CHAPTER 5 DEVELOPMENT OF THE IBID INTERVENTION
5.2.3 Step 3: Theory-based methods and practical strategies
Theory-based methods are the processes which are anticipated to have an effect on the behavioural determinants specified in Step 2. In addition, practical strategies are required in order to actually deliver the methods in the intervention (Bartholomew et al., 2011). A useful way of explaining this is provided by Bartholomew and colleagues (2011) ‘Models and practical applications form a continuum that extends from abstract theoretical methods through
practical applications to organised programs with specified scope, sequence and support materials’ (p.310).
In order to ensure that the techniques used in IBiD are specified and described using the most up to date and comprehensive taxonomy, and a ‘common language’, the intervention content and delivery has been mapped onto BCTs from the Taxonomy (v1) of 93 techniques (described in Chapter 2) (Michie, Johnston, et al., 2013). This taxonomy had not been published when the intervention was being developed. Previously published resources were used in order to select BCTs and practical strategies (content and delivery) to operationalise these. These included Abraham and Michie’s taxonomy of 26 BCTs (2008), a framework of health behaviour change competencies (Dixon & Johnston, 2010), existing therapeutic manuals for BD (Basco & Rush, 2005; Colom & Vieta, 2006) and CBT guides and workbooks (Centre for Clinical Interventions, 2008). Table 5.2 specifies how each determinant was addressed by specific intervention content and which BCTs this maps onto.
The concept of self-management in chronic illness also aids the formulation of IBiD. Five components of self-management have been defined and inform the application of BCTs to the intervention; problem solving, decision making, resource utilisation, forming of a
patient/health care provider partnership, and taking action (Lorig & Holman, 2003).
There is growing evidence for specific techniques in improving medication adherence, for example, Implementation Intentions (I. Brown, Sheeran, & Reuber, 2009), eliciting and targeting beliefs about illness and medication and practical barriers (O’Carroll, Chambers, Dennis, Sudlow, & Johnston, 2013) and in improving outcomes in BD (Lolich et al., 2012).It has also been recommended that BCTs applied to other health behaviours such as smoking or engaging in physical activity can be adapted and applied to adherence (Michie, Rumsey, et al., 2008).
A number of techniques were used in the overall intervention delivery, for example, Motivational Interviewing (MI) (Miller & Rollnick, 1991). MI is classified as one BCT in the Taxonomy (under BCT code 3.3 Social support, emotional) (Michie, Johnston, et al., 2013), however the approach encompasses a variety of techniques for motivating change (Hagger &
Hardcastle, 2014), most frequently involving goal setting, provision of social support and feedback and comparing possible outcomes using a pros and cons discussion (Morton et al., 2014). In IBiD, as well as these specific techniques, the client-centered focus of MI guided how the intervention was delivered. Participants were encouraged to make choices which were appropriate for them, to feel in control of these decisions and feel they have the ability to carry out any changes. The approach used was non-judgemental, made use of open questions, affirmations and reflective listening. In the face to face discussions with participants they were provided with encouragement that they could successfully manage their medication and condition. This corresponds to the BCT Verbal persuasion about capacity (code 15.1). The discussions also covered past successes in adherence and self-management, and therefore covered ‘Focus on past successes’ (code 15.3).
This ethos of MI ties in with self-management as opposed to more traditional patient education, whereby patients are active participants tailoring and applying the skills and knowledge gained to their particular needs and circumstances (Lorig & Holman, 2003).
Tailoring was a key aspect of the intervention and this is described fully in Section 5.3. In brief, information was presented to participants reflecting their individual beliefs and concerns about BD and treatment.
Therapeutic models have been applied to BD for example, Cognitive Behaviour Therapy (CBT) e.g. (Basco & Rush, 2005) and Psychoeducation e.g.(Colom & Lam, 2005) (see Chapter 3).
Psycho-education, in the context of BD refers to a therapeutic model focussing on adherence enhancement, early identification of prodromes (personal early warning signs preceding episodes), the importance of lifestyle regularity, exploring individuals' health beliefs and illness-awareness, and enabling the individual to understand the relationship between
symptoms, personality, interpersonal environment, and medication side-effects.(Colom & Lam, 2005). CBT as a therapy aims to identify and challenge negative thoughts and emotions. In mental health the aims include managing symptoms and preventing relapse and learning effective coping techniques for managing stress and mood and dealing with negative thoughts (J. S. Beck, 1995).
In the Taxonomy (Michie, Johnston, et al., 2013), the authors specify that encouraging adherence to medication in order to facilitate behaviour change (BCT code 11.1
Pharmacological support) is a technique in itself. However this related to, for example, using nicotine replacement therapy to aid smoking cessation. In the case of IBiD, the behavioural objective is adherence so therefore this is not a specific technique used in this intervention. If the measured behaviour outcome was illness relapse then the intervention would be using this technique to encourage adherence.
The remainder of this section describes the process of targeting specific determinants and proximal objectives through the development of practical strategies including the intervention content. Table 5.2 summarises each determinant from the matrix above and the practical strategy, IBiD section and relevant BCTs which this maps onto.
Table 5.2: Matrix of Determinants/ Proximal objectives, implementation in the IBiD intervention and BCTs these mapped onto.
Determinants/ Proximal objectives
Implementation strategies in IBiD IBiD section/ exercise BCTs (Michie, Johnston, et al., 2013)
Medication concerns Prompt participant to identify and compare reasons for adherence and non-adherence (medication concerns), then prompt them to weigh up the concerns vs the benefits of medication.
Balancing pros and cons – information and decisional balance exercise
9. Comparison of outcomes - 9.2 Pros and cons
Medication concerns - Side-effects
Provide information to allow participant to identify which physical symptoms are side-effects.
Prompt them to generate or select strategies to help manage these, minimise the impact, or find alternative treatments.
Advise participant to seek practical support from HCPs on managing side-effects and finding the right medications.
I’m worried about the side effects from these medications Common side effects and strategies to manage them Taking this medication affects my daily life
‘What should I do if I am having problems..’
I dislike the way these medications make me feel Medications prescribed for bipolar disorder Sussex Partnership NHS Trust leaflets Link to Choice and Medication website
1. Goals and Planning - 1.2 Problem solving
3. Social support - 3.2 Social support (practical)
5. Natural consequences - 5.6 Information about emotional consequences
9. Comparison of outcomes - 9.1 Credible source
Medication concerns – Dependence
Provide information on dependence, what constitutes addiction and withdrawal symptoms. Acknowledge concerns about dependence.
‘I sometimes worry that I might become addicted to or dependent on the medication I’m taking’
5. Natural consequences - 5.1, Information about health consequences
Medication concerns - Long term effects
Provide information on risk of long-term effects and how to reduce risks.
Prompt participant to identify and compare reasons for adherence and non-adherence (long-term effects concerns), then prompt them to weigh up the risk of long-term effects vs the benefits of medication.
‘I sometimes worry whether there might be long-term effects...’
Link to Choice and Medication website
Balancing pros and cons – information and decisional balance exercise
5. Natural consequences - 5.1, Information about health consequences
9. Comparison of outcomes - 9.1 Credible source, 9.2 Pros and cons
Determinants/ Proximal objectives
Implementation strategies in IBiD IBiD section/ exercise BCTs (Michie, Johnston, et al., 2013)
Necessity beliefs - Adherence and risk of relapse
Provide information about non-adherence and relapse risk.
Prompt participant to imagine and compare the outcomes of adherence and non-adherence for them in the future and the pros and cons of adherence and non-adherence (relapse risk).
Provide information about the challenges with managing bipolar and factors which precipitate non-adherence (antecedents).
Emphasise the emotional, social and environmental consequences of adherence and non-adherence and the specific impact which these could have on participants’ lives (relapse/ hospitalisation/ employment etc).
Prompt participants reflect on the consequences of previous adherence/
non-adherence. Provide information to stimulate future regret about non-adherence (based on previous experience).
Provide ways in which others have viewed BD and taking medication more positively.
Your thoughts and feelings about taking medication
Exercise - What does taking medication for bipolar mean to you?
Taking control: 3 steps to effective management - Challenges exercise
Balancing pros and cons – info and exercise (taking and not taking medication)
Exercise – impact of stopping or taking medication differently Making sense of the diagnosis: Does taking medication mean I have to accept I am ill?
13. Identity- 13.2 Framing/reframing 4. Shaping knowledge - 4.2 Information about antecedents 5. Natural consequences - 5.1 Information about health
9. Comparison of outcomes - 9.2 Pros and cons, 9.3 Comparative imagining of future outcomes
Necessity beliefs - Long-term necessity of medication (health in the future depends on
medication)
Provide information that medication is a preventative treatment to reduce relapse risk and framing BD as a long-term condition with ongoing susceptibility to episodes.
I don’t feel ill so why should I continue to take my medication?
Will I always have bipolar?
13. Identity - 13.2 Framing/reframing
Satisfaction with medication information
Provide information on medications for BD and the specific medications participants are prescribed.
Provide links to where to access additional information from credible sources.
Medications prescribed for bipolar disorder Sussex Partnership NHS Trust leaflets Link to Choice and Medication website Useful resources.
9. Comparison of outcomes - 9.1 Credible source
Feelings of stigma - medication related
Provide information (quotes from people with lived experience) on positive ways to perceive medication.
Encourage participant to build a positive identity of having a BD diagnosis and taking medication.
Taking medication is an unwelcome reminder of my condition (quotes)
‘I tend to hide the fact that I am taking these medications...’
9. Comparison of outcomes - 9.1 Credible source
13. Identity - 13.5 Identity associated with changed behaviour
Feelings of stigma - disorder related
Provide information on public perceptions of mental health (national survey) and prompt participant to compare with their own perceptions to attempt order to change cognitions about stigma.
There’s such a lot of stigma about giving yourself a label – Information & exercise
Public views about mental illness
9. Comparison of outcomes - 9.1 Credible source
13. Identity - 13.2 Framing/reframing
Determinants/ Proximal objectives
Implementation strategies in IBiD IBiD section/ exercise BCTs (Michie, Johnston, et al., 2013)
Therapeutic alliance Effective communication with HCPs
Advise participant to seek support and practical advice from HCP on adherence and managing BD.
Provide suggestions on how to communicate effectively with HCP and get the most benefit from consultations.
Taking control: 3 steps to effective management Challenges exercise (advice to use with HCP)
‘What should I do if I am having problems..’
Getting the most from your consultations
3. Social support - 3.1 Social support (unspecified), 3.2 Social support (practical)
Illness beliefs - Bipolar identity (acceptance of BD diagnosis)
Encourage participant to build a positive identity of having a BD diagnosis and taking medication.
Recommendation of where to seek more information on BD from credible sources.
Making sense of the diagnosis: Does taking medication mean I have to accept I am ill?
Exercise – What does bipolar mean to you?
Useful resources
13. Identity - 13.5 Identity associated with changed behaviour
9. Comparison of outcomes - 9.1 Credible source
Illness beliefs - Severity perception
Provide information on the consequences of mood episodes and why bipolar is treated as an illness
Understanding bipolar, Highs & Lows (Q&A) 9. Comparison of outcomes - 9.1 Credible source
Illness beliefs – Timeline beliefs (BD as a long-term condition)
Framing BD as a long-term condition with ongoing susceptibility to episodes.
Encourage participant to build a positive identity of having a BD diagnosis and taking medication.
Will I always have bipolar? 13. Identity - 13.2
Framing/reframing, 13.5 Identity associated with changed behaviour
Illness beliefs - Control perception Provide information that medication and self-management can help control BD.
Taking control: 3 steps to effective management 13. Identity - 13.2 Framing/reframing
Practical barriers - Forgetting, dealing with routine changes etc.
Prompt participant to identify own practical barriers to adherence then generate or select strategies to help overcome barriers.
Suggest environmental or social stimulus which prompt medication taking, advise participant of ways of minimising demands on mental resources (e.g. use of alarms, reminders, linking medication with another activity, requesting assistance from friends/ family), advise to change the physical environment to facilitate adherence (e.g. dosette boxes, location of medication storage), prompt detailed planning of daily medication taking (e.g. context, frequency, duration, intensity), advise to seek support from friends/ family and let them know their treatment plan and to contact HCPs for practical support on difficulties with medication.
Sometimes I find it difficult to take my medication
‘What should I do if I am having problems..’
Implementation Intentions exercise
1. Goals and Planning - 1.2 Problem solving, 1.4 Action Planning 3. Social support - 3.2 Social support (practical)
7. Associations - 7.1 Prompts/cues 11. Regulation - 11.3 Conserving mental resources
12. Antecedents - 12.1 Restructuring the physical environment
Determinants/ Proximal objectives
Implementation strategies in IBiD IBiD section/ exercise BCTs (Michie, Johnston, et al., 2013)
Practical barriers - Understanding how to get and take medication, and how and why changes may be needed.
Presentation of information on specific medications prescribed to each participant.
Provide advice to participant to seek practical support from HCPs on finding the right medications.
Medications prescribed for bipolar disorder Sussex Partnership NHS Trust leaflets Link to Choice and Medication website Useful resources
I’ve been on the same medication for years, do I need to change?
Why does the medication I am given keep changing?
3. Social support - 3.2 Social support (practical)
9. Comparison of outcomes - 9.1 Credible source
Symptom monitoring - Identifying personal triggers of episodes.
Provide information on potential triggers and prompt participant to identify previous triggers to enable identification of future ones (i.e.
define stimulus which cue self-management).
Is there a cause of bipolar (triggers information & exercise) 7. Associations - 7.1 Prompts/cues
Symptom monitoring Prodrome recognition
Provide advice to participant to identify personal prodromes of episodes.
Prompt participant to track triggers (e.g. life events) prodromes (e.g.
sleep, spending), behaviour (including adherence) and outcomes.
Monitoring your symptoms and looking after yourself Completing your own mood chart
Taking control: 3 steps to effective management
1. Goals and Planning - 1.2 Problem solving
2. Feedback and monitoring - 2.3 Self-monitoring of behaviour, 2.4
Prompt participant to identify barriers to effective self-management.
Presentation of information on practical strategies to try in the event of mood changes.
Prompt participant to generate or select strategies to put into place in the event of noticing prodromes.
Advise participant to work with HCP to help generate or select strategies.
Instruct and advise participant to use mood charting exercise to monitor prodromes, behaviour and outcomes and advise to use this with HCP to problem solve.
Taking control: 3 steps to effective management – Challenges exercise
Monitoring your symptoms and looking after yourself Completing your own mood chart
1. Goals and Planning - 1.2 Problem solving
2. Feedback and monitoring - 2.3 Self-monitoring of behaviour, 2.4 Self-monitoring of outcome(s) of behaviour
5.2.3.1 Treatment perceptions – Necessity & Concerns beliefs
As previously discussed, medication perceptions have been linked to adherence in BD (Clatworthy et al., 2009). Therefore the intervention needed to use techniques to attempt to help participants come to a view of medication that is consistent with adherent behaviour i.e.
reduce concerns and increase perceptions of need.
Persuasive communication involves guiding people towards an attitude or behaviour using persuasive arguments. A theoretical model of persuasive communication is the Elaboration Likelihood Model (ELM) (Petty & Cacioppo, 1986). The ELM involves two processing routines for persuasion; central and peripheral. In the central route, an individual takes the relevant information and scrutinises this, and is conducted on a conscious level. This is relevant in the IBiD intervention as the aim is to involve participants in the active process of making informed choices about treatment. The peripheral route relies on affective associations and perceived credibility of the information. Persuasive communication is part of a number of BCTs and therefore these were used in order to target beliefs, some examples of which are provided here.
Participants’ perceptions of the necessity of treatment were targeted by emphasising the consequences of adherence and non-adherence for them as an individual. This involved the use of an exercise to determine what the outcomes were of non-adherence for them in the past (mapped to BCT code 5.2: Salience of consequences) (Figure 5.3). This technique is used in psychoeducation programmes for BD (Colom & Vieta, 2006). A mood charting exercise
provided by Bipolar UK allowed participants to track their moods and their medication taking behaviour thus allowing them to visualise the relationship between their mood and adherence (Appendix K).
Figure 5.2: Your thoughts and feelings about taking medication
Cognitive restructuring (BCT code 13.2 Framing/ reframing) is used in CBT and aims to encourage participants to identify and re-evaluate their beliefs (Basco & Rush, 2005). The rationale being that behaviour is influenced by cognitions and mood and therefore modifying dysfunctional cognitions and moods will have an effect on behaviour (J. S. Beck, 1995). In IBiD, persuasive communication was used to frame medication-taking as a way to help participants to reduce the risk of problems associated with BD as opposed to changing who they are.
To target necessity beliefs and concerns about medication, a decisional balance exercise, as used in CBT interventions, was included (Basco & Rush, 2005). This prompts participants to weigh up the reasons for adherence versus non-adherence (Figure 5.3). This maps to the BCT Pros and cons (BCT code 9.2) (Michie, Johnston, et al., 2013). Problem solving and decision making are identified as a skill required for self-management. In chronic conditions such as BD, people must make decisions on a day to day basis with regard to changes in mood, side-effects or dealing with environmental changes or life events (Lorig & Holman, 2003). This incorporates the principles of MI where people are more likely to make changes if the individual themselves identifies the potential benefits of change as they are most salient (Miller & Rollnick, 1991).
Figure 5.3: Pros and cons of taking medication exercise
Information was provided so participants could have sufficient knowledge on which to weigh up their concerns. This was framed around the BMQ concerns items (e.g. side effects, long-term effects, fears of dependence). IBiD presents information about common side-effects to give participants knowledge to decide how to deal with them. Lorig and Holman (2003)
recommend that patients with chronic conditions are given information which enables them to determine if symptoms are an indication of a problem which needs to be addressed and how urgent this need is. Participants were also advised to seek additional information and support from their HCP and medication information websites. The provision of knowledge about
treatment is a key objective of psychoeducation programmes (Colom & Vieta, 2006) and is identified as a prerequisite to be able to make informed decisions (Lorig & Holman, 2003).
An additional topic in relation to medication raised by participants in the qualitative study in Chapter 4 was the importance of understanding the need to find treatments which are right for them individually. Text was included to explain the need for therapeutic experimentation and the importance of participants own involvement in trialling medication and doses to find the most effective treatment whilst minimising side-effects. This section of IBiD also highlights the importance of communication with HCPs and forming an effective partnership which is a part of self-management (Lorig & Holman, 2003) and therapeutic alliance has been identified as an important determinant of adherence and symptom experience (Strauss & Johnson, 2006;
L. Thompson & McCabe, 2012).
5.2.3.2 Illness perceptions & symptom monitoring
Illness perceptions which may be associated with effectively managing BD, include perception of illness severity and perceived control over BD (Adams & Scott, 2000; Scott & Pope, 2002a).
Information was included in IBiD on BD including the consequences of relapse, the chronic nature of the condition using persuasive communication in order to increase severity
perceptions. In addition, information on taking control in BD was included in order to increase perception of personal control.
Self-management requires ongoing symptom and behaviour monitoring and selecting and using coping procedures such as seeking information and help and making lifestyle changes (Mizock et al., 2014; S. Russell & Browne, 2005; Todd et al., 2012). Recognising the prodromes or early warning signs of BD episodes is the crux of self-management in BD (Lam et al., 2001; S.
Self-management requires ongoing symptom and behaviour monitoring and selecting and using coping procedures such as seeking information and help and making lifestyle changes (Mizock et al., 2014; S. Russell & Browne, 2005; Todd et al., 2012). Recognising the prodromes or early warning signs of BD episodes is the crux of self-management in BD (Lam et al., 2001; S.