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Development and evaluation of a manual for extended brief intervention for alcohol misuse for adults with mild to moderate intellectual disabilities living in the community: The EBI-LD study manual

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Abstract

Background: Extended brief interventions for alcohol misuse are effective in the general population. The process of manualising the first ever such intervention for people with mild to moderate intellectual disabilities in the UK is the focus of this study. Methods: The manual was an adaptation of existing manuals based on Motivational Enhancement and Cognitive Behaviour Therapy and was used in a feasibility randomized controlled trial, the EBI-LD study. The sessions were recorded and scored using an adapted version of the Yale Adherence and Competence Scale (YACS II). Feedback was provided by therapists. The trial is closed. Registered: isrctn.com; ISRCTN58783633. Results: The quality of the sessions provided was rated as good. Therapists were able to cover all topics within each session. Main challenges included session duration and homework task completion. Conclusions: We recommend the duration of the sessions to be extended to 40 min to accommodate carers in the session and to enhance their support in homework task completion.
J Appl Res Intellect Disabil. 2017;1–7. wileyonlinelibrary.com/journal/jar  
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Published for the British Institute of Learning Disabilities
© 2017 John Wiley & Sons Ltd
Accepted: 17 July 2017
DOI: 10.1111/jar.12409
ORIGINAL ARTICLE
Development and evaluation of a manual for extended
brief intervention for alcohol misuse for adults with mild to
moderate intellectual disabilities living in the community: The
EBI- LD study manual
Christos Kouimtsidis1| Katrina Scior2| Gianluca Baio3| Rachael Hunter4|
Vittoria Pezzoni5| Angela Hassiotis6
1iHEAR, Surrey and Borders Partnership NHS
Foundation Trust, London, UK
2Research Department of Clinical, Educational
& Health Psychology, University College
London, London, UK
3Department of Statistical Science, University
College London, London, UK
4Department of Primary Care and Population
Health Research, University College London,
London, UK
5Hertfordshire Partnership NHS Foundation
Trust, Saint Albans, UK
6Division of Psychiatry, University College
London, London, UK
Correspondence
Christos Kouimtsidis, Surrey and Borders
Partnership NHS Foundation Trust, London,
UK.
Email: drckouimtsidis@hotmail.com
Funding information
This paper presents independent research
funded by the National Institute for Health
Research (NIHR) under its Research for
Patient Benefit (RfPB) Programme (Grant
Reference Number PB- PG- 1111- 26022). The
views expressed are those of the author(s) and
not necessarily those of the NHS, the NIHR or
the Department of Health
Background: Extended brief interventions for alcohol misuse are effective in the gen-
eral population. The process of manualising the first ever such intervention for people
with mild to moderate intellectual disabilities in the UK is the focus of this study.
Methods: The manual was an adaptation of existing manuals based on Motivational
Enhancement and Cognitive Behaviour Therapy and was used in a feasibility rand-
omized controlled trial, the EBI- LD study. The sessions were recorded and scored
using an adapted version of the Yale Adherence and Competence Scale (YACS II).
Feedback was provided by therapists. The trial is closed. Registered: isrctn.com;
ISRCTN58783633.
Results: The quality of the sessions provided was rated as good. Therapists were able
to cover all topics within each session. Main challenges included session duration and
homework task completion.
Conclusions: We recommend the duration of the sessions to be extended to 40 min to
accommodate carers in the session and to enhance their support in homework task
completion.
KEYWORDS
alcohol extended brief intervention intellectual disabilities,
1 | INTRODUCTION
Historically intellectual disability was considered an exclusion criterion
for psychotherapy, leaving those affected by such conditions few (if
any) options for accessing available psychosocial treatments. There has
been of late a growing interest, both within the specialist intellectual
disability field and at government level, in developing psychological
therapies specifically designed for people with intellectual disabil-
ities and providing them with the same services as for the general
population. This premise is enshrined in the Equality Act (2010) but
also has been the cornerstone of government policy which strongly
advocates the use of universal health services by people with intel-
lectual disability (Department of Health, 2001, 2009). Recent studies
have shown that people with intellectual disability are vulnerable to
a number of mental health conditions such as common mental disor-
ders, psychosis and dementia (Cooper, Smiley, Morrison, Williamson,
& Allan, 2007; Lin et al., 2016) as well as substance use disorders (Van
Duijvenbode et al., 2015).
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People with intellectual disability have cognitive deficits that im-
pair their ability to learn new information or generalize new learning.
Difficulties include articulating emotional states, limited understand-
ing of abstract concepts, expressive or receptive speech difficulties,
delay in processing and retrieving information (Lindsay, Howells,
& Pitcaithly, 1993; Lindsay, Neilson, & Lawrenson, 1997; McCabe,
McGillivray, & Newton, 2006). Furthermore, a person with intellectual
disability is likely to have reduced verbal communication skills (Burnip,
2002) and may be more suggestible, tending to change their answers
to questions when provided with negative feedback (Everington &
Fulero, 1999). People with intellectual disability may also try to mask
their difficulties in understanding and following verbal communication
by drawing on social skills and set phrases that they know are con-
textually appropriate responses (Hassiotis et al., 2012). To compensate
for such impairments, existing or newly developed psychosocial ther-
apies require a number of adaptations in the way that they are deliv-
ered as well as in content. Central to the adaptations are use of role
play and materials in easy read formats, language that is appropriate
to the person’s understanding; sessions may need to include breaks
and the person may need to be supported by a family or paid carer to
complete any related homework (Hassiotis et al., 2012; McCabe et al.,
2006; NICE PH24;18).
Cognitive Behaviour Therapy (CBT) with people with mild to mod-
erate intellectual disabilities is the most commonly used psychological
treatment and the one widely adapted for this population for com-
mon disorders such as depression and anxiety (Hassiotis et al., 2012;
Lindsay et al., 1993, 1997; McCabe et al., 2006). More recent work
has been carried out on using computers to enable people with in-
tellectual disability to engage with CBT interventions (Vereenooghe,
Reynolds, & Langdon, 2016).
Despite the sparse literature regarding substance misuse in people
with intellectual disability there is increasing interest in studying such
problems because most people with intellectual disability now live
in the community and are likely to be exposed to substances in their
social networks as well as consuming them (Lin et al., 2016; Miller &
Whicher, 2010). UK and USA population- based studies indicate that
the prevalence of substance misuse in people with intellectual disabil-
ity ranges from 0.5% to 2.5% and may be as high as 22.5% for any sub-
stance in clinical samples (Cooper et al., 2007; Hassiotis et al., 2008;
McGillicuddy & Blane, 1999; Pezzoni & Kouimtsidis, 2015; Sturmey,
Reyer, Lee, & Robek, 2003). Approximately 5% of youths seen in drug
and alcohol services have a degree of intellectual disability (Barrett &
Paschos, 2006). Alcohol and cannabis are the commonest substances
that people with mild to moderate intellectual disability use. Those
most at risk are young males with mild intellectual disability or border-
line intellectual functioning (defined as IQ between 1 and 2 standard
deviations below the mean) who live independently, in poorer neigh-
bourhoods, with minimal support in the community and are less likely
to engage in social activities (Barrett & Paschos, 2006; Lin et al., 2016).
A variety of approaches have been tried for the treatment of
alcohol disorders in people with mild to moderate intellectual
disability, such as education about the risks associated with sub-
stance misuse, motivational interviewing, behavioural modification,
adaptation of materials by AA or similar organisations with interven-
tions, mostly delivered in group settings (Christian & Poling, 1997;
Degenhardt, 2000; Didden, Embregts, van der Toorn, & Laarhoven,
2009; Forbat, 1999; Lindsay, Allen, Walker, Lawrenson, & Smith,
1991; McCusker, Clare, Cullen, & Reep, 1993; McGillicuddy & Blane,
1999; McMurran & Lismore, 1993; Mendel & Hipkins, 2002). As a
whole, these studies suggest that the capacity of people with intel-
lectual disability to learn new information is enhanced by providing
additional cues and using techniques such as modelling, videotaped
vignettes and role playing. Often, sessions are augmented with cop-
ing skills lessons and assertiveness training (McCusker et al., 1993;
McGillicuddy & Blane, 1999). Two studies merit further attention
as they test similar interventions for a similar population. One is a
study of three sessions of group motivational interviewing delivered
over a 2- week period conducted with seven offenders with learning
disabilities in a medium secure unit (Mendel & Hipkins, 2002). The
authors found that the participants showed increased determination
to reduce drinking at the end of the treatment. The second study
(McCusker et al., 1993) is a 10- week evaluation of assertiveness
training and modelling compared to waiting list to educate about
substance misuse and to help the participants (N = 84 randomized
to treatment and waiting list controls) to respond appropriately
when offered substances in their social network. The authors found
that knowledge of the risks associated with use of illicit substances
increased at the end of the intervention and this was maintained
at 6- month follow- up. The methodological limitations of the stud-
ies include the uncontrolled design and possibility of type 2 error
in the former study, and insufficient methodological details in the
latter to allow appraisal of the findings, as well as the inclusion of
several substances which may have compromised the specificity of
the intervention.
The National Institute for Health and Clinical Excellence (NICE,
2010) recommends a variety of brief interventions for the treatment
of hazardous and harmful drinking. For hazardous drinkers (excessive
drinking above recommended levels without associated harm experi-
enced yet), NICE recommends brief advice (one session of 10 min) to
be delivered by a health professional within non- specialist healthcare
settings. For harmful drinkers (excessive drinking above recommended
levels with associated harm experienced), extended brief interven-
tions (EBI) are recommended, consisting of 3–5 individual sessions,
based on motivational interviewing/enhancement techniques, deliv-
ered by alcohol specialists within specialist services. The aim is either
to reduce alcohol intake to within recommended limits or to consider
abstinence and to reduce associated risk- taking behaviour. The dura-
tion of EBI sessions varies from 20 to 30 min and follow- up is offered.
In this study, the authors report the adaptation of an EBI manual to
treat hazardous and harmful use of alcohol in adults with mild to mod-
erate intellectual disability living in the community as part of a funded
feasibility study (Kouimtsidis et al., 2015), which is the first phase of a
potential full RCT. EBI represents the most intensive of the treatment
options recommended for these groups of alcohol users. It is although
a relatively low- intensity intervention and can be delivered by trained
professionals in the public and voluntary sector.
    
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2 | METHOD
2.1 | Study design
The adaptation of the study manual was the first stage of a two- stage
feasibility study (Kouimtsidis et al., 2015). The manual would under-
pin the intervention provided in a single blind parallel two arm ran-
domized control trial (RCT) of the clinical and cost- effectiveness of
EBI in reducing hazardous and harmful drinking in adults with mild
to moderate intellectual disability living in the community. Participant
and family/paid carer assessments were conducted at baseline, at 2-
and 3- month post- randomisation. Participants were recruited from
three areas in England covering urban and semirural and inner London
sites. Participants were (i) adults with mild to moderate intellectual
disability aged 18 years and over; (ii) referred by professionals as hav-
ingalcoholproblems;(iii)scoring≥8onthealcoholusedisorderiden-
tificationtest(AUDIT)andwithacumulativescore≤9inresponseto
questions 4, 5 and 6 of the AUDIT, which specifically assess alcohol
dependence (Babor, Higgins- Biddle, Saunders, & Monteiro, 2001); and
(iv) having an IQ < 70 as assessed by the Wechsler Abbreviated Scale
for Intelligence (WASI), unless a previous assessment was available.
2.2 | Participant characteristics
Thirty individuals were equally randomized to the intervention or
control arm. Thirteen individuals received the intervention (one was
excluded and one declined to participate following randomisation).
The mean age of those randomized to the intervention was 45 years
(SD = 8.6), 10 (66∙6%) were male, 12 (80%) were white, 10 (66∙6%)
were living alone and 9 (60%) had a mild intellectual disability. The
results of the study are presented elsewhere (Kouimtsidis et al.,
2017).
2.3 | Manual development
The adapted treatment manual was based on existing manuals of EBI
for harmful drinking in the general population (see below). The manual
was divided into three parts: part I provided an introduction to alcohol
use disorders, brief interventions for these, interventions in people
with intellectual disability, principles in communication with people
with intellectual disability and the role of carers in therapy; part II in-
cluded the treatment protocol and session content, and part III con-
sisted of appendices with all therapy aids. The first five sessions were
30 min long and were offered weekly. The final session (session 6) was
a follow- up (booster) session, and it was 1 hr long and was offered at
week 8. The first session aimed to build a therapeutic relationship.
Sessions 2 and 3 aimed to enhance motivation and were adapted
from the Motivational Enhancement Therapy (MET) published in the
UKATT MET Manual (UKATT Research Team, 2001). Sessions 4 and
5 aimed to develop new skills and were adapted from the UKCBTMM
manual (Kouimtsidis, Reynolds, Drummond, Davis, & Tarrier, 2007).
Finally, session 6 was a consolidation session, in which changes in
drinking and lifestyle that had been achieved were reviewed.
Motivational Enhancement Therapy is based on the trans-
theoretical model of behaviour change or stages of change model
(Prochaska, DiClemente, & Norcross, 1992). The model proposes
that the process of recovery from an addictive behaviour involves
transition through stages: (i) pre- contemplation in which no change
drinking is contemplated; (ii) contemplation in which change is con-
templated for the near future; (iii) preparation in which plans are
made on how to change behaviour in a definite way; (iv) action stage
in which the plans are put into action and change takes place; and (v)
maintenance in which a new pattern of behaviour emerges is estab-
lished and maintained. CBT is used to identify high- risk situations for
drinking, explore ways to avoid them, develop strategies to cope with
them, and finally, implement appropriate lifestyle changes to support
a healthier lifestyle of either controlled drinking or total abstinence.
Specific modifications that the research team considered necessary
in order to account for the cognitive deficits and communication
needs of adults with intellectual disability included practical aspects
such as increasing the number of sessions to five; the duration of
each session to 30 min, adding a 1 hour long booster session and
developing easy read materials to be used during and in between
sessions.
2.4 | Format and themes of the sessions
The first five weekly sessions were divided into three parts of 10 min
each. The first part is an introduction to each session, discussing the
theme of the session and reviewing the completion of assignments
allocated in the previous session. The last part provides a link with the
next session and the assignments to be agreed for the following week.
The specific themes of each session are as follows: building therapeu-
tic rapport, introducing the intervention, the role of the carer and dis-
cussing the relevant treatment practicalities (session 1); exploration of
the participant’s current lifestyle and personalized advice about his/
her drinking patterns (session 2); enhancing motivation, increasing the
participant’s willingness to change and negotiating treatment goals
(session 3). In session 2, the therapist can use additional motivational
strategies to overcome resistance such as simple reflection or reflec-
tion with amplification or double- sided reflections, as well as shifting
the focus of discussion and rolling with resistance rather than con-
frontation with the client. During session 3, several motivational strat-
egies are used, such as exploring discrepancy between intentions and
drinking behaviour; exploring and resolving any ambivalence about
drinking; “eliciting change” talk; providing information and advice
about drinking; discussing options for treatment aims and promoting
freedom of choice.
In session 4, the therapist defines and identifies the participant’s
hierarchy of high- risk situations where drinking may be likely; reviews
past and current coping strategies; anticipates future high- risk situa-
tions; identifies potential unpredictable events and develops a personal
generic coping plan with the participant. In session 5, the therapist re-
assesses current lifestyle and promotes potential positive changes that
will support an alcohol- free lifestyle or healthier options. The booster
session (session 6) aims to consolidate the participant’s motivation to
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change their drinking patterns, review successful changes and pro-
mote further changes consistent with the goal of therapy.
2.5 | Special role of family or paid carer
The important role of family and of the social environment in the
treatment of alcohol disorders has been well recognized (NICE
PH24;18). The advantages as well as challenges of involving family
or paid carers in the treatment of people with intellectual disability
has been discussed in the literature (Willner, 2006). As far as alcohol
treatment for people with intellectual disability specifically is con-
cerned, family or paid carers may support the person with intellectual
disability to move successfully through the programme, by encour-
aging practice in between sessions and providing feedback that can
help the person to commit to change their behaviour. The inclusion
of a support person in sessions—with the expressed approval of the
participant with intellectual disability—can, however, be challeng-
ing although it has been employed successfully in a previous study
(Hassiotis et al., 2012). It is important to regulate the involvement of
the carer to ensure that the participant does not become dependent
on or rely too heavily on the carer during the course of treatment.
Confidentially issues need to be addressed before treatment begins.
For the reasons outlined above, special attention was paid to the
role of family members or paid carers and their involvement during
the course of the treatment. Specific instructions for the therapist of
how to involve the carer in the session, how to promote their special
role and examples of how to handle and resolve some common chal-
lenges associated with carer involvement (such as the risk of nega-
tive comments, judgements and over critical attitude or reluctance
to change their own drinking behaviour) were added in the manual
for each session and in the therapeutic programme as a whole as a
separate chapter in Part I. To help carers understand their role as
well as that of the purpose of the treatment, the researchers de-
veloped a leaflet for carers. Participation of the carer was decided
upon at the beginning of each session. The majority of carers (7)
were either paid or family members (4) and two were health profes-
sionals. The majority of carers were invited to attend part of the
session. Two (2) family members have attended the whole duration
of the first few sessions. Carers feedback is presented elsewhere
(Kouimtsidis et al., 2017).
2.6 | Manual evaluation–treatment fidelity
1. A self-rated checklist assessing the therapist’s own reflection
of treatment delivery was scored after every session and used
during supervision.
2. Therapy sessions were audio recorded (Aveline, 2007). Recorded
sessions were rated by CK using a modified version of the Yale
Adherence and Competence Scale (YACS II) (Nuro et al., 2005).
This is a widely used tool that assesses both the frequency/inten-
sity (quantity), and how well techniques of MET and CBT are used
(quality), with a score from 1–7, with 4 considered as acceptable
(quantity = somewhat; quality = adequate) (Nuro et al., 2005).
3. Sessions 3 and 4 were piloted with two adults with intellectual
disability and past alcohol use disorders to test acceptability of
themes and techniques used, the clarity of the language and the
homework tasks and materials. The sessions were audio re-
corded and assessed by CK and KS, both experienced in devel-
oping, implementing and evaluating therapy interventions in the
field of intellectual disability (KS) and in addiction psychiatry
(CK). Feedback was given to the therapist, and the recordings
(with the permission of clients) were used in the training of the
other three therapists, recruited subsequently. The four sessions
were also scored using the YACS II to assess inter-rater reliabil-
ity of the modified version used in the study, as well as a way for
the two potential raters having mutual supervision, comparing
the scoring of the two rates (CK and KS). The analysis was based
on n = 2 participants, measured repeatedly over sessions. The
dataset contains 34 dimensions that have been assessed by CK
and KS. For those measures, the authors have computed Cohen’s
Kappa coefficient (Cohen, 1960). The resulting statistics sug-
gests that there is no evidence of substantial negative values.
However, only for a few of the items do the point estimates ex-
ceed 0.7, which is usually considered as a threshold for “high
reliability,” indicating that while aligned, and the assessments are
not exactly the same. There was a consistency of the vicinity of
rating, with ratings in the same direction. To that effect and
given the small number of sessions requiring scoring, it was
decided that scoring by two raters was not necessary..
2.7 | Therapist training
Four therapists were trained and provided the intervention across the
study sites. They were psychology graduates employed as assistant
psychologists or equivalent, working in intellectual disability services
in the NHS. They were offered 1- day training on motivational in-
terviewing and the use of the manual and were supervised by CK.
During the training, each session was discussed in detail. Role play
of how to use motivational interviewing and CBT techniques was
used. Therapists were advised that while they should make an effort
to adhere to the recommended session duration, their ultimate aim
should be to deliver all the components of the session. Following
this, therapists received weekly supervision by CK while seeing their
first study participant. Subsequently, feedback on sessions recorded
and scored was provided within a week from submission and full
supervision was provided at least once a month. A self- check list for
each session was completed by the therapists and used as the basis
for supervision. The audio material from the recorded and scored
sessions was also used to inform supervision.
3 | RESULTS
3.1 | Therapist feedback
One therapist provided therapy for all participants recruited from two
of the three recruiting sites (in total seven participants). The other
    
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three therapists were recruited and trained in sequence and delivered
therapy to six participants (three, two and one, respectively). Overall
the 13 participants attended a median of five sessions (range 2–6).
Nine participants attended all six sessions, one attended five, one–
three sessions and two attended only two sessions.
All therapists reported that the manual was helpful to their work
and easy to use. Therapist confidence improved over time as reported
in supervision and was shown in the self- rated checklists.
Therapists were able to cover all topics within each session as
shown by the completed checklists following each session. The first
therapist (seven participants) reported for session three “often needed
more time to cover all the material whereas session six did not require
the full hour.” This was not reported by the rest of therapists. However,
all therapists found that most of the five weekly sessions were difficult
to be kept to 30 min, with the average duration of sessions recorded
being 40 min (therapist 1: 32; therapist 2: 46; therapist 3: 49; therapist
4: 27). Extension of the duration of the session was mostly necessary
when the carer was involved during the whole duration of the session.
Therapists reported challenges with arranging attendance to the
sessions, in particular, the initiation of treatment. In between sessions
practice (mostly drinking diaries) also proved challenging for some par-
ticipants. Support provided by carers was paramount in identifying the
most suitable environment for the session to take place, starting on
time, securing enough time for the session to be completed, as well as
provision of support for homework completion. Drinking diaries were
developed for each day having a different colour for each day. Each
day was divided into three parts defined by the three meals of the
day (breakfast, lunch and dinner) in an attempt to promote healthy
lifestyle. During the last part of each session, extensive demonstration
and advice of how to use the diaries were given.
3.2 | Fidelity to the manual
Forty- three of 68 delivered sessions were audio recorded and 32
(47%) sessions were scored by CK using the YACS II in order to as-
sess fidelity of treatment delivery to the manual. The sessions scored
were selected across all sessions recorded, from nine participants
(four participants declined to be audio recorded), from three partici-
pating therapists (none of the two sessions of the last therapist were
included, as only one was partially recorded). The median score for
sessions for frequency/intensity (quantity) of techniques used was
above the acceptable score of 4 (in 29 of 32 sessions). The median
score for how well (quality) techniques were implemented for all ses-
sions was above 4 for the majority of sessions (30/32), see Table 1. As
session 1 aimed to build therapeutic relationship, it was challenging
to evaluate it using the YACS II. Regarding the techniques used and
assessed by the YACS II, “role playing” was used only during 5 of 32
therapy sessions with a median quality score of 4.
4 | DISCUSSION
As people with intellectual disability live in the community, they are
subject to peer pressure and are vulnerable to alcohol promotion
strategies such as low price for alcoholic beverages similarly to the
rest of the population. Therefore, alcohol misuse needs to be recog-
nized early and people at risk should receive advice and early sup-
port in order to modify their drinking and reduce the risk of physical,
psychological or social harms. Furthermore, during the screening for
this study, the authors found that a small number of the potentially
eligible participants were not only misusing alcohol but were alcohol
dependent (to that effect excluded for the current study). However,
none of them had received treatment tailored to their needs by either
specialist substance misuse services or specialist intellectual disability
services. Ensuring that health and social care professionals including
third sector and community support workers have the necessary ma-
terials to help those who might develop an alcohol disorder is essential
for secondary prevention.
The manual reported in this study brings the principles of a widely
used public health intervention for alcohol misuse to people with in-
tellectual disability. The manual was tested in a feasibility RCT, and
hence, there is no definitive evidence yet that the intervention itself
is effective or cost- effective. The feasibility study showed although
that the intervention as described in the manual can be delivered to
Therapists 1st 2nd 3rd
Mean YACS II
quantity (range)
Mean YACS II
quality (range)
Participants with
scored sessions (N)
5 (7) 3 (3) 1 (2)
Total sessions scored
(N*)
17 (37) 13 (17) 2 (12)
Session 1 0 2 0 3.2 (3.0–3.4) 3.2 (3.1–3.3)
Session 2 4 3 1 4.3 (3.0–5.6) 4.9 (3.3–5.6)
Session 3 3 3 1 4.9 (4.0–5.5) 5.2 (4.9–5.7)
Session 4 4 3 0 5.0 (4.2–6.2) 5.2 (4.2–6.0)
Session 5 3 1 0 5.0 (4.6–5.3) 5.0 (4.6–5.2)
Session 6 3 1 0 5.3 (4.1–5.9) 5.8 (5.3–6.3)
N, number of participants seen by therapist; N*, total number of sessions delivered; YACS, yale adher-
ence and competence scale.
TABLE1 Characteristics of sessions
scored
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community- based populations by suitably qualified professionals with
minimal training and support, and thus could be incorporated into
routine NHS care or non- statutory services. The manual, as a stand-
alone product, is a practical resource that can be useful for NHS prac-
titioners and third sector workers in delivering treatment for alcohol
misuse to people with intellectual disability or those with cognitive
and social communication impairments resulting from other disorders.
A report by the Treatment Fidelity Workgroup of the NIH Behavior
Change Consortium (Bellg et al., 2004) recommended five broad areas in
which fidelity could be enhanced during clinical trials: study design, train-
ing of treatment providers, delivery of treatment, receipt of treatment
and enactment of treatment skills. Specific suggestions to avoid threats
to fidelity included the following: development of a treatment manual
that includes information about treatment dose (length and number of
contacts) and specific content of each contact; standardisation of ther-
apist training; monitoring the intervention with fidelity checklists; and
inclusion of strategies to measure the recipient’s comprehension and
enactment of the intervention principles addressed. Hence the develop-
ment of a treatment manual is the first step in ensuring fidelity.
In the EBI- LD study, the authors followed Bellg et al., (2004)
suggestions. The authors have used a standardized tool to assess
fidelity scored by one rater, given that the pilot assessments per-
formed by two raters although aligned, they were not exactly the
same. The authors paid particular attention to the fidelity of the ses-
sions provided in line with the manual, with a priority on covering
all topics and aspects in each session, and less emphasis on the du-
ration of the session. The authors encouraged therapists to extend
the duration of the sessions if required in order to cover all rele-
vant topics, rather than diverting from the manual. Certain sessions
were more challenging to be delivered within the allocated time,
particularly session 3. In between the sessions practice, in the form
of homework was challenging for some participants. This might be
due to the frequency of drinking of the people participating in this
study, which was less than daily for the majority of them. This raises
the question of how essential completion of daily drinking diaries
for this population might be. Nevertheless, support and encourage-
ment by both therapist (with in- session practice) and carer were
considered essential, supporting the importance of involving car-
ers in therapy (National Institute for Health and Clinical Excellence
(NICE), 2010). Adjustment of the session duration was required to
enable the involvement of the carer in the session (Hassiotis et al.,
2012). Therefore, a duration of 40 min would be recommended in
clinical practice to enable therapists to provide all aspects of the
intervention. Despite the fact that drinking diaries are considered
an essential part of CBT interventions in alcohol use disorders, in
particular, in the effort to regaining control over drinking as well as
monitoring treatment compliance and progress (Kouimtsidis et al.,
2007), if this manual were to be rolled out, drinking diaries should
not have such an essential role and should be replaced by a simpler
way of monitoring of and reflecting on drinking events during the
previous week.
A key focus in this feasibility study was on how to ensure treat-
ment fidelity. Given the small sample size of the feasibility study, no
special measures were taken to train raters of the YACS II, nor for
the reduction of rater drift (Mulsant et al., 2002). This is a limita-
tion of the study. Nevertheless, the YACS II proved a useful tool for
the evaluation of session content, with the exception of session 1.
It showed that therapists found certain aspects challenging, for ex-
ample role playing. This is in contrast with previous work (McCusker
et al., 1993), which indicated that role playing was one of the suc-
cessful strategies for behavioural change. This could be attributed
to the fact that the manual did not emphasize the importance of
role play and it was not highlighted in the training as a core CBT
technique—this is a limitation which should be addressed in future
research and also in the use of the manual in clinical practice. Other
techniques or interventions such as identification of high- risk situa-
tions, past or future were difficult to incorporate in the early sessions,
as the focus of those sessions was mostly on motivational enhance-
ment. Motivational techniques proved relevant across all sessions.
A session specific, rather than intervention specific adaptation of
the YACS II, is recommended for use in future trials. Accordingly,
motivational interviewing items from the YACS II should be used to
rate the first three sessions and CBT items for sessions 4 and 5. The
combined (motivational interviewing and CBT items) tool, used in
this study, could also be used for the booster session.
ORCID
Christos Kouimtsidis http://orcid.org/0000-0001-9975-2955
Katrina Scior http://orcid.org/0000-0002-4679-0090
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How to cite this article: Kouimtsidis C, Scior K, Baio G, Hunter
R, Pezzoni V, Hassiotis A. Development and evaluation of a
manual for extended brief intervention for alcohol misuse for
adults with mild to moderate intellectual disabilities living in
the community: The EBI- LD study manual. J Appl Res Intellect
Disabil. 2017;00:1–7. https://doi.org/10.1111/jar.12409
... auch z.B. Henderson-Laidlaw & Hall, 2020;James, 2017;Kouimtsidis et al., 2017;Ratti et al., 2016;Unwin, Tsimopoulou, Kroese & Azmi, 2016). In Deutschland wurden darüber hinaus mehrere Studien zur medizinischen Versorgung von Menschen mit IM durchgeführt. ...
... Participants received care from three community intellectual disability networks of services in England. EBI was adapted to the learning style of participants in terms of more but shorter sessions than regular EBI and materials to use during sessions [34]. EBI consisted of techniques of motivational interviewing techniques and cognitive behavior therapy and was presented during five weekly 30-min sessions and 1-h follow-up sessions after 3 weeks. ...
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