INTERVENTION MANUAL
7.2 CONTENT OF AN INTERVENTION MANUAL
7.2.3 Section 3: Procedure
The third section of the intervention manual contains a description of the procedure to be followed when delivering the intervention. The description details the steps for carrying out the activities planned for each intervention session or module, in the selected mode; it also provides scripts for the information (content, treatment recom- mendations) to be relayed to clients. The detailed description of the procedure
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clarifies to interventionists what they are exactly to say or do, how, where, and when.
It facilitates the implementation, with fidelity and consistency across clients, of stan- dardized or tailored interventions.
7.2.3.1 Standardized Interventions
For standardized interventions, the procedure is described for each session, and the respective steps are presented in a sequence reflecting common logic and the propo- sitions of the intervention theory. Common logic suggests that the sessions are orga- nized into introduction, main part, and conclusion. The intervention theory proposes the sequence for providing the components and activities within the main part of the sessions. The theory indicates if some components and activities are considered foundational or building blocks for providing other components and activities. In the example of stimulus control therapy, it is essential to first give sleep education with an emphasis on factors that control sleep (i.e. sleep drive and biologic rhythms) because some of the stimulus control therapy instructions or treatment recommen- dations (e.g. avoid napping late in the day and in the evening) are based on these factors (e.g. napping in the evening interferes with sleep drive).
TABLE 7.2 Resources needed to deliver the first session of stimulus control therapy.
Category Items
Staff Connect with staff to ensure the appropriate room is reserved, the appropriate amount of objects is available
Environment Medium-sized room allowing:
• Seating of a group of four to eight clients in a roundtable format to promote group discussion
• Good lighting to make it easy to read written information
• Comfortable temperature
• Good acoustics and minimal external noise to make it easy to hear, particularly for clients with hearing problem, and to reduce distraction.
Objects: Folders to distribute to clients containing:
Sleep education and hygiene booklet List of stimulus control instructions
List of activities to be completed by clients once they identify quiet activities in which to engage when they cannot sleep
Daily sleep diary forms for clients to document the wake-up time agreed upon and to be followed consistently
Schedule for the remaining intervention sessions
Form graphing the clients’ sleep onset latency, wake after sleep onset, total sleep time, total time in bed, and sleep efficiency reported at baseline; two copies of the form are prepared; the interventionist keeps one and gives one to the client for review during the session
Group session log for interventionist to take clients’ attendance at the session
Pens for clients to take notes as needed and to write down
information (e.g. list of quiet activities) discussed during the session
For each session, the step-by-step procedure is described for the introduction, main part, and conclusion. The steps are portrayed in specific actions to be performed by the interventionist and the clients.
Introduction
The introductory steps of the first intervention session vary from those of remain- ing sessions. In the first session, the initial steps entail general introductions and provision of an overview of the intervention. General introductions aim to get the interventionist and clients to know each other. The interventionist introduces herself or himself to clients, stating her or his name and role in the delivery of the intervention. Clients are asked to introduce themselves, stating their first name only to maintain confidentiality in group sessions; to share briefly their experi- ence with the health problem; and to express their expectations of treatment.
This first step serves as an “ice-breaker” and fosters the development of a rapport between the interventionist and the client in interventions given on an individual basis; in addition, it promotes the development of a supportive relationship and cohesion among clients in interventions given in a group format. The interven- tionist can point to similarity in clients’ experiences as an additional means for promoting group rapport and cohesion.
The second step consists of providing an overview of the intervention. The inter- ventionist follows a script to explain the intervention’s goals, components, and dose (i.e. number and duration of sessions), as well as the clients’ responsibilities related to engagement in the intervention’s activities and enactment of treatment recom- mendations. The interventionist may emphasize the importance of clients’ enact- ment of treatment recommendations in experiencing beneficial changes in the health problem. The information relayed in this second step helps clients understand the rationale and the general nature of the intervention, as well as what is expected of them. Clarification of expectations at the beginning of the intervention delivery reduces the likelihood of misinterpretation of what the intervention is set to achieve, and consequently a sense of disappointment and dissatisfaction with the interven- tion, which lead to withdrawal and nonadherence to treatment.
In subsequent sessions, the introductory steps may include: brief introductions if the group membership has changed; an ice-breaking exercise to further enhance rap- port or cohesion among group members; self-completion of a brief questionnaire assessing clients’ experience of the health problem or perception of progress toward achieving individual goals (the responses to the questionnaire can be discussed later in the session if planned); or general but brief discussion of clients’ ability to apply the treatment recommendations, which serves as a leeway for a review of the recom- mendations and challenges in their implementation and as a strategy for allowing clients to express individual concerns. The fourth section of the manual (adapta- tions) describes the principles and methods for addressing individual concerns.
Main Part
The main part of the intervention session consists of the specific actions that repre- sent the application of the intervention components and activities planned for the session. The actions are presented in the sequence proposed in the intervention theory. Each step is specified in a statement that identifies who (interventionist or client) is to do what (action) in what way (how). It may be useful to indicate the time allotted for each component or activity within each session. A time range
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(e.g. 15–20 minutes) is specified to accommodate for discussion of clients’ concerns, while ensuring coverage of all content and performance of all activities planned for the session.
Each step is described in a clear statement of the action to be performed and the qualifiers of the performance of the action, followed by a script clarifying the information to be relayed to clients. The statement may begin with a verb that best reflects the action to be performed. The qualifiers identify the way in which the action is to be performed. It may be useful to mention proscribed behaviors following the description of the action, and to highlight actions that can be modified, if necessary, to meet clients’ individual concerns or life circumstances. The modifications are described in the fourth section of the manual.
The script is written in simple, nontechnical language that is easy to understand by clients with different levels of language proficiency or literacy. The scripted sen- tences are short, presenting one idea or point at a time. The sentences are structured in a way that makes it easy for clients to grasp the content and to follow through; that is, the sentences are prepared in spoken language. For example, the statement of the first introductory step, general introductions, of the stimulus control therapy is described as follows:
Step 1 – Introduce (action) self as therapist (who)
•
State interventionist’s first name.•
Identify role as being responsible for facilitating the sessions (qualifier).•
Review interventionist’s professional qualifications and relevant experience.Note: proscribed behavior: do not disclose private personal information.
Script:
•
I would like to welcome you to this first session.•
My name is Jane. I am the sleep therapist. I have personally experienced insomnia and understand what you are going through.•
I will facilitate the group sessions and work with you throughout the sessions of this treatment.Conclusion
The concluding steps relate to termination of the session. These steps include: (1) recapping the main points discussed during the session; (2) reviewing the treatment recommendations that clients are expected to enact in daily life; (3) explaining assign- ments or homework or treatment recommendations for clients to do in the time interval between sessions (e.g. setting goals, completing daily sleep diary, applying the stimulus control instructions); and (4) reminding them of the logistics of the next session (i.e. date, time, location). In the last session of health interventions given in multiple sessions or at the end of the session of interventions given in a single session, the concluding steps involve: informing clients of the completion of the intervention, inquiring about questions or concerns clients may have about the intervention, and highlighting the activities or treatment recommendations they are expected to con- tinue carrying out, if necessary, in daily life.
Table 7.3 provides excerpts of the manual for delivering the stimulus control therapy for insomnia, for illustrative purposes. The excerpts were selected to repre- sent the introduction, main part, and conclusion of the first and second sessions of a standardized intervention.
TABLE 7.3 Excerpts of manual for delivering sessions 1 and 2 of stimulus control therapy.
Session 1
Introduction (15–20 minutes)
Ask if clients have any questions and address them as needed.
Main Part: (60 minutes)
Inform clients of the next topic of presentation: sleep hygiene, using the following script as a guide:
Now that we have discussed what is insomnia, how it starts, and how it keeps going; we will now discuss what can persons with insomnia do to sleep better.
In general, persons with insomnia have to get rid of habits that hurt sleep and develop habits that help sleep.
I will present recommendations that help you be prepared to make the most of your night’s sleep.
Explain where clients can find information about these recommendations and what clients are expected to do with these recommendations, using the following script as a guide:
You will find information on these recommendations in the booklet available in your folder.
I would like you to read the booklet when you go home. Then see which of these recommendations are appropriate to you, and start applying the appropriate recommendations tonight.
Review each recommendation by explaining what it is about and how it contributes to good sleep, using the following script as a guide:
Let us review the recommendations. I will explain what each one is about and you can follow through in the booklet.
The first recommendation is: develop a regular schedule of daytime activity or exercise.
Activity or exercise may help improve the quality of your sleep.
Select the type of activity or exercise that you like/enjoy doing, such as walking, gardening, or swimming.
Do the activity or exercise on a regular basis.
It is preferable to schedule the activity during the day, late afternoon, or early evening but not immediately before bedtime. This is because activity or exercise stimulates the body and makes falling asleep soon afterward difficult.
After reviewing all recommendations and responding to clients’ questions, inform clients of the next topic of presentation: stimulus control instructions, using the following script as a guide:
Now, we will discuss the stimulus control instructions.
There are six instructions.
Explain where clients can find information about the instructions, using the following script as a guide:
You have a list of these six instructions in your folder.
You may want to pull this list out and follow through while I explain what each instruction is about.
Discuss each instruction, using the following script as a guide:
I am going to explain each of the six instructions, but I have to emphasize that all are important.
The first instruction states: go to bed only when you are sleepy.
It is often the case that persons with insomnia start thinking about bedtime right after dinner. They go to bed too early just to be sure they fall asleep at the desired time. However, since they are not sleepy, they are awake in bed. They start to do things they hope will bring on sleep, like reading, watching TV or just resting.
These things seem logical solutions to the sleep problem. But they are counterproductive and contrary to what persons with insomnia need to improve sleep.
So, persons with insomnia, like you, spend a lot of time in bed awake. This gets you to associate the bed and bedroom with wakefulness or being awake, rather than signals for sleepiness.
It does not pay to go to bed when you are not sleepy. Therefore, you need to stay up until you are sleepy and then go to bed.
It is helpful that you start to be aware of when you actually feel like you are getting sleepy. You can start to develop a sense of what sleepiness feels like and use that as a signal to go to bed rather than the clock time.
There are signals that tell you that you are sleepy, such as yawning, heavy eyelids, and rubbing your eyes.
You need to pay attention to these signals and if you feel them, then this means you are sleepy. It is only at the time that you feel sleepy that you go to bed with the intent to sleep.
Have clients identify signals or cues for sleepiness; ask each client to think about the signals they feel when sleepy and state them, using the following script as a guide:
Now, let us see how each one of you know that you are sleepy.
I would like you to think of the time you feel sleepy; what signals, of the ones I just listed or other ones you may notice, tells you that you are sleepy?
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7.2.3.2 Tailored Interventions
The procedure section in the manual of tailored interventions is comparable to the one described for standardized interventions in terms of organization and detailing the steps. For tailored interventions, there are some procedural variations.
The introductory steps are altered based on the number of clients scheduled to receive the intervention (e.g. brief general introductions of the interventionist and the client is done in individual session) and the mode of delivery (e.g. no introduction is required if clients are expected to access and self-complete web-based interven- tion modules).
In the main part, an overview of the principles, algorithm and decision rules guiding the tailoring process is provided. This is followed by a description of the key activities in the tailoring process. These delineate the specific actions to be done to TABLE 7.3 (Continued)
Once all clients identify their signals for sleepiness, summarize the discussion as follows:
You can see that the signals for sleepiness differ from one person to the other.
So, you need to monitor yourself, starting tonight, to learn more your personal signals for sleepiness.
Remember that when you feel these signals, you know that you are sleepy. You go to bed only when you feel sleepy.
Conclusion: (10 minutes) Assign homework as follows:
I am going to ask you, starting tonight to: (1) read the information in the booklet and start following the recommendations that are applicable to you; (2) follow the six stimulus instructions we discussed; and (3) continue to complete the sleep diaries every day. The diary is important to monitor your sleep.
Session 2
Introduction: (20–30 minutes)
Start discussion on implementation of the six stimulus control instructions, using the following script as a guide:
Let us discuss how the last two weeks went.
Overall, were you able to carry out the six stimulus control instructions? How tough was it?
Have clients comment about their overall experience implementing the instructions; ask clients to share their experience, one at a time, whether “good” or “bad.”
Once all clients give their comments, remind them:
I have to remind you that you are learning new habits and you are performing new behaviors.
These behaviors must be practiced consistently over the treatment period to work and to become routine.
Main part: (45–50 minutes)
Engage clients in a discussion of each stimulus control instruction, with a focus on getting clients to think about their behaviors and to link their performance of the behaviors with the quality and quantity of their sleep, using the following script as a guide:
Now, let us see how you did on each instruction.
How about the first instruction: Go to bed only when you are sleepy?
Use the following questions as prompts for discussion: Were you able to follow this instruction? Were you able to know that you are sleepy? That is, did you pay attention to how you feel when you get sleepy?
Tell me how you feel when you get sleepy.
Have clients state the signals for sleepiness they noticed.
Conclusion: (5–10 minutes) Remind clients that:
This is the last session of the treatment.
They have to (1) follow the six stimulus control instructions, for the treatment to work, (2) monitor their sleep, and (3) continue doing the things or behaviors that helped having a good night sleep and to eliminate those that led to poor night sleep.
assess tailoring variables, to determine the client’s level on the variables, and to select the interventions or components that are consistent with the client’s level of the tai- loring variables as specified in the algorithm.
The last activity entails the actual delivery of the selected intervention options or components. The procedure for implementing each possible intervention or compo- nent is detailed as described for standardized interventions. The following is a generic account of the specific actions to be performed in carrying out the first three activities in the tailoring process:
Activity 1: Assess tailoring variables
•
Inform clients that they have to complete a questionnaire about some charac- teristics, which is necessary to guide the delivery of the treatment.•
Remind clients that there are no right or wrong answers to the questions and that the interest is in learning about their condition or perspective.•
Explain that clients take time (i.e. no rush) to complete the questionnaire, and ask for clarification; interventionist can respond, as needed.•
Administer the questionnaire in the selected method.•
Get the completed questionnaire.Activity 2: Determine clients’ level on the tailoring variables
•
Review the clients’ responses to items assessing each variable.•
Assign appropriate score to each response, following the rules preset for the items.•
Compute the total score for the multi-item scale assessing each variable, fol- lowing the preset rule.•
Document the total scores for all tailoring variables on the respective forms.•
Interpret the clients’ total scores on the tailoring variables, by comparing the scores to normative values or cutoff values preset for the respective scales; this will determine the clients’ level on the tailoring variables.Activity 3: Select the interventions or components responsive to clients’ levels on the tailoring variables
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Have the algorithm guiding the tailoring process available.•
Follow the instructions, as specified in the algorithm, to identify the interven- tions or components to provide to clients.•
Inform clients of the selected interventions.•
Provide the selected interventions as described.For tailored interventions given via technology, the manual provides the over- view of the tailoring algorithm, the scripts of the information to be relayed to clients and the assignment/homework/treatment recommendations that clients are expected to carry out. The application of the tailoring algorithm is embedded in the program- ming for assessing the tailoring variables, determining clients’ levels on the variables, selecting and sending messages informing clients what interventions or components’, described in the modules, to access or what activity to engage in and enact.
The scripted information is incorporated in the modules accessed by clients. The suggestions for preparing the information in simple language, short sentences