Early Attention to the Implementation of Positive Recovery Journaling: An Intervention to Support Substance Use Disorder Recovery

Background and Purpose: Pilot studies of Positive Recovery Journaling (PRJ) have shown high feasibility and acceptability and significant associations between PRJ and well-being, especially for those in earliest recovery. Findings from a survey of counselors showed that implementing PRJ with clients for 8 sessions (“PRJ completion”) was associated with attending a consultation session and employing PRJ in a group format. Using PRJ in a primary substance use disorder treatment setting versus other settings had no advantage for PRJ completion. This study sought to deepen the understanding of these quantitative findings by analyzing qualitative responses from the same survey. Overall this study assesses aspects of implementation early in the testing of a new intervention, which is significant because substance use disorder treatment is generally under-represented in implementation science and early attention to implementation can improve subsequent treatment and implementation approaches.

Methods: We supported 37 counselors from 6 countries (US, Canada, Romania, Singapore, South Africa, UK) in the use of PRJ with their clients. We provided a 4.5 hour training, an 8-session treatment manual, ongoing support, expert consultation, and explanatory videos. Counselors completed surveys after conducting each PRJ session and at the end of the study. Open-ended survey questions invited counselors to describe their PRJ sessions with clients including ease and challenges; report about what clients liked/disliked and found helpful/unhelpful; and comment on their study experience. Using reflexive thematic analysis, we developed and refined themes derived from counselors’ observations about using PRJ with their clients.

Results: We identified four themes that extended our understanding of our quantitative findings: (1) perception of PRJ as helpful, likeable, easy across settings; (3) social benefits of groups that extended beyond the PRJ intervention; (4) group processes that amplified the benefits of PRJ; (5) aspects of PRJ implementation including the ways in which expert consultation was helpful. These qualitative findings explained the quantitative findings in three ways: (1) The quantitative data showed that those who used PRJ with groups were more likely to use PRJ for all 8 sessions; the qualitative data showed how the group process contributed to successful use of PRJ by enhancing its benefits and providing positive social dynamics. (2) In the quantitative data, there was no advantage to using PRJ in a primary substance use disorder program versus other settings; the qualitative data showed that counselors in mental health settings also found PRJ to be useful. (3) Quantitative results showed that making use of expert consultation correlated with PRJ completion; qualitative results showed that expert consultation was experienced as useful, suggesting it could have supported completion. Six additional themes provided insights into other aspects of PRJ and its implementation.

Conclusions and Implications: Qualitative data is invaluable in its ability to amplify and explain quantitative findings. Findings produced clear, actionable advice for improving the PRJ intervention and future implementation strategies.