For more information, see Gilchrist et al.10 Some text in this chapter has been reproduced with permission from Gilchrist et al.10 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
Aims
To iteratively adapt the ADVANCE group intervention for remote digitally supported delivery (ADVANCE-D).
Methods
We followed an iterative methodology using a person-based approach,167,168 and mHealth development framework169 to adapt ADVANCE, involving:
- Conceptualisation. Scoping reviews of existing literature and emerging guidance on delivering psychosocial interventions remotely and/or digitally were undertaken. We consulted key professionals from criminal justice, substance use and IPV perpetrator and survivor organisations to identify remote delivery and risk management practices.
- Formative research. Multiple rounds of consultations with key stakeholders: staff from substance use services, two Learning Alliances, men who used substances and IPV victims/survivors to ensure their views and experiences were grounded in adaptations of proposed approaches and materials. PPIE were consulted on paper prototypes of website sessions and engagement contexts, and their experiences of using technology170 to understand how best to deliver and communicate digital content. Comments were fed back to developers and designers to inform the development of a digital prototype of the first three website sessions, including the avatar (digital coach). NGTs138 were used to reach consensus with both Learning Alliances (total of 20 key stakeholders) on the paper prototype, the digital/blended model options and the look and feel of the avatar and website practice sessions.
- Pre-testing. Individual video consultations took place with eight male substance use service users on the website prototype. Men were given a link to a test website and then were asked to share their screen and to ‘think aloud’ while using it. Their views about intervention flow, structure and design were recorded.168 Decisions on whether to modify were based on whether changes were likely to impact on acceptability, feasibility, persuasiveness, motivation, engagement168 using MoSCoW criteria.139
Results
Decisions on the adaptation
- Delivering perpetrator interventions during lockdown required an enhanced risk management approach.
- Digitally supported interventions required different engagement and retention strategies.
- Digital poverty and limited digital literacy across our population required provision of access to technology and digital data.
We identified 23 key studies on the barriers and facilitators to uptake, engagement and retention, satisfaction and therapeutic alliance with remote interventions/services. We developed selection criteria around digital literacy and included guided content, that is, coaching. We found 27 articles adapting interventions for remote delivery, all of which had migrated a face-to-face intervention to online delivery, for example, using Zoom (Zoom Video Communications, San Jose, CA, USA).
Rationale for blended delivery of website sessions and coaching calls
Stakeholder consultation at the pandemic’s outset highlighted that many criminal justice and substance use services decided not to migrate to online delivery opting for telephone check-in sessions instead, to monitor risk, safety, relationship status, substance use and signpost services/make necessary referrals. The ADVANCE team planned to translate the 12 group sessions into 12 interactive avatar-led digital sessions, using quizzes and film clips to provide educational material and strategies on managing risk to maximise and maintain engagement. Blended delivery was agreed as the best approach to deliver ADVANCE remotely, combining the website sessions and phone/video call coaching from a facilitator.171,172 As the team developed the website materials, it became clear that personal contact would be needed to promote use of the materials and monitor risk: a meta-review identified a lack of human support limited engagement with digital interventions,173 and computerised CBT had a smaller impact on depression and anxiety if service users did not receive regular support worker contact.174 Other studies have shown significant improvements in outcomes for programmes that combine self-directed support with coaching.175,176 In ADVANCE-D, facilitators make the website material available to participants at the appropriate time on the digital platform as part of service delivery. They then provide an individual coaching call to follow up with service users after they have completed each website session.
Rationale for video groups
Over time, services became more confident that with appropriate risk management, video groups could be safely delivered. As exposing participants to emotive and potentially distressing material without offering support or challenging offence-supportive beliefs was considered a risk, website sessions were designed to build on the learnings from the video groups.
Addressing digital poverty
To address digital poverty,177–179 tablets with front-facing cameras with 4G connectivity and headphones were sent to men ready to use and research staff provided technology support. Monthly mobile data were contingent on attendance, and men who completed ADVANCE-D could keep the tablet. Women, who could view but not interact with the ADVANCE-D website content, were offered smartphones with mobile data, addressing the risk of their own phone activity being monitored or intercepted by the perpetrator and allowing them to view the safety messages for women.
Therapeutic alliance and group size
Online groups must pay attention to building therapeutic alliance and to group process.180 These can be developed through group agreements and structured formats to attenuate anxiety. Paying attention to social cues and signs of emotionality (facial expression, tone of voice or body language) and asking more questions than usual to clarify responses and reactions can help to build therapeutic alliance online.171 These techniques, as well as attending to group dynamics, giving equal time and attention to all members of the group and promoting positive, respectful communication, were built into the ADVANCE-D model and emphasised in training and integrity support meetings.
Studies of therapeutic groups, comprising 5–13 participants, suggests group size does not predict outcomes.181 Slightly smaller groups are more appropriate for participants with learning disabilities or behavioural problems or for CBT-based groups due to level of skills imparted.182 ADVANCE-D sought to recruit between 6 and 12 participants per group.
Participant risk and safety
Social distancing and lockdown resulted in extra challenges for IPV perpetrators, including mental illness.183 Thus, facilitators need to pay additional attention to participants’ emotional well-being, their substance use, their home living situation and note and act on any change in risk relevant factors.
Consultations with Drive, Caledonian and other IPV researchers184 emphasised the importance of a group agreement, including rules on not misusing technology (e.g. for illegal or abusive means), keeping cameras on to allow facilitators to gauge potential intoxication and substance use, personal identifying items (e.g. photos of children) to be out of range, and not attending/completing sessions intoxicated. Participants were asked to complete and join sessions in a private room where they could not be overheard and to use the headphones provided.
Check-outs, one-to-one coaching calls and specific ADVANCE-D materials, including the self-soothing boxes and relaxation techniques, were identified as strategies to help manage difficult thoughts or emotions. Consultations with Respect emphasised that scheduling times to complete website sessions with facilitators would encourage participant to refrain from substance use before/during a session.
The ISS workers completed the Domestic Abuse, Stalking, Harassment and Honour Based Violence Assessment (DASH)185 with women, and facilitators completed the Brief Spousal Assault Form for the Evaluation of Risk (B-SAFER)186 with men, to assess suitability and manage and mitigate risk, alongside regular supervision and four case management meetings between facilitators and ISS workers. The clinical risk lead provided integrity fortnightly support meetings online to all professionals to discuss ADVANCE-D content, group processes, online delivery, risk and safety management to support staff in their roles.187
ADVANCE-D
The content and underpinning theory remained the same as ADVANCE [WP3(i)]. ADVANCE-D includes: an individual session with a facilitator to set goals, develop a personal safety plan and increase motivation; a video group to prepare men for taking part; and six fortnightly video groups delivered by two trained facilitators. There are 12 weekly self-directed website sessions to recap and practice skills learnt in the video group sessions, each followed by a coaching call with facilitators to account for best practice in terms of monitoring and managing risk and safety and increasing skills and knowledge. A refresher session is offered 1 month after the last video group (Figure 14, Table 10).
| Video group session title | Session objectives |
|---|---|
| 1. Understanding abuse | Understand the aims of the groupUnderstand what IPA is and how substance use can affect such behavioursLearn new skills that can help in times of distressShift focus from managing your relationship to managing yourselfUnderstand how substance use affects self-regulationBe able to identify self-regulation and monitoring skills |
| 2. Handling challenges | Examine costs and pay-offs of being abusiveIdentify activating eventsHave improved self-awarenessUnderstand key aspects of IPA behaviours and how substance use affects themUnderstand the impact of IPA on women |
| 3. Difficulties in families | Recognise the impact of childhood experiencesBe able to identify the impact on children of witnessing IPABe able to identify the impact of parental substance use on childrenIdentify the strategies that lead to repeat or not repeatBe able to recognise and challenge relationship jealousyBecome aware of unhelpful automatic thoughts and core beliefs |
| 4. Times of distress | Recognise challenges to communication in relationships and when using substancesReduce abusive communication and increase respectful egalitarian communicationUnderstand what distress isLearn to manage mood and emotionsUnderstand how substance use affects distress |
| 5. Relating well | Identify high-risk situations for IPAIncrease skills for staying safeUnderstand the impact of behaviours in different relationships: substance-using relationship, non-substance-using partners, substance-using discordant relationshipsBe able to identify features and benefits of equal relationshipsBe motivated and capable of using respectful behaviours in relationships |
| 6. Planning to be better | Create and engage with positive social networksIdentify meaningful activities and positive behavioursSelect realistic positive goalsIdentify explicit positive life goalsDescribe new skills, identify strengths and progressIdentify positive resources to help maintain change |
| Website session title | Session objectives |
| 1. Introduction | Understand the aims of the sessionsUnderstand what intimate partner abuse (IPA) is and how substance use can affect such behavioursLearn new skills that can help in times of distress |
| 2. Managing myself | Shift focus from managing your relationship to managing yourselfUnderstand how substance use affects self-regulationBe able to identify self-regulation and monitoring skills |
| 3. Being a man | Examine costs and pay-offs of being abusiveIdentify triggering situationsHave improved self-awarenessPractise behavioural analysis |
| 4. Impact of IPA | Understand key aspects of IPA behaviours and how substance use affects themUnderstand the impact of IPA on womenContinue to practise behaviour analysis |
| 5. Children and parenting | Recognise the impact of childhood experiencesBe able to identify the impact on children of witnessing IPABe able to identify the impact of parental substance use on childrenAccept the past, build resilience and learn from mistakesIdentify the strategies that lead to repeat or not repeat |
| 6. Relating well | Promote respectful and equal behaviours in ongoing relationshipsGive up controlling behaviours within a relationshipBe able to recognise and challenge relationship jealousyBecome aware of unhelpful automatic thoughts and core beliefs |
| 7. Improving communication | Recognise challenges to communication in relationships and when using substancesReduce abusive communication and increase respectful egalitarian communicationDevelop a staying safe plan |
| 8. Dealing with distress | Understand what distress isLearn to manage mood and emotionsUnderstand how substance use affects distressUnderstand thinking errors and their impact |
| 9. Planning to be better | Identify high-risk situations for IPADevelop plans to manage high-risk situationsIncrease skills for staying safe |
| 10. Positive relationships | Understand the impact of behaviours in different relationships: substance-using relationship, non-substance-using partners, substance-using discordant relationshipsBe able to identify features and benefits of equal relationshipsBe motivated and capable of using respectful behaviours in relationships |
| 11. New future, people’s plans, positive activities | Create and engage with positive social networksIdentify meaningful activities and positive behavioursSelect realistic positive goalsIdentify explicit positive life goals |
| 12. Recap ‘what have we learnt’ | Describe new skills, identify strengths and progressIdentify positive resources to help maintain changeIdentify further referralsUnderstand where to reach help, support, follow-up and to say goodbye |
FIGURE 14 The ADVANCE-D model. Reproduced with permission from Gilchrist et al.6 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original text. (Figure not reproduced here; see the original article.)