Overview of the Breaking Free research and evaluation programme Based on the MRC framework for developing and evaluating complex interventions June 2015 1
Overview of the Breaking Free research and evaluation programme The ongoing programme of research into the effectiveness of Breaking Free Online and Breaking Free Pillars of Recovery, outlined below, is following the Medical Research Council framework for the development and evaluation of complex healthcare interventions (Craig et al., 2008), and the Royal Society guidelines for evaluating novel interventions (Wallach et al., 2006; Wallach, 2011). Completed studies Breaking Free Online Version 1.0 A quantitative outcomes evaluation of version 1.0 of Breaking Free Online. This study has been published in the Journal of Substance Use. Key findings: Using Breaking Free Online led to significant reductions in substance use, as well as significant improvements in mental health, quality of life, severity of dependence and perceived ability to abstain from using substances. St Mungo s Homeless hostels A qualitative outcomes evaluation of the use of Breaking Free Online by homeless drug users living in St Mungo s hostels in London. Usage of the programme was facilitated by mentors (i.e. hostel staff). This study, which was authored by Dr Joanne Neale (National Addiction Centre, King s College London) and Dr Caral Stevenson (Oxford Brookes University), has been published in Drugs Education Prevention and Policy. Key findings: Almost all service users expressed positive feelings about Breaking Free Online when interviewed after both their first and last session. They highlighted the programme s accessibility, flexibility, interactive capabilities and user-friendly interface. In addition to reduced substance use in some service users, a wide range of other personal, psychological, educational and social benefits were identified across the cohort. 2
Self-Help Services Dual diagnosis services A quantitative outcomes evaluation of the use of Breaking Free Online by service users at Self-Help Services in Manchester and Stockport who had a dual diagnosis of substance misuse and mild-tomoderate mental health difficulties. This study has been published in Advances in Dual Diagnosis. Key findings: Implementation of Breaking Free Online as part of the e-therapy service led to significant reductions in alcohol and drug use, as well as significant improvements in social functioning, depression, anxiety and social anxiety. Clinically relevant gains were also identified, with fewer service users reaching threshold scores for depression and anxiety at post-treatment compared to baseline. Effect sizes also indicated that the identified improvements across the psychometric measures were robust and significant. CRI Recovery services A qualitative outcomes evaluation of Breaking Free Online when delivered as computer-assisted therapy (CAT) by peer mentors and practitioners at four CRI recovery services in Lancashire, Staffordshire, Yorkshire and the West Midlands. This study has been published in Drugs and Alcohol Today. Key findings: Implementation of computer-assisted therapy for substance misuse had significant benefits in terms of both the recovery of the service users and the working practices of the staff and peer mentors. Feedback on Breaking Free Online was overwhelmingly positive. All individuals interviewed perceived the programme as being highly beneficial, and highlighted different ways in which specific strategies within it contributed to successful recovery. Data also provided valuable insights into the process by which technological innovation is diffused throughout a large organisation such as CRI. Breaking Free Online Theoretical basis for underpinning model A detailed overview and discussion of the current evidence base for the components and structure of the Lifestyle Balance Model, which underpins the Breaking Free Online and Breaking Free Pillars of Recovery programmes. The study draws on literature around node-link mapping techniques, cognitive-behavioural case formulation, and the growing evidence around the importance of lifestyle to substance use, relapse and recovery. This study, which was co-authored by Dr Alexandre Laudet (Director of the Center for the Study of Addictions and Recovery, National Development and Research Institutes, New York), has been published in Substance Abuse Treatment Prevention and Policy. Key findings: This literature review demonstrated strong theoretical support for the Lifestyle Balance Model, the six domains of biopsychosocial functioning it contains, and its emphasis on the role of lifestyle in both perpetuating substance dependence and influencing recovery progression. 3
Breaking Free Online Validity of full assessment A statistical standardisation and validation study of the psychometric assessment that is contained in Breaking Free Online. This structured assessment measures the aspects of biopsychosocial functioning that comprise the Lifestyle Balance Model and changes in these areas of functioning, which is conceptualised as recovery progression. This study of data from 2,218 service users has been accepted for publication in Substance Use and Misuse. Key findings: The structured assessment, which is used to populate the Lifestyle Balance Model that underpins Breaking Free Online, was found to have excellent psychometric properties in the form of very strong internal reliability and convergent validity. In addition, exploratory factor analyses revealed the assessment to provide a foundation for the programme that is statistically and theoretically sound. Breaking Free Online Validity of abbreviated assessment A psychometric assessment standardisation and validation study of 2,712 users of Breaking Free Online. This assessment is an abbreviated version of the structured assessment that is included in Breaking Free Online. Named the Recovery Progression Measure (RPM), this 7-item scale is designed to be used as a rapid measure of recovery progression in substance misuse treatment settings. This study will be submitted for peer review shortly. Key findings: The Recovery Progression Measure was found to have excellent internal and test-retest reliability. In addition, concurrent and predictive validity were found to be excellent, and the measure was demonstrated to have high sensitivity and specificity. St Mungo s Homeless hostels A qualitative exploration of Breaking Free Online delivered as computer-assisted therapy by mentors to homeless drug users. This study, which was authored by Dr Joanne Neale (National Addiction Centre, King s College London) and Dr Caral Stevenson (Oxford Brookes University), has been published in the Journal of Substance Abuse Treatment. Key findings: Successful delivery of Breaking Free Online as computer-assisted therapy in the context of homeless hostels related to intrinsic features of the programme, including its accessibility, flexibility and user-friendly interface; delivery context, such as privacy and the availability of computers; the extent to which clients were focused on their recovery; and the attitude of the mentors. 4
Breaking Free Online Alcohol A quantitative outcomes evaluation of the use of Breaking Free Online by 300 service users to address their problem drinking. This paper has been published in Alcoholism Treatment Quarterly. Key findings: Using Breaking Free Online led to significant reductions in the average weekly units of alcohol consumed (from 76 pre-treatment to 26 post-treatment) and severity of alcohol dependence. In addition, 48% of service users achieved complete abstinence following treatment, with the remainder showing significant reductions in alcohol consumption. Significant improvements in mental health and quality of life were also found. Helping Groups to Grow Dual diagnosis service A quantitative outcome study of the implementation of the Breaking Free Pillars of Recovery group and one-to-one keyworking programme by Helping Groups to Grow, a community service in Dyfed- Powys for people with substance misuse and mild-to-moderate mental health difficulties. This paper, which was co-authored by Dr Lee Hogan (University of Bangor), has been accepted for publication in the Journal of Groups in Addiction and Recovery. Key findings: Delivering the Breaking Free Pillars of Recovery programme led to significant reductions, immediately post-treatment, in levels of substance use and severity of dependence. In addition, significant improvements in mental health, social functioning, quality of life and selfefficacy were found. Breaking Free Online Version 2.0 A quantitative outcomes evaluation of the use of version 2.0 of Breaking Free Online by 393 service users to address their alcohol and drug dependence in the context of substance misuse treatment services. This paper has been published in the Journal of Medical Internet Research Mental Health. Key findings: Using Breaking Free Online led to significant reductions in levels of substance use and severity of dependence (across different types of substances). Significant improvements in mental health and quality of life were also found. Additional analysis showed that these therapeutic gains were even more significant when individuals used the programme with the support of a relative or friend, suggesting that psychosocial support can play an important role in maximising outcomes. 5
Ongoing studies Chapman-Barker Unit Inpatient detox unit Qualitative outcomes evaluation data are currently being collected and analysed. The service users included in this study have highly complex needs. The Chapman-Barker Unit is using Breaking Free Online to structure people s time immediately post-detox, and also to help them transition safely back to the community as part of the aftercare provision. Preliminary findings: Specific intervention strategies within Breaking Free Online are particularly effective at different points of the recovery journey. The service users interviewed have provided many concrete examples of how specific strategies within Breaking Free Online have benefited them in different ways e.g. to use their time positively and constructively, manage their anxiety, and cope with their cravings and urges while they are still inpatients; and to avoid relapse and address their lifestyle issues following their discharge from the unit. Pillars of Recovery Group and keyworking programme A quantitative outcomes evaluation of the 6-month follow-up data for the service users who participated in the initial outcomes evaluation at Helping Groups to Grow in Dyfed-Powys is currently underway. Preliminary findings: The therapeutic gains from the Breaking Free Pillars of Recovery group and one-to-one keyworking programme, in terms of reductions in levels of substance use and severity of dependence, and improvements in mental health, social functioning, quality of life and self-efficacy, were maintained at 6 months post-treatment. CRI Recovery services Three studies of the use of Breaking Free Online throughout CRI s recovery services are currently being undertaken: 1) A controlled, longitudinal quantitative study comparing outcomes of service users accessing Breaking Free Online with those receiving treatment as usual. 2) A follow-up qualitative study of the diffusion and implementation of Breaking Free Online across the organisation. 3) A qualitative study of the role of Breaking Free Online in supporting peer mentors in maintaining abstinence and building recovery capital. 6
Turning Point Recovery services Two studies are currently being undertaken in collaboration with the Clinical Psychology team at Turning Point: 1) A controlled, longitudinal quantitative study comparing outcomes of service users accessing Breaking Free Online with those receiving treatment as usual. 2) A qualitative study exploring the role of Breaking Free Online in providing continued care to service users recently discharged from in-patient detoxification facilities. Addaction Recovery services An outcomes evaluation of different methods of implementing Breaking Free Online in four regions (Lancashire, Cornwall, Devon and Dumfries & Galloway) in which Addaction provide substance misuse services is now underway. These delivery methods are one-to-one support for service users receiving substitute medication for opiate addiction; group and one-to-one work with non-opiate and crack users (predominantly people using cannabis, amphetamines and novel psychoactive substances); and outreach support for service users living in rural locations. This study is based on a mixed methodology (i.e. quantitative and qualitative) design. Alberta Health Services, Canada Young people s services An outcomes evaluation of the use of Breaking Free Online and other online resources to support young people with substance misuse and mental health difficulties is currently underway. This study is being conducted by the Addiction and Mental Health Strategic Clinical Network at Alberta Health Services. 7
Prisons Programme of research Breaking Free Online and Breaking Free Pillars of Recovery have been included in Gateways. This is an NHS England and Ministry of Justice pathfinder in ten prisons in North-West England that aims to break the cycle of substance misuse, offending and imprisonment by strengthening support for people when they transition from custody back to the community. In partnership with Dr Sam Weston at Keele University Department of Criminology, a comprehensive programme of research into the effectiveness of Breaking Free Online and Breaking Free Pillars of Recovery within prison settings is currently being undertaken. This research programme includes an initial mixed-methods pilot evaluation, which has been accepted for publication in Drugs Education Prevention and Policy. This study found that offenders using Breaking Free Online in prisons demonstrated highly significant reductions in substance consumption and substance dependence and improvements in quality of life, and significant improvements on most dimensions of recovery progression. The qualitative component of the study found that even offenders with low levels of digital literacy were able to use the online programme effectively, and consequently found it helpful to their recovery. Several stated that they intended to continue using the programme in the community following their release. Offenders accessing the Pillars of Recovery group and key working programme also reported multiple therapeutic benefits and identified the peer support and mutual aid facilitation elements to be particularly beneficial. This study is now being followed up with a comprehensive mixed-methods evaluation of the role of the Breaking Free Health and Justice programmes in providing continuity of care between custodial and community settings. In addition, ethical approval has been granted by the National Offender Management Service at the Ministry of Justice for a randomised controlled trial (RCT) with offenders in the prison estate. This will compare the effectiveness of Breaking Free Online and Breaking Free Pillars of Recovery with standard treatment (i.e. treatment as usual). Prisoners who participate in the RCT will be followed up post-release. A mixed-methodology (i.e. quantitative and qualitative) design will be used to examine the longer-term impact of Breaking Free Online and Breaking Free Pillars of Recovery on substance use, mental health and reoffending behaviour. For more information on the Breaking Free research programme, or to request PDFs of published articles, please contact Dr Sarah Elison (Head of Research): Email: selison@breakingfreegroup.com Tel: +44 (0) 161 834 4647 8