Evaluating the 'First Step' in treatment for individuals seeking substance use interventions

First Step is a co-designed alcohol and drug brief intervention, tailored to meet the specific needs of Lives Lived Well (LLW) clients, based upon motivational interviewing and cognitive behavioural techniques. This was achieved through active consultation with UQ staff and nine LLW counselling staff across multiple LLW programs and regions (including staff from QLD and NSW), managers and upper managers. Components of First Step were adapted from other evidence-based brief interventions, namely the Quikfix intervention (Hides et al., 2020). Program content has been developed so that it can be delivered both face-to-face and over-the-phone. The First Step brief intervention includes comprehensive materials (e.g., manual, information sheets and worksheets) that have been designed specifically for this study, that can be used by all counsellors; and that have the flexibility that they can be applied to a wide range of presenting client concerns. It is designed to be the first step in a stepped care model of treatment. Therefore, while all clients will have the opportunity to complete the brief intervention, they will also have access to further treatment as needed. The First Step brief intervention is comprised of three modules delivered over two treatment sessions. Module 1 - Assessment Feedback/Information: focuses on providing comprehensive personalised feedback to the client based on the LLW outcome measures they were required to complete upon enrolling with LLW for treatment. The areas feedback can be provided for are: 1) Substance use (frequency and amount, and severity and risks for up to three drug types); 2) Mental health (including depression and anxiety, suicide risk, trauma, psychotic symptoms, and gambling); 3) Social and life factors; and 4) Additional factors (including domestic and family violence, violence to others, child safety/protection, justice issues, homelessness, and chronic pain). Substance use, depression and anxiety, and social and life factors are discussed with every client. The remaining areas are only discussed if the outcome measures indicate this is an area of concern for the client. Psychoeducation is then offered to the client using relevant substance-related fact sheets and information sheets on common comorbid conditions. This information will be discussed with the client in session and/or emailed to the client after the session. Module 2 – Motivational Interviewing: focuses on motivational enhancement and goal setting. Motivational interviewing techniques are used to build motivation and commitment to change. The client’s patterns of substance use are first explored, and, the pros and cons of making a change/not making a change in their substance use are discussed. Options for change (reduce substance use or the potential harm associated with use) are then explored. These MI techniques are supported by information sheets and worksheets, to be completed during the session. The module ends with the client setting a substance-related goal using an implementation intention framework, a technique based on the Theory of Planned Behaviour. The intent is for the goal to be very simple and specific, and able to be achieved in the next week, to build the client’s self-efficacy. The goal comprises of three core elements: 1) When the goal will be executed (it is important this is a specific day/time, and if appropriate within a specific location); 2) How the goal can be accomplished – the client is provided with one or two simple strategies to help them achieve their goal; and 3) what the goal is. The client is asked to rate their level of confidence (1-10) in achieving their goal and they identify and address any potential impediments. The goal and additional resources are emailed to the client at the end of the session. Module 1 and 2 are usually delivered in one session. Module 3 – Targeted Coping Skills Training: explores risk profiles, based on client’s scores on the S-UPPS which is completed with the LLW outcome measures, which may underlie the client’s substance use behaviours. The risk profile is discussed with the client and then training is provided in 2-3 coping strategies to target the profile. If the risk profile identified is negative urgency – anxiety prone, the coping strategies include belly breathing; mind chill – based on the thought diffusion techniques from Acceptance and Commitment Therapy; and urge surfing from unpleasant emotions, which encourages clients to notice their unpleasant emotions and accept their urge or impulse, recognising that it will pass. For the risk profile negative urgency – depression prone, the coping strategies include good vibes, which focuses on evidence-based behavioural activation strategies; three good things, which encourages clients to identify three good things that happened during the day; mind change, based on CBT techniques to reframe negative thoughts; and urge surfing from unpleasant emotions. The coping skills for the impulsivity profile include Stop-Think-Do, to help them slow down their decision making processes; urge surfing, which focuses on noticing and accepting their urge or impulse rather than emotion; and Breathe-Ground-Centre-Focus to encourage staying in the present moment. Those high in sensation seeking receive training in savouring techniques to increase their awareness and ability to focus on and experience positive feelings from everyday activity (e.g. mindful eating) and are encouraged to identify and schedule natural highs from functional activities (e.g. exercise, skateboarding, rock climbing) and daily experiences (food, sex, music). Those with the positive urgency risk profile are also trained in savouring techniques and urge surfing, and they work through the coping strategy fun finder, which encourages them to identify and schedule substance-free activities which bring them positive reinforcement. For clients with the final profile of lack of perseverance, they are taken through an activity to help them identify their values or purpose, and then goal setting activities to help them live in line with their identified values. The session ends with the client setting a second substance use goal which incorporates coping, using an implementation intention framework. There are accompanying worksheets to assist clients to complete and practice their relevant coping strategies. These are designed to be completed in session, which the client can then take home to use as a reference. The intervention is designed to be delivered in 2 50-60 minute sessions. Ideally these sessions would occur in consecutive weeks after the completion of baseline measures. However, due to counsellor caseloads and allowing for non-attendance and rescheduled sessions, it is likely the intervention will be delivered over 4-6 weeks after baseline completion. The intervention will be delivered by all LLW counsellors at the implementation site. The counsellors will receive training in the First Step intervention and are also supported by an intervention manual. They will receive one full day of training as a whole group, followed by ongoing, fortnightly training in smaller groups before the trial commences, which will then become ongoing, individual supervision for the duration of the trial. At the end of each session, counsellors complete a checklist to indicate which components of the intervention they delivered. Treatment sessions will also be audio-recorded and a random selection will be reviewed to check treatment fidelity.