Using the Behavior Change Technique Taxonomy v1 to conceptualize the clinical content of Breaking Free Online: a computer-assisted therapy program for substance use disorders

Node-link mapping

Node-link mapping is an intervention technique in which various aspects of functioning are visually represented. Node-link mapping provides the structure for BFO content based upon the theoretical model underpinning the program, the Lifestyle Balance Model (LBM: [40]). Node-link maps allow the individual to visualize how different aspects of their lives and functioning inter-connect. This shares some commonalities with case formulation approaches often used in CBT [41, 43]. Throughout the SUD sector, node-link mapping has been found to be an effective tool for those who experience co-morbid substance use and mental health difficulties. In particular, those with psychological difficulties reported more positive perceptions of health keyworkers when using node-link mapping in comparison to those who only received treatment as usual [44]. Further evidence suggests that participants who used node-link mapping techniques in addition to receiving treatment as usual reported significantly lower rates of opiate use compared to those who only received treatment as usual [45]. This approach also underpins ITEP as node-link mapping provides a simplified, structured and effective method to the delivery of psychosocial interventions, and has demonstrated increased patient satisfaction [46]. The LBM is presented in the format of a node-link map to complement treatment provision in line with the ITEP agenda endorsed by Public Health England.

Behavior change techniques which link to node-link mapping are information about antecedents, information about health consequences, salience of consequences, information about social and environmental consequences, and information about emotional consequences [5]. Node-link mapping in BFO uses psychoeducation as a means to conceptualize this process, therefore, the behavior change techniques contained within node-link mapping may also be contained within the technique of psychoeducation.

Psychoeducation

Psychoeducation consists of information about the links between various aetiological factors underpinning a given morbidity, in this case SUDs. Such factors may include environmental, cognitive, emotional, behavioral and lifestyle contributors to and consequences of SUDs and the ways in which these factors may be associated with clinical outcomes. Providing psychoeducation about the links between cognitive, emotional and behavioral factors has been demonstrated to be effective in reducing drinking frequency in service users dependent on alcohol [47], although research has demonstrated that participants who only receive psychoeducation reported significantly higher rates of drug use following intervention compared to those who received CBT [48]. However, this study also found that those who received psychoeducation still reported a significant reduction in drug use after the intervention compared with prior to receiving any support. This suggests that, despite its comparative weaknesses as a stand-alone intervention compared with CBT, psychoeducation is still a viable and clinically effective intervention for SUDs. The potential for using psychoeducation in conjunction with CBT techniques may also overcome any weaknesses of these therapies as stand-alone interventions. BFO utilizes psychoeducational resources alongside other psychosocial techniques, including CBT, to help service users understand their difficulties and the importance of taking positive action to address identified areas of difficulty within the LBM.

Components of the BCTTv1 which link to psychoeducation are information about antecedents, information about health consequences, salience of consequences, information about social and environmental consequences, and information about emotional consequences [5]. The relevant behavior change techniques contained within psychoeducation also inform node-link mapping and the personalized content contained within the nodes.

Motivational enhancement

Enhancing motivation to change is beneficial for SUDs as it increases treatment engagement and retention and can therefore improve outcomes [49]. Research has demonstrated that use of motivational enhancement therapy (MET) can lead to lower blood alcohol concentration [50], as well as reducing drinking frequency in service users with alcohol dependency and improving their general functioning, particularly social functioning [51]. This can be achieved through enabling the individual to explore or recognize a problem and helping them to develop an action plan to overcome this [52].

Rohsenow and colleagues [53] found that in 165 cocaine dependent service users with particularly low initial motivation to engage in treatment, MET resulted in decreased substance use and a reduced rate of relapse at one year follow-up. However, it was also found that those with initially high motivation did not reduce their substance use intake at follow-up after engaging in motivational enhancement, potentially due to these techniques being perceived as unnecessary if the service user was already motivated to change their behavior, although this effect size was only small (ƒ = 0.20) and restricted to an in-patient participant sample. Participants after an MET intervention viewed cocaine as having stronger negative effects. This further reinforces the benefit of this approach in increasing levels of engagement with therapy and in altering perceptions of substance use. The BFO intervention uses MET to provide continual feedback to the service user regarding their recovery progression through a range of visual devices depicting their substance use, emotional wellbeing, resilience and quality of life. This links to the behavior change technique of focusing on past successes and providing a non-specific reward [5].

Implementation intentions

Implementation intentions connect an intention to behave in a specified manner within a particular context, thus creating a situation-specific cue to perform the behavior [54]. Implementation intentions are typically represented as ‘IF…THEN’ statements, which describe a potential situation that could occur (for example ‘IF I am near the bar’) and then specify a behavior which will be enacted (‘THEN I will phone my support worker’). Evidence suggests that those who formed implementation intentions regarding their alcohol use reported reduced rates of drinking at follow-up compared to controls, although the strength of the implementation intention is dependent upon the level of commitment to this from the participant [54]. This is important to consider when developing plans as it may affect enactment of behavior; however it could be seen that approaches such as motivational enhancement, which increase engagement, may help to increase the strength of commitment. Implementation intentions link to the behavior change technique of action planning [5] and BFO uses this strategy within goal setting to increase the probability of goal attainment.

Mind traps and cognitive restructuring

Cognitive distortions or thinking errors are called ‘mind traps’ within the application of ITEP. This is where people experience a particular thinking style that may be subjectively biased or distorted, which can trigger substance use. Those who experience a mental health problem such as depression can be thought to have an automatic negative bias about themselves, the world and their future [55]. Cognitive restructuring or reframing teaches people to review such negative thoughts, and mind traps, to see whether or not there is an alternative way to view the situation and to challenge beliefs [41, 56]. For example, a service user may believe they are helpless in a particular situation and that using a substance will help them with a challenging aspect of life without acknowledging the negative consequences of their drug use [57].

Cognitive restructuring is central to CBT [58, 59], and has been demonstrated to be an integral part of CBT-based relapse prevention approaches for SUDs [58]. Within BFO, service users learn to identify when they experience specific mind traps. These include the ‘helpless trap’ (as explained above), the ‘blame trap’ (where they do not accept personal responsibility for their actions, including those related to or arising from their substance use), the ‘guilt trap’ (where substances can be used to mask feelings of remorse), the ‘catastrophe trap’ (where everything is blown out of proportion and substances can be used as a coping method), and the ‘all or nothing trap’ (which may render a service user who experiences a slip more likely to succumb to a full blown lapse). Cognitive restructuring would encourage them objectively to evaluate this decision before acting upon it. The strategy of testing out thoughts and beliefs can be linked to re-attribution and re-framing in the BCTTv1 [5].

Reward and reinforcement

Reward and reinforcement involves providing a tangible reward or some other form of positive feedback such as praise for the enactment of a desired behavior, in order to reinforce the behavior [5]. Research has found that cocaine and heroin users are more likely to secure employment and abstain from substance use following treatment if their behavior is rewarded, compared to those who do not receive a reward for their behavior [60–62]. The use of rewards can also reinforce participation in recreational non-drug related activities [63]. However, the use of rewards to reinforce positive outcomes is directly proportional to the immediacy and value of the reward: the greater and more imminent the reward, the stronger the likelihood of the desired outcome [64]. Therefore it is important to determine and deliver the appropriate level of reward for a behavior, in order to achieve the maximum desired outcome. The removal of the reward should also be considered, for example if the reward stops then behavior may also stop. However evidence from Petry and colleagues [65] has suggested that after the removal of the reward, behavioral changes can still be maintained, in this instance with regard to drug abstinence and quality of life. The BFO intervention program utilizes this technique by providing service users with visual rewards such as trophies, rosettes, medals and garlands for attaining different levels of progress in relation to their recovery. BFO users also receive personalized certificates for their achievements, which they can download and print. The behavior change techniques which relate to reward and reinforcement are non-specific reward, non-specific incentive, reward approximation and reward completion [5].

Refusal and assertiveness skills

Refusal and assertiveness skills demonstrate how to respond assertively to people, as opposed to reacting aggressively or passively. These skills have been demonstrated to be effective in teaching those with alcohol dependence an appropriate way to refuse the offer of a drink [66, 67]. Within the BFO program, this technique is part of a broader relapse prevention strategy referred to as ‘recognize-avoid-cope’. Within this strategy, the components ‘recognize’ and ‘avoid’ are specifically related to refusal and assertiveness skills, referring to the service user’s ability to recognize a high-risk situation and take proactive steps to avoid that situation if at all possible. Previous research has found that the ability to refuse substances, and to be assertive when doing this, was significantly lower in adolescents and males compared to their counterparts, thereby increasing the likelihood of substance using behavior [68–70]. Therefore it is important that these skills are explored and developed, particularly within this population. Assertiveness and refusal skills are linked to the behavior change techniques of problem solving, action planning, instruction on how to perform a behavior, behavioral practice, behavior substitution, and reducing exposure to cues for the behavior [5].

Harm reduction

Harm reduction techniques aim to reduce negative consequences such as injury and death associated with substance using behavior. Work by Marlatt and Witkiewitz [71] found evidence to support the efficacy of harm reduction techniques in reducing alcohol use and related negative consequences compared to standard abstinence-based programs. Harm reduction principles can be useful in informing intervention approaches that address a range of high-risk behaviors such as substance use [72] and behaviors associated with this such as injecting substances [73]. Whilst this technique implies that the behavior may not necessarily cease, it provides individuals who may not be ready, or do not wish to pursue abstinence, with the knowledge required to use substances more safely. Within BFO, drug awareness and overdose management information resources are provided that ensure service users have access to accurate and factual information. This links to the behavior change techniques of information about health consequences, salience of consequences, behavioral substitution and habit reversal [5].

Activity scheduling/behavioral activation

Activity scheduling is a technique commonly used in CBT to promote wellbeing and overcome the reduction in behavioral activity typically associated with periods of poor mental health, particularly depression [41]. Low mood is prevalent during detoxification and in the early stages of recovery. Included in this reduction of activity is a reduction in behaviors that are found to be pleasurable and those that lead to a sense of achievement and self-esteem [42], which may contribute to substance use as a form of coping. Behavioral activation also teaches service users to build routine, avoid boredom and begin to restore structure and a sense of normality to their daily life, which may often be negatively influenced by substance use. This links to goal setting (behavior) and action planning in the BCTTv1 [5].

Studies have demonstrated that setting structured goals for enactment of activities for achievement and self-esteem can significantly improve mood [74]. Activity scheduling has also been shown to be effective in supporting drug-dependent individuals in reducing their substance use [75]. In particular, those who engage in increased amounts of leisure activity have been found to report reduced drug use [76]. These benefits could be realized through activity scheduling as an alternative when substances are often used, developing peer or family relations with non-substance users, and increasing life satisfaction by participating in a non-substance using activity that is of interest, including treatment [77].

Self-monitoring

Self-monitoring of behavior is in itself contained within the BCTTv1 [5] and involves reflecting upon one’s own thoughts, emotions and behaviors, and keeping a record of these for a specified period of time [78]. Feedback is sometimes also provided in order to demonstrate changes over time in the thoughts, emotions and behaviors being monitored, relating to the behavior change technique of feedback on outcomes of behavior [5]. Self-report has been stated to be an effective method by which to monitor progress in interventions [79], with self-reports suggested to be more honest and reliable when carried out on a computer due to the confidential nature of this method of assessment [80]. Self-monitoring has been identified as a key behavioral change technique for reducing excessive alcohol consumption [81], and also for addressing other forms of SUD, especially when implemented using digital technologies [82]. However, there are factors which can affect the validity of the self-report method. These may include forgetting, memory distortion or the social context within which the self-report occurs, for example within a treatment service, with a practitioner or at home [83]. However self-report methods have typically been found to be reliable, and the use of computers to record this data can also help to minimize errors [84]. Throughout the BFO intervention, service users are required to self-monitor their substance use and key ingredients of recovery progression such as emotional, wellbeing, resilience and quality of life.

Emotional regulation

Emotional regulation incorporates learning how to recognize, understand and normalize emotions, and to avoid ignoring or supressing feelings [85]. This is particularly pertinent as evidence indicates common use of substances as a coping mechanism and also as a method of increasing positive emotional states [86]. The literature suggests that impaired substance use-related control is associated with poor emotion regulation [87]. Similarly, increased emotion regulation skills have been found to decrease substance use, particularly in those with dually diagnosed mental health difficulties [88]. In order to facilitate this change in the understanding of how emotions and substance use interrelate, BFO provides psychoeducation about the links between thoughts, emotions, behaviors and substance use, and how to recognize the early warning signs which could signal poor emotional wellbeing triggering lapse or relapse. Emotion regulation links to the behavior change techniques of information about emotional consequences, behavioral practice and reducing negative emotions [5].

Coping strategy enhancement

Poor coping techniques are associated with SUDs [56] and so coping strategy enhancement is used to develop coping techniques that are more appropriate and effective than using substances [89–91]. This links into the previous discussion of emotion regulation, which suggests that substance use may in itself serve as a coping mechanism for managing negative emotions [86]. The use of effective coping strategies in a risky situation has been found to lead to an increase in self-efficacy (belief in one’s own ability), resulting in a decreased likelihood of relapse [92]. Conversely, this could mean that ineffective coping strategies can ultimately contribute to relapse. Suggested effective coping strategies include reinforcement techniques and relapse prevention [93]. In BFO, techniques such as ‘attention switching’ and ‘attention narrowing’ are also used, linking in to the behavior change technique of distraction [5]. The service user is guided through a virtual walk through a forest (in the form of an immersive audio-visual sequence) and prompted to attend to all their senses [94], in order to shift their attention away from symptoms of heightened physiological arousal which can be caused by, for example, cravings for substances or affective states such as anxiety or anger. Distraction has been evidenced as being more effective than thought suppression, which has been linked with an actual increase in the unwanted thought [95]. Coping strategy enhancement uses the behavior change techniques of problem solving, social support (unspecified), behavioral practice and distraction [5].

Relapse prevention

Work by McLellan and colleagues [96] indicates that SUDs are chronic relapsing conditions. Therefore it is imperative that relapse prevention strategies are available for those in treatment. Techniques used in BFO to prevent relapse include understanding the consequences of drug use and creating action plans to avoid lapse or relapse in risky situations [5, 56, 91]. These approaches have been reported to have efficacious outcomes in reducing the severity of relapse and increasing the durability of relapse prevention, regardless of substance type [97]. Further evidence suggests that although relapse prevention may not be as effective as active interventions used for SUDs, it is still thought to be a reliable and effective intervention method [98]. Relapse prevention is the main focus of the ‘cope’ component of the ‘recognize-avoid-cope’ technique used within BFO, which teaches service users to plan ahead to identify high risk situations, work out how to avoid them, and cope positively with them if, for any reason, they cannot be avoided. This relates to goal setting (behavior), problem solving and action planning from the BCTTv1 [5].

Crisis management

A crisis can be defined as a stressful life event which poses a challenge or threat and is difficult to cope with [99]. Crisis management acts as an effective short term, fast-acting intervention to support people experiencing distress [100]. Typical stages of crisis management include immediate intervention, stabilising the service user and building up a support network, promoting understanding, problem solving, and increasing self-reliance and self-efficacy [101, 102]. However, crisis management techniques are not meant to be used as a stand-alone therapy and should be used in conjunction with other approaches [103]. The BFO program signposts service users to mutual aid groups – specifically, Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous and SMART Recovery – to help them to identify and access appropriate support networks during times of crisis. Therefore, social support (unspecified) and reducing negative emotions from the BCTTv1 are used in this technique [5].

Goal setting

Setting goals related to reducing substance use is important as it provides a focus for recovery [67, 104]. Evidence suggests that effective goals should be specific, measurable, achievable, realistic and time-bound [105]. This is related to the behavior change techniques of goal setting (behavior) and goal setting (outcome) [5]. In the BFO program, goal setting is facilitated within the ‘lifestyle’ component of the LBM. Service users are asked to specify an overall lifestyle goal and then work to achieve this by progressing through a series of systematically planned smaller goals. Service users are also guided to anticipate the barriers they may face when attempting to complete these goals, and plan to overcome these. This process employs the additional behavior change techniques of problem solving and action planning [5].

Mindfulness-based CBT

Mindfulness is a meditative technique that involves observation and awareness of one’s thoughts and emotions [106]. The integration of mindfulness-based stress reduction [107] and CBT [108] has led to the emergence of mindfulness-based cognitive behavioral therapy, primarily for the treatment of depression. In addition, mindfulness-based CBT has been demonstrated to be effective in reducing the consumption and cravings of substances [109], including reductions to instances of lapse and relapse in SUDs [56, 110, 111]. This approach has also been demonstrated to be effective in the treatment of co-existing mental health and substance misuse issues. In one study, it was found that the relationship between craving and depression was reduced in those practising mindfulness compared to the treatment as usual group [112]. Research has found that participants who completed a mindfulness course demonstrated decreased substance use and cravings, and increases in facets of mindfulness including acting with awareness, compared to the group who participated in treatment as usual [113]. Practising mindfulness strategies, particularly developing an awareness and openness to one’s thoughts and related emotions, as opposed to suppressing them, has been found to benefit emotion regulation [114]. Mindfulness strategies employed within BFO include ‘urge surfing’, which targets cravings for substances, and in the context of ‘attention narrowing’ or focused attention, which is employed as a technique for managing heightened states of physiological arousal. The behavior change strategies used within this technique are instruction on how to perform a behavior, behavioral practice, reducing negative emotions and distraction [5].