Ayna B. Johansen

Constructing a Theory- and Evidence-Based Treatment Rationale for Complex eHealth Interventions: Development of an Online Alcohol Intervention Using an Intervention Mapping Approach

Background Due to limited reporting of intervention rationale, little is known about what distinguishes a good intervention from a poor one. To support improved design, there is a need for comprehensive reports on novel and complex theory-based interventions. Specifically, the emerging trend of just-in-time tailoring of content in response to change in target behavior or emotional state is promising. Objective The objective of this study was to give a systematic and comprehensive description of the treatment rationale of an online alcohol intervention called Balance. Methods We used the intervention mapping protocol to describe the treatment rationale of Balance. The intervention targets at-risk drinking, and it is delivered by email, mobile phone text messaging, and tailored interactive webpages combining text, pictures, and prerecorded audio. Results The rationale of the current treatment was derived from a self-regulation perspective, and the overarching idea was to support continued self-regulation throughout the behavior change process. Maintaining the change efforts over time and coping adaptively during critical moments (eg, immediately before and after a lapse) are key factors to successful behavior change. Important elements of the treatment rationale to achieving these elements were: (1) emotion regulation as an inoculation strategy against self-regulation failure, (2) avoiding lapses by adaptive coping, and (3) avoiding relapse by resuming the change efforts after a lapse. Two distinct and complementary delivery strategies were used, including a day-to-day tunnel approach in combination with just-in-time therapy. The tunnel strategy was in accordance with the need for continuous self-regulation and it functions as a platform from which just-in-time therapy was launched. Just-in-time therapy was used to support coping during critical moments, and started when the client reports either low self-efficacy or that they were drinking above target levels. Conclusions The descriptions of the treatment rationale for Balance, the alcohol intervention reported herein, provides an intervention blueprint that will aid in interpreting the results from future program evaluations. It will ease comparisons of program rationales across interventions, and may assist intervention development. By putting just-in-time therapy within a complete theoretical and practical context, including the tunnel delivery strategy and the self-regulation perspective, we have contributed to an understanding of how multiple delivery strategies in eHealth interventions can be combined. Additionally, this is a call for action to improve the reporting practices within eHealth research. Possible ways to achieve such improvement include using a systematic and structured approach, and for intervention reports to be published after peer-review and separately from evaluation reports.

Practical support aids addiction recovery: the positive identity model of change

BackgroundThere is a need for studies that can highlight principles of addiction recovery. Because social relationships are involved in all change processes, understanding how social motivations affect the recovery process is vital to guide support programs.MethodsThe objective was to develop a model of recovery by examining addicted individuals’ social motivations through longitudinal assessment of non-professional support dyads. A qualitative, longitudinal study design was used, combining focus groups and in-depth interviews with addicted individuals and their sponsors. Data were analyzed using the principles of grounded theory: open coding and memos for conceptual labelling, axial coding for category building, and selective coding for theory building. The setting was an addiction recovery social support program in Oslo, Norway. The informants included nine adults affected by addiction, six sponsors, and the program coordinator. The participants were addicted to either alcohol (2), benzodiazepines (1), pain killers (1) or polydrug-use (5). The sponsors were unpaid, and had no history of addiction problems.ResultsSupport perceived to be ineffective emerged in dyads with no operationalized goal, and high emotional availability with low degree of practical support. Support perceived to be effective was signified by the sponsor attending to power imbalance and the addict coming into position to help others and feel useful.ConclusionsThe findings appear best understood as a positive identity-model of recovery, indicated by the pursuit of skill building relevant to a non-drug using identity, and enabled by the on-going availability of instrumental support. This produced situations where role reversals were made possible, leading to increased self-esteem. Social support programs should be based on a positive identity-model of recovery that enable the building of a life-sustainable identity.

Constructing a Theory and Evidence-Based Approach to Promote and Evaluate Autonomy in Addiction

ABSTRACT In this article we use theory and empirical evidence to synthesize a model for the analysis of autonomy in people with addictions. We review research on motivation and denial as accepted addiction constructs that need to be replaced with non-stigmatizing and autonomy-supportive language when seeking to ‘treat’ addicts. We present three main factors involved in relational autonomy in addiction (mentalizing, positive self-concept, and stigma), and illustrate our model by examining variations on these parameters in two case studies of heroin addicts. We conclude that a growth perspective is needed to assess functioning in populations believed to be ‘addicted’ and make suggestions for assessment.

How a Fully Automated eHealth Program Simulates Three Therapeutic Processes: A Case Study

Background eHealth programs may be better understood by breaking down the components of one particular program and discussing its potential for interactivity and tailoring in regard to concepts from face-to-face counseling. In the search for the efficacious elements within eHealth programs, it is important to understand how a program using lapse management may simultaneously support working alliance, internalization of motivation, and behavior maintenance. These processes have been applied to fully automated eHealth programs individually. However, given their significance in face-to-face counseling, it may be important to simulate the processes simultaneously in interactive, tailored programs. Objective We propose a theoretical model for how fully automated behavior change eHealth programs may be more effective by simulating a therapist’s support of a working alliance, internalization of motivation, and managing lapses. Methods We show how the model is derived from theory and its application to Endre, a fully automated smoking cessation program that engages the user in several “counseling sessions” about quitting. A descriptive case study based on tools from the intervention mapping protocol shows how each therapeutic process is simulated. Results The program supports the user’s working alliance through alliance factors, the nonembodied relational agent Endre and computerized motivational interviewing. Computerized motivational interviewing also supports internalized motivation to quit, whereas a lapse management component responds to lapses. The description operationalizes working alliance, internalization of motivation, and managing lapses, in terms of eHealth support of smoking cessation. Conclusions A program may simulate working alliance, internalization of motivation, and lapse management through interactivity and individual tailoring, potentially making fully automated eHealth behavior change programs more effective.

Using a Film Intervention in Early Addiction Treatment: a Qualitative Analysis of Process

PurposeThere is a need for knowledge about how self-help materials can be made useful in treatment for Substance Abuse Disorders (SUD), as a supplement to ongoing treatment, or as independent tools for change.ObjectiveIn this study, we explored the use of self-help films in early addiction treatment, taking into account both patient and therapist perspectives, as well as dyadic functions. We explored how active mechanisms might be related to intervention format and implementation context. A secondary aim was to examine the potential mechanisms related to the specific content of the intervention: mindfulness and acceptance psychoeducation.MethodsA qualitative exploratory research design, including a general inductive analytic approach, constructivist grounded theory, and source triangulation features, was used to code and analyze interview material. Emerging themes were developed into concepts, and finally an operational model. Participants included 12 patients and 22 therapists, in in-/outpatient addiction clinics, all in urban areas of Norway. The purpose of the design was empirical grounding of developed concepts, to promote different potential user perspectives (patients’ and therapists’) and obtain process data.ResultsThe core concept constructed, “Alliance as experiential process,” gives a description of the data where patients and therapists accept or reject the film as a result of an experience process conceptualized as alliance formation. The alliance process model reflects the observation that patients constructed alliances autonomously, while therapists built alliances indirectly through their patients’ experiences.ConclusionsUse of a self-help film may be a helpful adjunct to face-to-face therapy for patients who create a personally meaningful attachment to the film. Mindfulness/acceptance may offer one basic framework for such connection to take place.

Adoption and Identity Experiences Among Adult Transnational Adoptees: A Qualitative Study

ABSTRACT To establish more comprehensive ways to assess transnational adoption adjustment, we need to better understand the adoptive identity experiences of transnational adoptees. We explored adoption identity by describing sociopsychosocial aspects and self experiences related to transnational adoption adjustment in a purposive sample of 16 adult Korean-American adoptees. A qualitative, descriptive analysis resulted in three themes: biological parents, birthdays, and adoption history, with three subthemes of adoptive family, pride, and difficulties. The study is a first to qualitatively examine adoption identity and the themes may be used to develop a survey of adoption identity for adult transnational adoptees.

Constructivist Simultaneous Treatment of Borderline Personality Disorder, Trauma, and Addiction Comorbidity A Qualitative Case Study

This qualitative case study explored one client’s recovery from borderline personality disorder, trauma, and problem gambling. The client attended 18 months of integrative treatment and was followed for 5 years. The study included 106 data points of both client and therapist data. We identified three phases to treatment. First, alliance formation and normalization appeared as mechanisms, and the client experienced dependence. Second, working alliance and countertransference appeared as mechanisms, and the client experienced reduced gambling and suicidal ideation. Third, external controls and increased opportunity appeared as mechanisms, and “moving into the world” was the client experience. The findings give preliminary support to a phase-based constructivist treatment including trauma assessment to normalize self-feelings, countertransference work to support motivation for restraint, and case management principles to support continuity of change efforts.

Key Intervention Characteristics in e-Health: Steps Towards Standardized Communication

PurposeThis paper reports expert opinion on e-health intervention characteristics that enable effective communication of characteristics across the diverse field of e-health interventions. The paper presents a visualization tool to support communication of the defining characteristics.MethodsAn initial list of e-health intervention characteristics was developed through an iterative process of item generation and discussion among the 12 authors. The list was distributed to 123 experts in the field, who were emailed an invitation to assess and rank the items. Participants were asked to evaluate these characteristics in three separate ways.ResultsA total of 50 responses were received for a response rate of 40.7%. Six respondents who reported having little or no expertise in e-health research were removed from the dataset.Our results suggest that 10 specific intervention characteristics were consistently supported as of central importance by the panel of 44 e-intervention experts. The weight and perceived relevance of individual items differed between experts; oftentimes, this difference is a result of the individual theoretical perspective and/or behavioral target of interest.ConclusionsThe first iteration of the visualization of salient characteristics represents an ambitious effort to develop a tool that will support communication of the defining characteristics for e-health interventions aimed to assist e-health developers and researchers to communicate the key characteristics of their interventions in a standardized manner that facilitates dialog.

Erratum to: Key Intervention Characteristics in e-Health: Steps Towards Standardized Communication

1 University of Leeds, Leeds, UK 2 Merrill-Palmer Skillman Institute and Department of Psychiatry & Behavioral Neurosciences, Wayne State University, Detroit, MI, UK 3 Interdisciplinary Research Unit, Elective Surgery Center, Regional Hospital Silkeborg, Silkeborg, Denmark 4 Department of Clinical Medicine, Aarhus University, Aarhus, Denmark 5 Explorable AS, Kristiansand, Norway 6 Trimbos Institute The Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands 7 Arkin Mental Health Care, Amsterdam, The Netherlands

Practical Support Facilitates Recovery Processes in Professionally Organized Addiction Self-Help: An Explanatory Case Study

Understanding how a self-help program with a positive psychology focus and professional leaders influences change is important to guide support programs. We used a qualitative, explanatory, organizational case study including method and source triangulation to describe and explain leadership mechanisms supporting recovery. Horizontal leadership processes included overcoming stigma and becoming a helper, and vertical processes included internalized willingness to lead, vision formation, pride and professionalization, continuity and accessibility, and flexible leadership. Resource-focused and professionally led self-help is likely compatible and complementary to 12-step programs, as it integrates peer support and collaborative leadership with the best of professional programs, including sober leadership.