We Can Do This: Web-based therapeutic intervention for reducing methamphetamine use amongst Aboriginal and Torres Strait Islander people: Randomised wait-list control Trial

We Can Do This' is a culturally appropriate web-based therapeutic intervention (WBTI) for methamphetamine use comprising 6 modules (described below) based on brief cognitive behavioural, motivational interviewing, Acceptance Commitment Therapy (ACT) and culturally-specific interventions. At first log-in, participants will enter names of relevant support people into their ‘healing circle.’ These may personal contacts or professional people who may be called upon to provide support. The healing circle may be easily accessed at all times via an icon at the top right-hand corner of the screen. Based on feedback from advisory groups, participants will not be forced to complete modules in a set order but will be able to select modules based on preference. At first and subsequent log-ins, participants will monitor their mood using a simple visual rating tool, and monitor methamphetamine use via the time-line follow-back. Instructions will recommend that participants access the WBTI once a week for six weeks, however they are free to access the it as frequently as they wish during the intervention phase. Participants will have the option of receiving weekly health practitioner support face to face or via phone calls from trained staff at the participating health service in their geographical area. Practitioners may be psychologists, counsellors, nurses or Aboriginal health workers/practitioners. If this option is taken up, the participant’s contact details will be forwarded to the relevant health practitioner and the participant will receive an introductory phone call during which the health practitioner will explain their support role and schedule the weekly support sessions. Alternatively, participants may choose to proceed without weekly support. In either case, participants will be prompted to consider talking to someone at the end of each module. At the end of each module, printable summary pages of their inputs may be emailed to participants as attachments. If receiving weekly support this summary may also be emailed to their practitioner. Participants may also opt to share these summaries via email with other members of their healing circle. Participants will be sent an email or text to remind them to log-in each week, regardless of which modules have been completed. If all modules are completed early, participants may repeat modules. MODULE CONTENT 1. Are You Ready? (~15 mins) is an online adaptation of the decisional balance exercise that is frequently used with Motivational Interviewing although is not strictly defined as a component of motivational interviewing per se. This exercise commonly included as a component of treatment manuals for substance use using a range of therapeutic modalities. It proceeds in four sections corresponding to ‘Good things about using ice;’ ‘Bad things about using ice’; ‘Bad things about stopping ice’; and ‘Good things about stopping ice.’ A brief video illustrating relevant issues for one of the characters introduces each section. Within each section, the participant is presented with 10 items (one per page) that they rate on a slide bar as ‘not true for me,’ ‘a little bit true for me’ or ‘true for me’. After rating the final item in each section, all 10 items are presented in a list in order of relative weighting, and the participant can add additional items to the list via a text box at this point. The ‘weighting’ for each group of items is represented by a pile of stones with the relative weighting given to each item is represented by the size of the stone (larger stones for those items rated as ‘true’; smaller stones for those rated as ‘a little bit true’). By the end of all four rating exercises, the good and bad things about using ice and stopping ice are represented visually by four piles of stones. Participants are then asked to identify the good thing about stopping ice that is most important to them and visualise the difference that stopping ice would make to this area of their lives. They have the option of scheduling an encouraging text message to themselves reminding them of this important motivator later in the week. 2. The 'Cravings and Triggers' module (~15 mins) contains exercises designed to assist the participant identify their own triggers (situations, thoughts and feelings that can lead to urges to use) and cravings (urges to use) with a view to making a plan for how to deal with them. The section begins with an informational video providing psychoeducation on methamphetamine and the brain, including explaining the nature of addiction and withdrawal. This psychoeducation provides the rationale for the subsequent exercises, which prompt the participant to reflect what cravings feel like for them, and to identify the internal (thoughts/feelings) and external (situations) triggers that lead them to use. The first exercise presents the participant with an image of a person and they are invited to tap on various body parts to read about common symptoms of cravings, alongside strategies that can help to cope with that symptom. For example, tapping on the nose will bring up the message: “Smell can bring on strong cravings. You can interfere with them by smelling something else- lemon, coffee, soaps – anything that you find calming and not related to using ice.” The next exercise comprises a series of check-box forms (with free-text boxes to enable adding personal detail) prompting the participant to identify their own external then internal triggers. Each section is introduced with a related video and written information. Another video then introduces the question of whether some triggers may be simply avoided, and participants are prompted to consider getting rid of any ice and equipment they may have left. The participant is then prompted to make a plan to reduce stress choosing realistic and relevant strategies from a list, and to practice identifying and responding constructively and compassionately to unhelpful thoughts using Socratic questioning. In sum, the information entered into this module amount to a 'cravings plan' that may be printed or emailed. 3. 'Having a Craving? Don’t Panic!' (~5-20 mins) is a brief behavioural experiment in which the participant is prompted to rate the intensity of their craving on a scale from 0 to 10, set a timer for 5, 10 or 20 minutes, during which time they are instructed to do something else. The participant has the option of playing ‘Tetris’ on their device, as there is some evidence that playing Tetris acts as visual cognitive interference and reduces the incidence and intensity of cravings in real-world settings. When the timer finishes, the participant receives a text message prompting them to return to the exercise and re-rate their craving, after which they can repeat the exercise or move on to another module. 4. High Risk Situations (~10 mins) includes a series of questions designed to assist the participant to identify potential high-risk situations, and to make a plan to cope with them without using methamphetamine. Possible strategies include: where possible, avoiding the situation altogether, making a plan to leave if things get hard, rehearsing how to say ‘no’ to people when drugs are offered, preparing by letting people know that they have decided not to use, having support people nearby/contactable, reminding themselves of their primary motivation for reducing or stopping use. 5. 'Quiet Reflections' (~5-20 mins) contains a series of reflections and mindfulness exercises that may be selected from a ‘launch page’ within the module. These reflections emphasise connection to culture, community and identity, and provide pathways for addressing culturally situated grief and loss and connecting with cultural programs. The module also contains a basic introduction to mindfulness via psychoeducation and a brief breathing exercise. 6. 'Values-driven goal setting' (~15 mins) is an adapted version of the ‘Bullseye Values Survey’ developed by Lundgren et al. (2012) and further popularised through its routine use in ACT. This exercise does not focus on drug use specifically and is intended to help the participant build a valued life outside of their use. In our adapted version, the participant is presented with three baskets Labelled: ‘Less important; ‘Important’ and ‘Very important’. Values appear on the screen and the participant sorts them into the appropriate basket. In the next stage of the exercise, those values rated as ‘very important’ appear one by one and can be placed on a stylised image of a dart-board- close to the centre if the participant feels they are living well in accordance with that value, and further away from the centre if they are not living in line with that value. Once all the values have been placed on the board, the participant is encouraged to select a value placed further from the centre to work on in the next section. The participant is then asked to write a ‘specific, achievable action that would help them move closer to living out that value. This is followed by three questions: ‘What would be the first step towards this goal?’; ‘Who could help you do this?’ and ‘When will you do this?’. After nominating a day and time, the participant has the option to send a text message to themselves reminding them to take the first step. The participant can then choose to work on another value, print their plan or select another module.