Table 5 Selected Recommendations and Supporting Evidence from Audio Recordings. This table summarizes our findings and recommendations for improving not only START NOW psychotherapy but also other psychotherapies for treating OUD

1. Content Strategies for New Psychotherapies

1a: Participants want psychotherapies that target impulsivity

- “Focusing is the most important thing we’ve learned.”

- “[We need help] to re-train our brain [as] addicts to learn, to think, and act more rationally.”

- In regards to ABC system for functional analysis of behavior, “it’s good to bring [ABC] back up again. You need to repeat things to remember them.”

1b: Target participants’ failure to plan for the future

- “The biggest thing that I am interested in is life things, skills in general. Skills to live life and how they can help us stay clean.”

- “[Setting and Making My goals] is an important lesson of the day.”

- “[It was] effective breaking down our goals, step by step, understanding how to reach it.”

1c: Psychotherapy vignettes should be more culturally relatable and appropriate

- “I wish the material was directly correlated back to our problems.”

- “There needs to be more focus on how to deal with substance abuse.”

1d: Add more self-care skills training

- “I liked today’s session. [Self-care is important because] a lot of addicts don’t really take care of themselves. We forget.”

- “I’m much less likely to take care of myself when I’m using and also taking care of myself helps me keep from using. It works both ways.”

1e: Add more skills training for building positive relationships

- “I thought it was good, especially the “stick with the winners” [because it talked about] being around positive people and having positive people in your life to have a good structure of life.”

- In regards to increasing my support system, “I really loved this session. I liked it better than any other session. It grabbed my attention.”

2. Implementation Strategies

2a: Improve training for all START NOW clinicians

- “There’s nothing wrong with the content. It’s all about the delivery.”

- “The resident with [my doctor] seemed like she was not prepared.”

2b: Writing down responses should be optional

- “I like to write things down.”

- “I hate writing things down. I’ll never do it.”

- “I can’t write because of my arm, but I really loved this session.”

2c: Each participant should have their own personal workbook

- “It would be beneficial to take binders home and have actual things to look at home. I can think about it all I want.”

2d: Real life practice exercises (“homework”) should be encouraged but not mandatory

- “Positive reinforcement at the end of the session will help me to motivate myself to do the practice exercises.”

- “I never do the homework because I have so much going on at home.”

- “Homework is better when not written. I use it at home with mom.”

- “I would rather do the activity by just talking about it—not writing the homework.”

3. Other observations

3a: Initial resistance can be easily overcome. Subsequent session improves participants’ opinions of START NOW.

- “I thought it was more structured than other groups I have been in and the new techniques are great.”

- “It was written in the workbook, but it felt real to me. I was surprised it was in the book.”

- “I think that every time we have a session it gets a little better. Like when we first started this, everybody didn’t have a routine. Everybody was learning. But now it seems like it flows better.”

3b: Clinician-patient relationships should be strong.

- “[My clinician] does a really good job. Talks to us like we are human. He tells you the truth with respect.”

- “I trust [my clinician] completely.”

3c: Treat participants as a mature audience

- “[Some content] feels a lot like what my son in fourth grade would bring home from my guidance counselor.”

- “Felt childish. [The lesson] could be a little more involved and aimed towards people who are adults dealing with addiction problems.”