal goal, the obstacle, and the instrumental means to
intention to be more physically active [19] are not sufficient overcome the obstacle [1, 2, 31, 30, 45, 65–67]. Moreover,
to ensure actual exercising, as indicated by low attendance it increases implicit (systolic blood pressure) and explicit
rates (e.g., 43-91 % attendance rates; [10, 18, 38]) and high (self-reported) energization, when the chances of success-
dropout rates (e.g., 26 % after three weeks; [18]) in prior fully realizing the future outcome are expected to be high
physical activity intervention programs. These numbers ex- (e.g., [42, 53]). These non-conscious processes should allow
emplify the two problems of getting started and staying MCII to support goal attainment even in populations that
on track that have been found to be central to success- are known to experience great difficulties in acting on their
ful goal striving [24, 21–23]. Interventions have often fo- intentions and whose cognitive functioning is decreased. In
cused on the removal of external obstacles such as the line with this assumption, MCII helped chronic back
lack of free access to fitness facilities [6] or unavoidable pain patients to increase their physical performance in
reasons for missing a session [58], but the intention- standardized lifting and ergometer tests 3 weeks and
behavior gap between the intentions of patients with 3 months after discharge above and beyond the usual
schizophrenia to exercise and their actual behavior has treatment [14]. Building on these findings, we predicted
remained. In fact, this intention-behavior gap has been that MCII could be effectively applied by therapists to help
found to be pervasive and to occur in a wide range of patients with schizophrenia spectrum disorders to become
domains and populations (e.g., [24, 54]). more physically active.
In light of the importance of physical activity and the per-
vasiveness and tenacity of the gap between the intention to Social context effects: highly structured vs.
exercise and actual behavior, the present research examined Autonomy-focused settings
whether the brief CBT-based self-regulation interven- A patient’s insight into his or her disorder and its treat-
tion technique Mental Contrasting and Implementation ment is an important prognostic factor for the positive
Intentions (MCII; [41, 44]) can help patients with schizo- course of schizophrenia [52]. To promote such insight,
phrenia to translate their intention to exercise into actual treatment approaches should allow patients to take
exercising behavior. We examined participants’ attendance responsibility for themselves rather than being highly
at regularly offered jogging sessions in clinical settings in regulated and therapist-controlled [26, 29]. Living in
which patients’ actions are regulated by highly structured non-institutionalized settings is one way to promote
treatment programs and in settings in which individuals patients’ responsibility. However, it also creates higher
can and must autonomously choose their actions. demands on individuals’ self-organization and self-
regulation. Given that MCII supports individuals’ self-
Mental contrasting and implementation regulation, we assumed as secondary outcome that
intentions (MCII) the strategy’s effects on physical activity (i.e., attending a
The theory-based Mental Contrasting and Implementation jogging program) in people with schizophrenia should
Intentions approach has been found to be an effective and be particularly pronounced in settings in which
Sailer et al. BMC Psychiatry (2015) 15:211 Page 3 of 12

people can and must autonomously choose their ac- to these wards after several weeks of acute treatment
tions independent of norms relative to settings in once they have regained stability and are non-suicidal;
which people are regulated by highly structured treat- patients in the early phases of psychotic episodes can also
ment programs that prescribe and reinforce norma- be directly admitted. Ward 1 (Reichenau) has a highly
tive actions [39, 43]. This additional prediction could structured environment involving intense therapeutic
be validated by evidence of a Group (MCII vs. con- efforts to activate patients and 24/7 availability of psychi-
trol) x Setting (autonomy-focused vs. highly struc- atric care. Wards 2 and 3 (Reichenau and Münsterlingen)
tured treatment program) interaction effect. focus more on autonomy and self-supply, with daytime care
from a team of nurses, medical doctors, and psychologists.
Method These latter wards are intended for early interventions
Design, settings, and participants and mainly treat young patients, whereas Ward 1 has no
Design age-based specialization.
This multi-center pilot intervention trial studied participa-
tion in a jogging program for patients with schizophrenia. In Participants
our 2 × 2 between-subjects design, patients were recruited The sample of the present study consisted of 36 inpatients
from two types of wards with different degrees of autonomy (11 female) with a mean age of 30.89 years (SD = 11.41)
(quasi-experimental variation) and allocated to two condi- and a diagnosis of a schizophrenia spectrum disorder
tions (intervention vs. control; experimental variation). (Ward 1: n = 20; Ward 2: n = 10; Ward 3: n = 6). Of these
36 participants, twelve had completed post-secondary
Settings education, seven had completed secondary education,
The study involved three specialized wards in two psychi- fifteen had completed compulsory education, and two had
atric hospitals (Reichenau, Germany and Münsterlingen, not graduated. On average, participants had spent
Switzerland) that offer inpatient and outpatient treatment 11.78 years (SD = 3.15) in school. The baseline psychiatric
to patients with schizophrenia spectrum disorders but do characteristics of participants are presented in Table 1.
not treat patients with substance-induced psychotic disor- Fourteen percent of the participants had an acute or
ders. In these three open and non-acute wards, patients transient psychotic disorder, showing the same limitations
recovering from a recent psychotic episode receive in cognition, perception, affect, and volition as patients
standard treatment according to current guidelines, with chronic forms of schizophrenia. This percentage
including pharmacotherapy, individual and group psy- did not differ between the studied groups. Participants’
chotherapy, and occupational therapy, among other baseline physiological characteristics are described in the
treatment regimes. In general, patients are admitted results section.

Table 1 Socio-demographic and psychiatric characteristics at baseline

All participants N = 36 MCII group N = 19 Control group N = 17 p
N or M (SD) N or M (SD) N or M (SD)
Gender male 25 12 13 .39
female 11 7 4
Main Diagnosis
Paranoid Schizophrenia 20 12 8
Persistent Delusional Disorders 1 1 0
Acute and Transient Psychotic Disorders 5 2 3
Schizoaffective Disorders 10 4 6
First Episode 11 7 4 .39
PANSS Negative Score 19.1 (6.0) 18.1 (5.7) 20.2 (6.3) .31
BDI-II 13.8 (8.5) 16.1 (9.4) 11.2 (6.9) .09
Prescribed Medications
Chlorpromazine Equivalent x100mg 7.0 (4.9) 6.3 (3.5) 7.9 (6.1) .32
SSRIs 3 2 1
Benzodiazepines 7 4 3
Mood Stabilizers 3 1 2
Anticholinergics 7 6 1
Sailer et al. BMC Psychiatry (2015) 15:211 Page 4 of 12

Data collection occurred between April and October program and the study. Patients who were explicitly inter-
2012. Patients were eligible for the study if they received ested and gave their consent were randomly assigned to
in- or outpatient treatment in one of the three wards one of two treatment conditions (MCII or control). The
during the project period, met the criteria for an F2 eight trained therapists involved in the study screened
diagnosis according to ICD 10 (F20.0 – F29), remained potential participants, assigned the treatment condition to
in treatment for at least one week, and expressed explicit patients, and delivered the interventions. To assure proper
interest in attending jogging sessions. This last prerequisite randomization, the therapists were provided with closed
was derived from the theoretical notion and empirical and identical envelopes that contained materials for either
finding that the MCII approach is only expected to the experimental or control condition and were asked to
support the translation of an individual’s intention pick one envelope for each patient. These therapists were
into action if he or she is at least moderately committed the only staff with knowledge of the treatment condition,
to the intention (e.g., [40]). Participation in the study and they were instructed not to reveal the condition. The
was voluntary. Exclusion criteria were severe psychotic individuals conducting the exercise sessions, the nursing
symptoms and any medical contraindications for exercising staff, and the researchers did not know the treatment
(e.g., cardiovascular or acute infectious diseases). condition. Prior to the study, the therapists had re-
A total of 119 patients were treated at the three wards ceived training on how to carry out the interventions,
during the study period, of which 83 patients were not the assessments, and the randomization procedure.
eligible for the study as they had no F2 diagnosis (n = 20), The therapists implemented the interventions in the
left the ward before the first intervention (n = 2), or participants’ individual therapy sessions. The duration
expressed no interest in jogging (n = 61). The resulting of an individual patient’s study participation depended
participation rate was 30.25 %. None of the patients were on the duration of his or her stay in the hospital; after
disqualified for the study because of medical reasons or inclusion, patients remained in the study until they
because they were too psychotic. Figure 1 shows the flow were discharged from the clinic. The structure of the
chart of participants. exercise program was flexible.

Procedure and randomization Exercise program

During the project period, patients who were admitted to We chose jogging as a target behavior because it does
the three wards were screened for inclusion and exclusion not require specific skills or equipment and thus allows
criteria. Therapists asked patients in individual therapy patients to continue exercising after their hospital stay.
sessions whether they wanted to participate in the jogging Moreover, jogging was feasible for most participants, and

Assessed for eligibility

(n = 119)

Not eligible

No F2 diagnosis (n = 20)
Enrollment

Left ward before the

first intervention (n = 2)

No interest
in jogging (n = 61)
Allocation

Randomized (N = 36)

Control group (n = 17) Intervention group (n = 19)

Analyses

Analyses (n = 17) Analyses (n = 19)

Fig. 1 Flow chart of participants’ progress through each stage of the randomized controlled trial
Sailer et al. BMC Psychiatry (2015) 15:211 Page 5 of 12

it had been the most widely accepted exercise program Experimental condition (MCII)
among the patients in the respective wards in the past. In the experimental group, therapists and participants
The sessions were scheduled for 30 minutes. Each session read the same informational text. In addition, they
started with joint warm-up exercises. Subsequently, all worked through the MCII strategy. Participants listed
patients ran a circuit around the psychiatric hospital three positive outcomes they associated with attending
(approximate length was 1,000 m). Participants were the exercise sessions (e.g., “losing weight”) and three
informed that the jogging sessions were not about obstacles (e.g., “feeling tired”). After completing the
performance. They were encouraged to run at their mental contrasting procedure, they identified their most
own pace and only for as long as they wanted; they significant obstacle and wrote it down. Together with their
could rest or stop at any time and walk back to the ward. therapist, participants then devised a specific solution for
At the end of each jogging session, joint cool-down this obstacle. Finally, they formulated an if-then plan in
exercises were offered. All sessions were accompanied the form: “If [obstacle], then I will [solution].” Participants
and monitored by research or nursing staff. As partic- wrote down their if-then plan three times. In weeks 2
ipants might have refused to wear an electronic accel- and 3, participants again wrote down their if-then
erometer device because of residual symptoms of plan twice to reinforce the intention. Thus, both groups
psychosis, the staff monitored the training in terms of had equal contact with the therapists with regard to time
duration of participation (in minutes) and intensity and attention.
(through participant self-reports). According to these
reports, most participants exercised at a moderate Measures
level of intensity. In each ward, two jogging sessions Primary outcomes
conducted by research or nursing staff were scheduled After inclusion in the study, participants’ attendance at
every week. We ensured that no conflicting therapies scheduled jogging sessions was recorded throughout the
or other events were scheduled for the same time remainder of their hospital stay using a set of indicators
(jogging sessions took place after standard treatment ses- implemented in previous studies [9]: (a) jogging session
sions were over for the day). attendance (percentage of scheduled sessions attended),
Patients in the highly structured wards were reminded and (b) persistence (percentage of weeks in which a partici-
by the staff immediately before each session, but pa- pant attended at least one of the two jogging sessions).
tients in the autonomy-focused wards received no such Because patients were regularly discharged from treatment,
reminders. Thus, attending the jogging sessions made we only used the four weeks following inclusion into
higher demands on patients’ self-regulation in the the study in order to achieve a sufficient sample size.
autonomy-focused wards relative to the highly struc- Occasionally, participants had objective and legitimate
tured wards. Experimental and control participants reasons for missing scheduled jogging sessions, including
exercised in the same groups, and the groups were working probationary, physical injury, appointments with
open to patients who were not participating in the social care workers, visits from family members, and
study. vacation. These sessions were excluded from the evaluation
of attendance for these participants.
Interventions
Goal intention control condition (control) Clinical and control variables
In the control group, therapists and participants to- Negative symptoms before inclusion into the intervention
gether read an informative text about physical activity. program and at discharge from treatment were assessed
The text emphasized the short- and long-term benefits using the Positive and Negative Syndrome Scale [33]. This
of exercising and referred to expert opinions. It also instrument is a widely used clinical rating scale for the
contained information about the clinic’s jogging pro- quantification of symptom severity in psychotic patients.
gram, including the fact that participants were invited The negative scale includes seven items: blunted affect,
to run at their own pace and could stop or rest when- emotional withdrawal, poor rapport, passive/apathetic
ever they wanted. This information served to point out social withdrawal, difficulty in abstract thinking, lack of
that regular exercise is a desirable and feasible behav- spontaneity and flow of conversation, and stereotyped
ior. In addition, the text highlighted the fact that ob- thinking. Each item is rated by the clinician on a 7-point
stacles may occur that require one to prepare oneself Likert scale; the minimum score is thus 7, and the
in advance (e.g., motivation problems, tiredness, etc.). maximum is 49. The instrument has good reliability [32]
After reading the text, participants wrote down three times and internal consistency [34], as well as concurrent and
the goal to attend the jogging sessions. In weeks 2 and 3, predictive validity [11].
participants again wrote down the goal intention twice in Severity of depression before admission to the study and
order to reinforce the intention. at discharge from the clinic was assessed with the Beck
Sailer et al. BMC Psychiatry (2015) 15:211 Page 6 of 12

Depression Inventory (BDI-II [7, 27]). This instrument Ethics approval and registration
contains 21 items, with each answer scored on a scale The study was approved by the ethics committee of the
from 0 to 3; higher scores indicate more severe depressive University of Konstanz and registered on ClinicalTrials.gov
symptoms. The resulting categories are 0–13: minimal (registration number: NCT01547026). Patients were only
depression, 14–19: mild depression, 20–28: moderate admitted to the study after signing a form to indicate their
depression, and 29–63: severe depression. The instrument informed consent.
has high test-retest reliability and internal consistency, as
well as good criterion validity [8, 7].
Data analyses
Physical activity apart from the jogging program was
We used SPSS (Version 20) to analyze the data. Para-
assessed using the short-form version of the International
metric tests with Alpha = .05 and effect size measures
Physical Activity Questionnaire (IPAQ; [15]) before inclu-
(i.e., partial eta square) were employed to evaluate group
sion into the study and at discharge from the clinic. This
differences. We computed 2 between (Group: MCII vs.
measure assesses the duration (number of days and
control) × 2 between (Setting: autonomy-focused vs.
hours/minutes per day) that an individual has engaged in
highly structured) ANOVAs as well as Chi2 tests (and
walking, moderate, and vigorous activity over the past
Fisher’s exact test when preconditions were not ful-
7 days. On the basis of these data, Craig and colleagues
filled) to examine the equivalence of the four condi-
[15] suggest calculation of a metabolic equivalent (MET)-
tions. To test the Group × Setting hypothesis, we
based IPAQ score by weighting each type of activity by its
computed 2 between (Group: MCII vs. control) × 2
MET energy requirement: (3.3 x walking duration)
between (Setting: autonomy-focused vs. highly struc-
+ (4 × moderate activity duration) + (8 × vigorous activity
tured) ANCOVAs in order to adjust the results for
duration). In a sample of 35 individuals with schizophrenia,
differences between conditions in terms of clinical
Faulkner et al. [20]) found a reliability coefficient of .68 and
and socio-demographic variables (i.e., BDI, IPAQ, and
a correlation of .37 with an accelerometer, indicating satis-
BMI scores before the intervention as well as age and
factory validity.
education), as these variables might have influenced
Commitment to attend jogging sessions was assessed
the results. To test our specific hypotheses in greater
with three items: “How likely do you think it is that you will
detail, we computed planned comparisons between
attend the jogging sessions?”, “How important is it to you
the groups for each kind of setting. In order to inves-
to attend the jogging sessions?”, and “How disappointed
tigate the change in clinical control variables over
would you be if you failed to attend the jogging sessions?”
time, we computed repeated measurement ANOVAs
Participants answered these items using a 7-point Likert
with pre and post assessments as a within subject fac-
scale ranging from 1 (not at all) to 7 (very). Reliability was
tor and intervention condition as a between subject
good (Cronbach’s Alpha = .82). Participants’ commitment
factor. The preconditions for parametric testing were
was assessed two times: at study entry and two weeks
not violated.
thereafter (after the MCII or the goal intention control
intervention had been implemented).
Participants’ attention and comprehension was rated Results
by the therapists after the intervention session using a Equivalence of groups
three-item scale (“The patient was able to maintain Of the 97 individuals who fulfilled the first two inclusion
attention throughout the session,” “The patient was able criteria (i.e., F2 diagnosis and not leaving the ward before
to understand the information,” “Based on your clinical the first intervention), 36 were interested in participating
experience, how likely do you think it is that the patient (i.e., a response rate of 37.11 %). The mean age of the actual
will be able to recall the information from this session participants was 30.89 years (SD = 11.41). In comparing
tomorrow?”). Answers ranged from 1 (fully applies) to 5 participants’ ages between conditions, we observed no main
(does not apply at all). Reliability was high in the present effects of group and no Group × Setting interaction effect,
study (Cronbach’s Alpha = .88). both Fs [1, 33] < 1.83, both ps ≥ .186, both partial eta-square
All patients received antipsychotic medication. We (ηp2) < .06, but a main effect of setting, F [1, 33] = 20.26,
assessed the amount of such medication in Chlorpromazine p < .001, ηp2 = .39, such that participants in the highly
equivalents at the date of inclusion into the study. structured setting were older (M = 37.20, SD = 11.48) than
Each week, therapists asked patients who had missed participants in the autonomy-focused setting (M = 23.00,
jogging sessions about the reasons for their absence and SD = 4.15). With regard to gender, 11 female and 25 male
documented them. Finally, socio-demographic data were participants took part in the study. A chi-square analysis
assessed, including age, gender, and education. Measure- revealed no differences in the distribution of the men and
ments of weight at entry and body height also allowed us women among the four different experimental conditions,
to compute each participant’s body mass index (BMI). χ2 (1, N = 36) = 6.10, p = .107.
Sailer et al. BMC Psychiatry (2015) 15:211 Page 7 of 12

First episode and diagnosis Education

In relation to the number of patients with first episode With regard to participants’ education, we observed no
disorder and in relation to the type of diagnosis, we found main effect of group and no Group x Setting interaction
no group and setting main effects and no Group × Setting effect, both Fs [1, 33] < 1.97, both ps ≥ .171, ηp2 < .06, but a
interaction effect (all ps ≥ .294). main effect of setting, such that participants in the highly
structured setting tended to report more years of education
PANSS
(M = 12.75, SD = 3.63) than participants in the autonomy-
With regard to the PANSS scores measured before the focused setting (M = 10.56, SD = 1.93), F [1, 33] = 3.67,
intervention, no main effects and no interaction effects p = .064, ηp2 = .10.
were found, all Fs [1, 33] < 1, all ps ≥ .338, ηp2 < .03. The
BMI
clinicians rated participants in all conditions as having
moderate levels of negative symptoms (grand M = 19.08, Finally, concerning Body Mass Index (BMI), we found no
SD = 5.97). main effect of setting and no Group × Setting interaction
effect, both Fs [1, 29] < 1.89, both ps ≥ .181, ηp2 < .07, but a
main effect of group, such that participants’ BMI before
BDI the intervention was higher in the MCII group (M = 25.49,
Concerning the BDI scores assessed before the intervention, SD = 3.09) than in the control group (M = 23.57, SD = 3.10),
we observed no main effects, both Fs [1, 33] < 2.54, both F [1, 29] = 4.41, p = .045, ηp2 = .14.
ps ≥ .121, ηp2 < .08, but a Group × Setting interaction effect, In summary, although the four experimental conditions
F [1, 33] = 4.10, p = .051, ηp2 = .11. MCII participants re- were comparable for most of the background variables, we
ported more symptoms (M = 18.00, SD = 8.90) than control found differences in some variables. Consequently, we
participants (M = 8.13, SD = 6.64) in the highly structured included these variables (i.e., the BDI, IPAQ, and BMI
setting, F [1, 33] = 7.26, p = .011, ηp2 = .19, but no such dif- scores before intervention as well as age and education) in
ference between MCII (M = 12.71, SD = 9.84) and control our primary analyses in order to adjust for these differences.
participants (M = 13.89, SD = 6.13) was found in the
autonomy-focused setting, F [1, 33] < 1, p = .773, ηp2 < .01. Primary outcomes: attendance and persistence
Attendance
IPAQ In order to test our hypothesis that MCII would increase at-
With regard to the IPAQ scores assessed before the tendance rates relative to the control condition, particularly
intervention, we found no main effect of group and no when applied in an autonomy-focused setting rather than a
Group × Setting interaction effect, both Fs [1, 33] < 2.79, highly structured setting, we entered the percentage of the
both ps ≥ .105, ηp 2 < .09, but a main effect of setting, total sessions attended into an ANCOVA, adjusting for
F [1, 33] = 17.46, p < .001, η2p = .35, such that participants in BDI, IPAQ, and BMI scores before the intervention, as well
the highly structured setting (M = 2225.83, SD = 1543.76) as for age and education. We observed no main effects of
reported engaging in more physical activity in the week group, which has been our main hypothesis, and setting,
before the intervention than participants in the autonomy- both Fs [1, 24] < 1.61, p ≥ .218, ηp2 < .07, but the expected
focused setting (M = 745.91, SD = 490.72). Group × Setting interaction effect, F [1, 24] = 5.33, p = .030,
ηp2 = .19. As expected, in the autonomy-focused setting,
MCII participants (M = 68.75 %, SD = 12.50) attended more
Commitment
sessions than control participants (M = 35.94 %, SD =
Concerning participants’ commitment after the interven- 30.21), F [1, 24] = 5.72, p = .025, ηp2 = .20. In the highly
tion, no main effects and no Group × Setting interaction structured setting, however, no differences in the already
effects were found, all Fs [1, 33] < 1.57, all ps ≥ .220, higher attendance rates were observed between MCII (M =
ηp2 < .05. Participants in all conditions were highly com- 72.92 %, SD = 27.09) and control participants (M = 70.31 %,
mitted to attending the training sessions (grand M = 4.92, SD = 43.27), F [1, 24] = 0.65, p = .428, ηp2 = .03, suggesting
SD = 1.40). a potential ceiling effect. See Table 2 and Fig. 2.

Attention Persistence
Concerning participants’ attention during the intervention In order to test our analogous hypothesis that MCII in-
sessions, no main effects and no Group × Setting inter- creases persistence relative to the control condition, par-
action effects were found, all Fs [1, 33] < 1.57, all ps ≥ .220, ticularly when applied in an autonomy-focused setting
ηp2 < .05. Clinicians rated participants’ attention during the rather than a highly structured setting, we entered the
intervention session and comprehension of the intervention percentage of weeks during which the participants
as high in all four conditions (grand M = 1.61, SD = 0.56). attended at least one of the two jogging sessions into an
Sailer et al. BMC Psychiatry (2015) 15:211 Page 8 of 12

Table 2 Number of participants and program attendance for SD = 29.11) and control participants (M = 73.96 %,
the MCII and control groups by highly structured and SD = 40.20), F [1, 24] < 1, p = .943, ηp2 < .01.
autonomy-focused treatment settings
Week 1 Week 2 Week 3 Week 4 Weeks 1-4 Changes over time in clinical and control variables
Participants [n] Although IPAQ scores tended to decrease over time, we
MCII Group 19 18 16 15 19 observed no main effects of time for IPAQ or commitment
Highly structured ward 12 11 11 11 12
scores, both Fs < 2.91, p > .130. However, we found main
effects of time for BDI and PANSS scores. In the total
Autonomy-focused 7 7 5 4 7
wards sample, BDI scores significantly dropped over the
course of the treatment, from 13.75 (SD = 8.52) to 9.77
Control Group 17 17 16 14 17
(SD = 9.17), F [1, 33] = 8.08, p = .008. PANSS scores were
Highly structured ward 8 8 8 7 8
also significantly reduced over the course of the treatment,
Autonomy-focused 9 9 8 7 9 from 19.08 (SD = 5.97) to 15.78 (SD = 5.34), F [1, 33] =
wards
13.79, p = .001. Most importantly, no Group × Time inter-
Using Fisher’s exact tests, we found no significant differences between groups
in terms of the number of patients who remained in the study or left in the
action effects were found for commitment, PANSS, BDI,
first four weeks or IPAQ, all Fs < 1, all ps > .700.

Discussion
ANCOVA, adjusting for BDI, IPAQ, and BMI scores The present pilot study examined whether the brief CBT
before the intervention as well as age and education. We self-regulation intervention Mental Contrasting and
observed no main effect of setting, F [1, 24] < 1, p = .895, Implementation Intentions (MCII) could increase physical
ηp2 < .01, but a tendency towards a main effect of group, exercise behavior in a sample of patients with schizophrenia
F [1, 24] = 3.44, p = .076, ηp2 = .13, such that MCII spectrum disorders, particularly in autonomy-focused set-
participants (M = 85.94 %, SD = 25.77) tended to be more tings rather than highly structured settings. The findings
persistent than control participants (M = 60.42 %, SD = provide initial support for this assumption. MCII increased
40.65). This tendency was qualified by a trend to- attendance rates for scheduled exercise sessions as well as
wards a Group × Setting interaction effect, F [1, 24] = 3.70, persistence in participation over four weeks in a treatment
p = .067, ηp2 = .14. As expected, in the autonomy-focused setting in which patients can and must choose their actions
setting, MCII participants (M = 87.50 %, SD = 14.43) independently, but did not increase the (already higher)
were more persistent than control participants (M = attendance rates or persistence in a highly structured
46.88 %, SD = 38.82), F [1, 24] = 6.36, p = .019, ηp2 = .22. In treatment setting [39, 43]. Participants in the MCII
the highly structured setting, however, no differences in condition who were not reminded of the exercise sessions
persistence were observed between MCII (M = 85.42 %, (i.e., autonomy-focused wards) participated as much in

Fig. 2 Average program attendance over the course of four weeks in percent by group (MCII vs. control) and setting (autonomy-focused vs.
highly structured). Standard errors are represented in the figure by the error bars attached to each column
Sailer et al. BMC Psychiatry (2015) 15:211 Page 9 of 12

the sessions as participants who were repeatedly prompted The benefits of the MCII brief intervention were not
by nursing staff to participate in the sessions (i.e., highly diminished by any adverse effects on clinical variables
structured ward); that is, constantly reminding patients such as negative symptoms of schizophrenia or symp-
without further motivational intervention had an effect toms of depression. All patients received standard
comparable to that of MCII. This moderation by the type treatment for psychiatric symptoms, and all improved
of environmental setting is in line with the theoretical during the project period; MCII had no additional ef-
considerations developed by Oettingen and colleagues, fect on their psychiatric symptoms. However, given the
who outlined the importance of the social context for short treatment period, the main focus of the present
successful goal pursuit in early stages [39, 43]. Notably, study was on attendance and persistence in the
adherence rates during the study were rather high. jogging program rather than on examining the effect
Overall, participants attended 61.75 % of the offered of exercise behavior on psychiatric symptoms. In
exercise sessions. In 73.44 % of the possible weeks, addition, our randomization strategy served to level out
they attended at least one of the two weekly jogging differences in participants’ symptoms at baseline be-
sessions (persistence). These rates resemble those observed tween the conditions, as such differences might also
in other trials, such as the Diabetes Prevention Program influence participation in exercise sessions. Although
(DPP; [35]), in which 74 % of individuals with impaired we did not find differences for most of the symptoms,
glucose tolerance met the goal of at least 150 min of we observed differences in the depression symptoms.
physical activity per week after 24 weeks, and the However, we adjusted for the differences observed
Look AHEAD trial [37], in which overweight or obese between the groups at baseline by including them as
patients with type 2 diabetes attended an average of 84 % covariates in our analyses. Most importantly, the
of the possible group and individual lifestyle intervention beneficial effects of MCII in the autonomy-focused
sessions during the first year. Although participants’ com- ward were evident whether we included the covariates
mitment ratings did not change over the course of the or not.
study, their physical activity apart from the jogging sessions With regard to research on self-regulation interven-
tended to decrease over time in both conditions. However, tions, the present study implies that MCII can be effect-
this decline is compatible with the frequently observed ively applied in clinical populations with deficits in
post-psychotic fatigue, persistent negative symptoms, and cognition, perception, affect, and volition. In fact, the
sedating medication effects [4]. severity of symptoms did not moderate the approach’s
beneficial effects on physical exercise in the present
Implications study. These findings are also in line with previous
The present findings have clear practical implications. research. For example, Brandstätter et al. [12] found
Although many psychiatric institutions promote physical support for the effectiveness of the implementation
activity as an adjunct treatment and it has been argued intention strategy in improving goal attainment in schizo-
that physical activity interventions should become a phrenia patients in a laboratory-based reaction time
routine component of comprehensive psychiatric care study. These findings complement the present study,
for individuals with mental illness (e.g., [47]), physical as they show the effectiveness of the implementation
activity interventions for this group of patients are intention self-regulation strategy not only in a real-life
typically assumed to require a structured clinical setting treatment program but also in a controlled laboratory
and thus entail high costs (e.g., [9]). Moreover, even in rela- setting with a fine-grained response time measure. In
tively controlled settings, prior physical activity interven- addition, the present study applies theory-based research
tions found only moderate effects. For example, Archie et on motivational processes to the commencement and
al. [6] examined whether free access to a fitness center continuation of physical activity in patients with schizo-
could increase exercise program adherence, finding that phrenia, a research gap that has been highlighted by
increasing motivation by providing free access to exercise Vancampfort et al. [59]. Thereby, our MCII brief inter-
facilities was not sufficient to reduce the intention-behavior vention complements and extends other motivational
gap in individuals with schizophrenia. The present findings intervention approaches addressing exercise in pa-
suggest that exercise interventions can benefit from adding tients with schizophrenia that have been derived from
self-regulatory and planning strategies, especially in Self-Determination Theory [17] and from Goal Setting
outpatient and community settings in which patients Theory [36]. Self-Determination Theory focuses on the
live autonomously (e.g., assisted living). The present study degree to which a behavior is self-motivated and self-
justifies more research on self-regulation interventions determined. In line with the assumptions of this theory,
like MCII in order to develop therapeutic tools that can patients’ reported regulation has been found to be corre-
be easily applied and are cost-efficient in settings without lated with their physical activity: Whereas autonomous
a highly structured environment. regulation was positively correlated with physical activity,
Sailer et al. BMC Psychiatry (2015) 15:211 Page 10 of 12

external regulation and amotivation were negatively corre- might replicate the present study using a larger sample of
lated with physical activity [59]. Moreover, negative symp- individuals with schizophrenia; in addition, researchers
toms have been found to be associated with lower could implement a more detailed assessment of psychiatric
autonomous motivation to engage in physical activity symptoms including positive and manic symptoms as well
[62]. In a recent review of qualitative articles, Soundy as anxiety, and could utilize objective-based measures to
et al. [56] highlighted the significance of this theoret- improve the quality of the measurement of physical activity
ical approach and especially of physical activity pro- apart from the jogging program (e.g., [55]). However, the
grams, as they may help individuals to regain autonomy double-blinded randomized and controlled design and the
in other parts of their lives – for example, by increas- robustness of the results strengthen the confidence in the
ing social competence and self-confidence. Goal observed effects. Another limitation is the fact that we
Setting Theory focuses on the phrasing of goals. In assessed prescribed medications only at the baseline.
line with the assumptions of this theory, setting spe- Although it is possible that participants changed their
cific rather than broad goals was found to promote medications during the study, entailing substantial effects
exercise program attendance in schizophrenic patients on affect, volition, and cognition (for a meta-analysis, see
[64]. Thus, in addition to the importance of the [50]) as well as potentially inducing several undesired
source of the motivation to exercise and the formula- side-effects (e.g., [5]), any changes in medication should
tion of the exercising goals, the self-regulation of in- be distributed equally between the two experimental
dividuals’ exercise goal setting via mental contrasting groups, such that potential differences should not be able
and of their goal striving via the formation of imple- to explain the improved attendance and persistence of the
mentation intentions plays an important role when it MCII group relative to the goal setting control group. As
comes to establishing strong goal commitment and to another limitation, experimental and control participants
effectively translating goal intentions into actual exercised in the same group. Contamination of treatment
behavior. Although the specific prerequisites for the suc- conditions was thus theoretically possible (e.g., by patients
cessful application of self-regulation interventions such as motivating each other to participate – for example, by
the MCII strategy warrants further research, the present making plans amongst themselves to participate jointly in
study is a first step towards identifying the approach’s the jogging sessions and reminding each other). However,
applicability to clinical populations. Assuming that as such influence should have equal treatment effects, it
these findings will be replicated and extended, future cannot explain the observed differences between the con-
research could examine whether the MCII self- trol and experimental conditions. In addition to forming
regulation strategy could also be used to promote separate exercise groups, future research might seek to
other illness-related behaviors for people with schizo- assess the intensity of participants’ exercise using a more
phrenia (such as such as consistently taking their fine-grained measure than the subjective ratings that were
medication, attending therapy sessions, and not using applied in the present study. We also limited our exercise
drugs or drinking alcohol) or for other client groups. program to a single type of exercise, namely jogging. This
could affect the generalizability of our data, in the sense
Limitations that patients with a preference for jogging are a specific
The limitations of this study include the mix of experimen- group of patients. However, jogging had been the most
tal and quasi-experimental manipulations of independent widely accepted form of physical activity at the clinics
variables. The degree of patient autonomy (i.e., the intensity prior to our study, and the threshold for participation
with which the staff asked and reminded patients to is low. We also believe that the underlying problem –
participate in the jogging sessions) was a quasi-experimental patients’ intention-behavior gap – is the same for any
variation. However, the fact that a pilot study has shown kind of exercise behavior. Thus, we believe that our
initial evidence of the moderating effect of the degree data on MCII, which shows that the strategy helped
of autonomy in the living environment justifies the to bridge this gap, can be generalized to a broader range
experimental varying of this variable in future studies of exercise behaviors. Nevertheless, future studies should
(e.g., as an additional control condition). Other limitations include different types of exercise as target variables.
of this study include the small sample size and the rela- Finally, we only included patients who expressed their
tively broad diagnostic group. Moreover, the current study wish to participate in the exercise program. It would be
did not manage to achieve perfect randomization: Patients desirable to include all patients and to motivate even those
in the intervention group tended to be older and had who do not express a wish to participate in physical
higher BMIs, more severe depression, and more extensive activity. Despite these limitations, the present study
formal education. Although we statistically adjusted for demonstrates that MCII applied as a brief intervention
these differences, comparability between our patient can be especially effective in situations in which patients
groups may not have been fully achieved. Future research are not closely guided (Additional file 1).
Sailer et al. BMC Psychiatry (2015) 15:211 Page 11 of 12

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