Participants
Participants (N=20) were either certified PRSs or individuals seeking/working towards PRS certification. Recruitment of peers was conducted through PRS network listservs, social media pages, and word-of-mouth led by a PRS on our team. A research assistant (RA) contacted all interested participants to confirm eligibility and schedule assessments and training. While most PRS were SUD-focused peers, a small subset of were mental health peers (n = 2). Mental health peers are individuals with lived experience with mental health disorders, who receive similar training and certification as SUD focused PRSs.
Procedures
Training
Trainings were held virtually using Zoom, in a group format with two-to-five participants per training. Trainings were delivered by a certified PRS with supervisory and training credentials as a PRS and training in BA, and a Clinical Psychology doctoral student with BA expertise. Each training lasted approximately two hours, and began with an overview of basic PRS competencies, including: rapport building, non-verbal and verbal communication skills, disclosure, supporting self-efficacy, and collaborative goal setting. The remaining half of the training focused on fostering proficiency in core skills of BA for SUD: (1) understanding the cycle of substance use including identifying negative feelings, urges and behaviors; (2) breaking the cycle (i.e., changing behavior) to produce positive outcomes; (3) discussing and identifying life values; and (4) exploring/identifying positive, rewarding activities that are in alignment with one’s life values. The training included interactive discussions, breakout rooms and role plays to foster skill development.
Assessments
Assessments were completed before and after the training (within two weeks for each). Assessments included both written quantitative measures completed independently (with research assistant assistance if needed) using REDCap, as well as a role play with a trained RA. Participants were provided with a $25 gift card for each assessment and a certificate of completion, which individuals seeking PRS certification were able to use to verify two service hours towards their certification requirements.
Each role play was recorded with participant consent, lasted approximately 10-15 minutes and utilized a trained RA actor. Participants were provided with a brief background on the patient and role play instructions (written and verbally) at both assessment points. Mock patient backgrounds varied slightly from the baseline to post-training assessment to avoid recall effects, but presented similar content including SUD, receiving MOUD, and referral through a community outreach program. Participants were instructed that they had ten minutes to learn about the person and their experiences and engage in a supportive manner. Additional instruction was provided at the post-training assessment to discuss life values and identify activities at post-treatment; this was not provided at baseline under the assumption that participants had not receiving prior BA training.[2]
RAs included post-baccalaureate, master’s, and doctoral-level student researchers. RAs received in-depth patient vignettes and approximately three hours of role play training, including practice role plays and discussing how to respond to different scenarios. For example, RAs were to respond to closed-ended questions with “yes/no” responses, ask for clarifying information when high-level clinical jargon was used, and to not disclose information from the vignette unless probed for.
All procedures were approved by the University of Maryland, College Park Institutional Review Board and all participants provided verbal consent prior to study participation. Data were collected between December 2021-February 2022.
Measures
The Evidence-based Practice Attitude Scale-36 (EBPAS-36)
Attitudes towards EBIs were assessed utilizing the EBPAS-36 (21). This scale assesses attitudes towards EBIs broadly (i.e., not BA specifically). Higher total scores indicate higher acceptance and positive attitudes towards EBIs.
Substance use stigma
Participant experiences of internalized (i.e., negative feelings towards themselves), enacted (i.e., experienced discrimination) and anticipated (i.e., expected future discriminative experiences) stigmas were assessed utilizing the Substance Use Stigma Mechanisms Scale (SU-SMS; 22) If participants did not self-report substance use[3] in a brief demographic questionnaire, the measure was not administered. Higher subscale and total scores indicate higher levels of stigma.
The Abstinence Orientation Scale (AOS)
Openness to various pathways to recovery, namely MOUD, was assessed using the AOS (23). Higher total scores indicate stronger negative views towards MOUD.
Social Distance Scale (SDS)
The SDS (24) measures varying degrees of closeness (i.e., warmth, hostility, indifference, or intimacy) in participants towards members of diverse social, ethnic or racial groups. To administer the SDS, researchers developed a vignette describing an individual whom portrays characteristics of interest. Participants then indicate how likely they would or would not be to engage in certain behaviors/activities with the individual in the vignette. This study included two vignettes describing two different levels of recovery. The first vignette portrayed an individual who: is actively receiving MOUD; has decreased their use of heroin and cocaine but is still in intermittent periods of active use; has a goal of working towards gaining one-week of take homes. The second vignette portrayed an individual who: is actively using heroin and fentanyl; does not have interest in reducing or stopping their use; has entered and discontinued inpatient treatment various times. A total score was computed by adding together the two vignette’s scores in order to indicate total levels of desired social distance to the portrayed individuals. Higher total scores indicate greater preference for distance.
International Personality Item Pool NEO-60 (IPIP-NEO-60)
Openness and conscientiousness, personality traits that have been associated with positive therapist-client outcomes (17,19), were assessed using the respective IPIP-NEO-60 subscales (25). Higher subscale scores indicate stronger endorsement of the trait.
ENhancing Assessment of Common Therapeutic factors (ENACT)
The ENhancing Assessment of Common Therapeutic factors (ENACT) scale (26) is a 15-item measure developed to assess competence among non-specialists delivering mental health interventions. In consultation with an experienced PRS on the research team, we selected ENACT items that were most relevant to basic PRS competencies: non-verbal communication and active listening; verbal communication skills; rapport building and self-disclosure; demonstration of empathy, warmth and genuineness; collaborative goal setting and addressing client’s expectations; promotion of realistic hope for change; and incorporation of coping mechanisms and prior solutions. The ENACT is scored on a scale of 1-4 (1=harmful; 2-3=some or all basic skills; 4=advanced skills). The ENACT provides a detailed codebook defining each score for each skill; the research team and PRS reviewed the existing codebook and adapted as needed to align with typical expectations of PRSs and their work. In order to assess BA skills, the research team also developed a codebook following the same scoring structure as the original ENACT (i.e., a 1-4 scale) for two skills: identifying/discussing life values, and activity identification. Total scores were created by adding all items for each skill domain, resulting in a total ENACT items score and a total BA score.
Role Play Coding
The coding team consisted of a post-baccalaureate RA and PRS with experience in delivering BA. Coders received training from a doctoral student familiar with both the ENACT and BA, which included detailed discussion of the codebook and coding practices. Following training, coders met weekly to code role play recordings. All items were scored independently; immediately after independent scores were determined, coders discussed and resolved any discrepancies via consensus. Consensus scores were used for analytic purposes. Whereas the ENACT, and consequently the BA, codebook scored items as having either “1 = harmful,” and “2 = some basic skills,” etc., coders noted that there was no available score for instances where participant behaviors/skills were not harmful, yet the participant did not display any basic skills. Applicable instances were tracked during data collection to allow for differentiation between individuals with some basic skills versus individuals with no basic skills yet no harmful behaviors (e.g., takes up space by talking without utilizing basic skills, but causes no harm). Role play skills were then ultimately scored such that 0=harmful; 1=no basic skills; 2=some basic skills; 3 = all basic skills; 4 = advanced. Though participants were not instructed to used BA skills at baseline, BA competency was still rated such that it was possible that PRSs utilized skills in alignment with BA (e.g., identifying activities) on their own.
Data Analysis
In order to assess change in BA and ENACT competence, total BA and ENACT scores at baseline and post-training were compared using a paired t-test. To examine potential predictors of post-training BA and ENACT scores, linear regression models were used, utilizing baseline EBPAS-36, SU-SMS, AOS, and SDS vignette total scores, IPIP-NEO-60 conscientiousness and openness subscale scores, and total years of PRS work experience as predictors. All linear regression models controlled for baseline BA and ENACT scores. Three participants did not complete the SU-SMS due to lack of SUD experience and were not included in analyses using this measure. All participants (N = 20) completed all other measures.
[2] All participants self-reported prior trainings at baseline assessment. No participants reported previous BA training.
[3] Of note, individuals can be a PRS based on shared mental illness diagnoses and/or having a family member or close friend with SUD.