Transforming substance misuse services through computer-assisted therapy: Lessons learnt from a partnership between Breaking Free Group and CGL

Transforming substance misuse services through computer-assisted therapy:
Lessons learnt from a partnership between Breaking Free Group and CGL
Stephanie Dugdale
Research Associate, Breaking Free Group
© 2014 Breaking Free Online Limited. All rights reserved. www.BreakingFreeGroup.com

© 2016 Breaking Free Group. All rights www.BreakingFreeGroup.com
Medical Research Council
(Craig et al., 2008)
Feasibility
Evaluation
Implementation
Developmen
t

© 2016 Breaking Free Group. All rights www.BreakingFreeGroup.com
• Online treatment and recovery programme for substance use and co-morbid mental
health difficulties.
• Centred on the Lifestyle Balance Model (Davies et al., 2015)
Breaking Free Online

© 2015 Breaking Free Online Limited. All www.BreakingFreeGroup.com
• Growing evidence base of both qualitative and quantitative research (Elison et al., 2013,
2014a, 2014b, 2015a, 2015b; Dugdale et al., 2016a, 2016b)

Aims
• To investigate the ongoing implementation process of BFO within CGL.
• To explore how the relationship between CGL and BFO has facilitated the normalisation
of the programme as a treatment option throughout the organisation.

Method
Quantitative Qualitative

Method
Quantitative
• Quantitative measures of:
- substance dependence (SDS: Gossop et al., 1995);
- mental health (PHQ: Kroenke, Spitzer, Williams & Löwe 2009);
- quality of life (WHOQoL: Skevington, Lotfy, & O’Connell, 2004); and
- recovery progression (RPM: Elison, Davies & Ward, 2016).

Male = 292 Female = 274566
Participants

56.54
15.55
27.92
Programme
Alcohol Alcohol and drugs Drugs

4.47
12.2
7.72
35.77
15.45
0.41
2.03
12.21
4.88
0.82
4.07
Substances
Amphetamines Cocaine Crack Heroin
Marijuana Methamphetamine Tobacco Prescribed medication
Substitute medication Club drug Novel psychoactive substance

Variable
Initial score
Mean (SD)
Current score
Mean (SD)
z r
WHOQoL 9.15 (4.3) 10.11 (4.74) -5.60** 0.24
RPM 38.03 (13.68) 33.79 (15.82) 7.20** 0.30
PHQ-4 6.69 (3.5) 5.30 (3.74) 4.73** 0.30
SDS alcohol 9.12 (4.02) 7.18 (4.32) 10.04** 0.46
SDS drug 9.38 (3.94) 7.36 (4.09) 5.32** 0.46
Results

0
20
40
60
80
100
120
140
Moderate (<21 unit/week) Hazardous (21-50 units/week) Harmful (50+ units/week)
Alcohol Use - Men
Initial Current

0
20
40
60
80
100
120
Moderate (<14 units/week) Hazardous (14-35 units/week) Harmful (35+ units/week)
Alcohol Use - Women
Initial Current

Method
Qualitative
• Semi structured interviews were conducted with a total of 61 staff, peer mentors and
service users.
• Thematic analyses were conducted over three separate studies based on models derived
from health psychology and implementation science:
1) Implementation of Breaking Free Online using Roger's diffusion of innovation theory
2) The continued adoption of Breaking Free Online
3) Conceptualising the impact of peer mentoring on the ability of peer mentors to maintain their
recovery

Study 1:
Implementation of Breaking Free Online using Roger's diffusion of innovation theory
• Introducing a novel digital innovation into an
existing healthcare structure can be seen as
‘disruptive’ (Edmondson et al., 2001).
• This may affect adoption and uptake of the
innovation.
• Diffusion of Innovations theory (Rogers, 1995,
2002, 2004) was used to conceptualise the
spread of BFO throughout CGL services.

• A lack of IT resources and competing demands on staff time were a barrier to effective
implementation of BFO.
• Benefits of the programme included being able to interact with the clinical content and
the option to access the programme at home.
• Participants realised the potential of BFO within CGL and believed that it fit with the
ethos of the company – continued adoption:
“Within the next year I’d like to see us
with lots of volunteers and peer
mentors who have done the
programme who want to then
facilitate every client coming in”.
“Well, for things to change, people
need to change, mindsets need to
change, so it’s just getting over
those first hurdles”.
Study 1:
Implementation of Breaking Free Online using Roger's diffusion of innovation theory

Study 2:
The continued adoption of Breaking Free Online
• Following the previous study, CGL now has a
nationwide licence to deliver BFO.
• Diffusion can be seen to have occurred
throughout services on a macro organisational
level.
• Need to investigate whether the programme
has become integrated as part of routine
clinical practice: Normalisation Process Theory
(Murray et al., 2010).
Coherence
Cognitive participation
Collective action
Reflexive monitoring

Study 2:
• Staff recognised the advantages of BFO over ‘traditional’ group
therapy, including the option to use the programme as a means
of self-help:
• The ability to open an account through the online case management system made it easier
to promote and access BFO.
• Service users may benefit from having tangible
evidence to demonstrate their recovery:
“It’s about people
educating themselves,
and taking charge of
their own recovery.”
“You can monitor your
progress, and you can get a
certificate. As a service user,
for you to accomplish
something and actually see
it in black and white, it's
brilliant”

Study 2:
• Several staff commented on their preference for group therapy, and thought that BFO
should be used in conjunction with this:
• Some staff were unsure of their role in implementing BFO, and differences were reported
between services and staff with regard to their approach towards implementation.
• Peer mentors were often given the
responsibility of running BFO:
“A peer mentor's recovery journey will
be a lot more recent. So, I think it's
vital that peer mentors lead on this.”
“It can't take over what you get, you know, this
therapeutic work that you have with your key
worker, I think you always have to have that. But
in addition to that, I think it's a good idea, yeah”

Study 3:
Conceptualising the impact of peer mentoring on the ability of
peer mentors to maintain their recovery
• Peer mentors were delivering BFO within CGL,
however some evidence suggests that this role
could actually lead to relapse (Colon et al.,
2010; Tober et al ., 2013)
• The Transtheoretical Model (Prochaska et al.,
1992) can conceptualise peer mentors’
recovery journeys through services and allow
identification of facilitators to recovery or
relapse.
Precontemplation
Contemplation
Preparation
Action
Relapse
Maintenance
Recovery Termination

Study 3:
• Participants perceived the peer mentoring role as
beneficial to themselves and their recovery:
• Peer mentors also noted the benefits of this role for others:
• However, there was some initial trepidation
surrounding their new roles.
“It’s given me a reason to
get up every morning. It’s
given me a purpose.”
“The help peer mentors gave me when
I was giving up full blown addiction, I
just wanted to…yeah, I wanted to do
what they do , I want to help people.”

Study 3:
• Through their new role, peer mentors were able to regain control over their behaviour and
develop into a ‘self’ distinct from their previous substance using identity.
• This role facilitated maintenance of recovery by creating
opportunities to build recovery capital.
• BFO was identified as one such form of recovery capital, which was used to remind peer
mentors of key psychosocial techniques that could be used to maintain their recovery.
“The life I had and the life
I've got now... they're
completely different”
“If I'm having a bad day, I can just go online and just do some work
on Breaking Free for a few hours, and I feel better afterwards. As
I said, it's one of the things that keeps me in recovery.”

Summary
• BFO offers an alternative to traditional interventions by utilising online technology as a
delivery mode.
• The principal focus when designing such healthcare
interventions should be establishing clinical
effectiveness
• Implementation analysis is also key, and health
psychology theory may help to structure these investigations.
• This evidence has been used to guide further research and developments to the
programme.
Feasibilit
y
Evaluation
Implementation
Development

References
Colon, R. M., Deren, S., Guarino, H., Mino, M., & Kang, S.-Y. (2010). Challenges in recruiting and training drug treatment patients as
peer outreach workers: A perspective from the field. Substance Use & Misuse, 45(12), 1892-1908.
Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., & Petticrew, M. (2008). Developing and evaluating complex
interventions: the new Medical Research Council guidance. BMJ, 337, a1655.
Davies, G., Elison, S., Ward, J., & Laudet, A. (2015). The role of lifestyle in perpetuating substance dependence: A new explanatory
model, The Lifestyle Balance Model. Substance Abuse, Treatment, Prevention and Policy, 10(2).
Dugdale, S., Elison, S., Davies, G., Ward, J., & Dalton, M. (2016). A qualitative study investigating the continued adoption of
Breaking Free Online across a national substance misuse organisation: Theoretical conceptualisation of staff perceptions. The
Journal of Behavioral Health Services and Research, 1-13.
Dugdale, S., Elison, S., Ward, J., Davies, G., & Dalton, M. (2016). Using the Transtheoretical Model to explore the impact of peer
mentoring on peer mentors’ own recovery from substance misuse. Journal of Groups in Addiction and Recovery.
Edmondson, A. C., Bohmer, R. M., & Pisano, G. P. (2001). Disrupted routines: Team learning and new technology implementation in
hospitals. Administrative Science Quarterly, 46(4), 685-716.
Elison, S., Davies, G., & Ward, J. (2015a). An outcomes evaluation of computerised treatment for problem drinking using
Breaking Free Online Alcoholism Treatment Quarterly, 33(2), 185-196.
Elison, S., Davies, G., & Ward, J. (2016). Initial Development and Psychometric Properties of a New Measure of Substance Use
Disorder “Recovery Progression': The Recovery Progression Measure (RPM).Substance use & misuse.
Elison, S., Davies, G., & Ward, J. (2015b). Sub-group analyses of a heterogeneous sample of service users accessing computer-
assisted therapy (CAT) for substance dependence using Breaking Free Online. Journal of Medical Internet Research, 2(2), e13.
Elison, S., Humphreys, L., Ward, J., & Davies, G. (2013). A pilot outcomes evaluation for computer assisted therapy for
substance misuse- An evaluation of Breaking Free Online. Journal of Substance Use, 19(4), 1-6.

References
Elison, S., Ward, J., Davies, G., Lidbetter, N., Dagley, M., & Hulme, D. (2014). An outcomes study of eTherapy for dual diagnosis
using Breaking Free Online. Advances in Dual Diagnosis, 7(2), 52-62.
Elison S, Ward J, Davies G, Moody M. (2014b). Implementation of computer-assisted therapy for substance misuse: A qualitative
study of Breaking Free Online using Roger's diffusion of innovation theory. Drugs and Alcohol Today, 14(4), 207-218.
Gossop, M., Darke, S., Griffiths, P., Hando, J., Powis, B., Hall, W., & Strang, J. (1995). The Severity of Dependence Scale (SDS):
Psychometric properties of the SDS in English and Australian samples of heroin, cocaine and amphetamine users. Addiction,
90(5), 607–614.
Kroenke, K., Spitzer, R. L., Williams, J. B., & Löwe, B. (2009). An ultra-brief screening scale for anxiety and depression: the PHQ-4.
Psychosomatics, 50(6), 613-621.
Murray, E., Treweek, S., Pope, C., MacFarlane, A., Ballini, L., Dowrick, C., . . . O'Donnell, C. (2010). Normalisation process theory: a
framework for developing, evaluating and implementing complex interventions. BMC medicine, 8(1), 63.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors.
American Psychologist, 47(9), 1102-1114.
Rogers, E. (1995). Diffusion of innovations. Simon and Schuster.
Rogers, E. (2002). Diffusion of preventive innovations. Addictive Behaviors, 27(6), 989-993.
Rogers, E. (2004). A Prospective and Retrospective Look at the Diffusion Model. Journal of Health Communication, 9(sup1), 13-19.
Skevington, S. M., Lotfy, M., & O’Connell, K. A. (2004). The World Health Organization’s WHOQOL-BREF quality of life assessment:
Psychometric properties and results of the international field trial. A report from the WHOQOL group. Quality of Life Research,
13(2), 299–310.
Tober, G., Raistrick, D., Fiona Crosby, H., Sweetman, J., Unsworth, S., Suna, L., & Copello, A. (2013). Co-producing addiction
aftercare. Drugs and Alcohol Today, 13(4), 225-233.

Stephanie Dugdale
Research Associate
Email: sdugdale@breakingfreegroup.com
Phone: +44 (0) 161 834 4647
Website: www.breakingfreegroup.com
Contact details

Transforming substance misuse services through computer-assisted therapy: Lessons learnt from a partnership between Breaking Free Group and CGL

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Transforming substance misuse services through computer-assisted therapy: Lessons learnt from a partnership between Breaking Free Group and CGL