Piloting a tailored telehealth program for managing stimulant use in traumatic brain injury

Treatment comprises 10 x 1hr weekly telehealth sessions with a psychologist and occupational therapist (week 1-10), followed by 2 x 1hr booster sessions occurring in weeks 14 and 18. The treatment is a synthesis of cognitive behaviour therapy (CBT) and occupational therapy with co-designed optimisation for individuals with a brain injury and substance use disorder (Gullo & Gullo, 2024, Diagrammatic representation of the bioSocial Cognitive model of Occupational Functioning (biSCOF) - substance use. doi:10.6084/m9.figshare.27713220). The treatment addresses person and environment factors involved in stimulant use and helps individuals develop effective coping strategies for them to facilitate pursuit of goals and strengthen confidence in the ability to control their stimulant use (i.e., refusal self-efficacy). Therapists will develop a collaborative relationship with participants (and carers) to work together as a team to modify personal and environmental factors that lead to stimulant use and impede occupational performance and participation. Therapists express empathy and reinforce participant autonomy in sessions, while having a structured agenda. Key elements will include craving management, learning to identify and manage high-risk situations for using (e.g., high anxiety, social pressure), learning to identify and modify exaggerated positive expectations of stimulant use (e.g., “Only stimulants can…reduce my anxiety” or “...make a party fun”), motivational enhancement, and increasing non-substance related activities. Consistent with gold-standard CBT for substance use disorder manuals (e.g., Carroll, A cognitive-behavioral approach: Treating cocaine addiction, U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, 1998; Kadden, R., Carrol, K., Donovan, D., Cooney, N., Monti, P., Abrams, D., Litt, M., & Hester, R. (1995). Cognitive-behavioral Coping Skills Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals with Alcohol Abuse and Dependence. National Institute on Alcohol Abuse and Alcoholism. NIH Publication No. 94–3724), the beginning phase of intervention will involve case formulation, assessment and personalised feedback, and psychoeducation (sessions 1-4). It will also include immediate strategies to reduce access to substances and stimulus control (i.e., removing craving triggers). The second phase will involve a personalised sequence of modules that is based on the case formulation (e.g., managing unhelpful thoughts, craving management) and participation goals (sessions 5-9). The final phase focuses on long-term relapse prevention and maintaining progress towards participation goals (session 10). In addition to utilising saliva drug tests to validate participants are not intoxicated during treatment or assessment sessions, financial reinforcement of negative (“clean”) saliva tests will be incorporated into the intervention, i.e., Contingency Management. Each session will involve an on-camera saliva drug test to confirm self-report of substance use/abstinence and facilitate rescheduling of sessions for intoxicated participants. In order to better accommodate and support the remote, telehealth delivery of the 10-week intervention, additional twice weekly check-in video calls will be made to observe an on-camera drug saliva test. Participants will be asked to self-administer and share results of the oral fluid testing device by positioning it in front of the camera used for synchronous video during the telehealth session. Participants will receive AUD$15 per negative (“clean”) test result and, after three in a row, earn a bonus AUD$10 (i.e., maximum AUD$55 per week per participant). Amounts are in line with existing evidence and our co-design input from consumers (Gullo et al., in preparation; Clay et al., 2023; Ronsley et al., 2020). Incentives will be provided in the form of gift vouchers. Treatment sessions will be videotaped for review in therapist supervision to assist in maintaining fidelity (fortnightly, provided by senior psychologist researcher). Participants may refuse to have their sessions recorded during the informed consent process or at any time without comment or penalty. Participants may also ask to pause the recording at any time during sessions if there are some parts of the session that they do not want recorded. For reporting purposes, a random session will be selected each month for fidelity rating by a member of the research team (greater than or equal to 15% sessions rated).