Implementation of computer-assisted
therapy for substance misuse: a qualitative
study of Breaking Free Online using
Rogers diffusion of innovation theory
Sarah Elison, Jonathan Ward, Glyn Davies and Mark Moody
Dr Sarah Elison is the Head of
Research, Dr Jonathan Ward is
the Managing Director and
Glyn Davies is the Service
Development Director, all are
based at Research and
Development Department,
Breaking Free Online,
Manchester, UK.
Mark Moody is the Executive
Director based at North &
Midlands Regional Office, CRI,
Leeds, UK.
Dr Sarah Elison, Dr Jonathan Ward
and Mr Glyn Davies are all
employees of Breaking Free Online
where the Breaking Free Online
treatment programme has been
developed.
DOI 10.1108/DAT-05-2014-0025
Abstract
Purpose The purpose of this paper is to explore the adoption and implementation of computer-assisted
therapy (CAT) using Breaking Free Online (BFO) in a social care and health charity working with people
affected by drugs and alcohol dependence, Crime Reduction Initiatives (CRI).
Design/methodology/approach Semi-structured interviews were conducted with service managers,
practitioners, peer mentors and service users. Data were thematically analysed and themes conceptualised
using Rogers Diffusion of Innovation Theory (Rogers, 1995, 2002, 2004).
Findings A number of perceived barriers to adoption of BFO throughout CRI were identified within the
social system, including a lack of IT resources and skills. However, there were numerous perceived benefits
of adoption of BFO throughout CRI, including broadening access to effective interventions to support
recovery from substance dependence, and promoting digital inclusion. Along with the solutions that were
found to the identified barriers to implementation, intentions around longer-term continuation of adoption of
the programme were reported, with this process being supported through changes to both the social
system and the individuals within it.
Research limitations/implications The introduction of innovations such as BFO within large
organisations like CRI can be perceived as being disruptive, even when individuals within the organisation
recognise its benefits. For successful adoption and implementation of such innovations, changes in the
social system are required, at organisational and individual levels.
Practical implications The learning points from this study may be relevant to the substance misuse
sector, and more widely to criminal justice, health and social care organisations.
Originality/value This study is the first of its kind to use a qualitative approach to examine processes of
implementation of CAT for substance misuse within a large treatment and recovery organisation.
Keywords Substance misuse, Innovation, Technology, Computer assisted therapy, Recovery, Treatment
Paper type Research paper
Introduction
In recent years there has been a shift away from conceptualising substance dependence as
a chronic relapsing condition towards a solution-focused recovery paradigm (Best and
Laudet, 2010; el-Guebaly, 2012; White et al., 2012). This new paradigm focuses on increasing
the individuals internal and external coping resources, or recovery capital (Best and Laudet,
2010; Cloud and Granfield, 2008; Laudet and White, 2008), to enable them to overcome the
psycho-social difficulties driving their substance dependence. Now this shift is taking place, it is
important to ensure that service users have access to evidence-based recovery-oriented
interventions that they can use both with the support of professionals and alongside their
community peers. While it is important to involve the recovery community in the design and
VOL. 14 NO. 4 2014, pp. 207-218, C Emerald Group Publishing Limited, ISSN 1745-9265 j DRUGS AND ALCOHOL TODAY j PAGE 207
 delivery of any recovery-oriented interventions, these must also be underpinned by a robust
scientific evidence-base (Craig et al., 2008). Optimising fidelity of delivery is an additional
challenge given that many interventions are designed to be both peer-facilitated and
practitioner-facilitated.
One potential solution is to deliver interventions as computer-assisted therapy (CAT), using
digital technology to provide intervention content during sessions (Carroll and Rounsaville,
2007). A growing body of research has demonstrated that evidence-based psycho-social
interventions (PSI) using this method of delivery can result in significant improvements in a range
of clinical outcomes (Bickel et al., 2008; Carroll et al., 2008, 2009, 2011; Elison et al., 2013; Kiluk
et al., 2010; Moore et al., 2011; Sholomskas and Carroll, 2006). This method of delivery may
also carry the additional advantage of increasing standardisation of delivery and hence the
effectiveness of change techniques that are included in these interventions (Bickel et al., 2008;
Moore et al., 2011).
Despite the potential for technology to increase access to effective interventions, the
introduction of such technology could be perceived as disruptive by some healthcare
professionals, with the phrase digital disruption (Schmidt and Cohen, 2010) now being used to
describe how new technologies may disrupt current work practices. How disruptive this process
is perceived to be may impact on how readily potentially effective technology-based
interventions are diffused throughout health care systems, and thus how accessible such
interventions are to service users (Dixon-Woods et al., 2011; Fitzgerald et al., 2002).
This is predicted to be an increasingly salient issue as the growth of Health 2.0 transforms the
ways in which technology allows individuals to monitor their health and access interventions.
Additionally, the process by which new methods of health care might be incorporated into
common, daily practice may also be a worthwhile focus of study. Indeed, the process of diffusion
of innovative healthcare provision has been a key focus during the current NHS reforms,
evidenced by the recent NHS document outlining procedures for disseminating innovative
health care interventions (NHS, 2011).
Diffusion of Innovation Theory (Rogers, 1995, 2002, 2004) (see Figure 1) seeks to explain how
novel ideas, products and practices are adopted by members of a specific social group, so using

Figure 1 Rogers diffusion of innovation theory

CONTINUED
ADOPTION

CHARACTERISTICS
ADOPTION
OF USERS
DISCONTINUANCE

PROCESSES

KNOWLEDGE PERSUASION DECISION CONFIRMATION

LATER ADOPTION

CHARACTERISTICS PERCEPTIONS OF
REJECTION
OF SOCIAL SYSTEM INNOVATION
CONTINUED
REJECTION
TIME

Sources: Rogers (1995, 2002, 2004)

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this theory may aid conceptualisation of change processes when new technologies are adopted
and diffused through health care organisations. This theory has been used in recent years in a
review examining dissemination of innovative treatment approaches to substance dependence
more generally (Miller et al., 2006). However, this review did not focus on technology-based
treatment approaches, but instead included more traditional human-facilitated treatments.
This qualitative interview study therefore utilises Rogers Diffusion of Innovation Theory (Rogers,
1995, 2002, 2004) to conceptualise change processes that occur when a new substance misuse
treatment programme delivered via a digital technology platform, Breaking Free Online (BFO) is
adopted and implemented within Crime Reduction Initiatives (CRI), a criminal justice, social care
and health charity. BFO is an online treatment programme for substance misuse and associated
mental health difficulties (Elison et al., 2013, 2014) that can be delivered as CAT or self-help.
The BFO programme provides access to 22 interactive evidence-based intervention strategies
taken from cognitive-behavioural therapy (CBT Beck et al., 2011) and mindfulness approaches
(e.g. Marlatt et al., 2008). Audio and visual technology is used to deliver intervention content that
has traditionally been delivered with service users via face-to-face interaction with a practitioner or
paper-based documents. The content of the programme was developed through consultation
with mental health and substance misuse professionals and service users and a review of the
literature around evidence-based approaches for substance misuse. All intervention content is
structured via a six domain model that conceptualises various aspects of biopsychosocial
functioning that are associated with substance misuse and comorbid mental health difficulties.
This model, the Lifestyle Balance Model has been developed by the authors and is based
on the commonly used five factor model used in mental health case formulation (Greenberger
and Padesky, 1995; Williams and Garland, 2002). Initial outcomes evaluation indicates that the
BFO programme may significantly improve cognitions and behaviours around substance misuse,
and also general quality of life (Elison et al., 2013; Elison et al., 2014; Neale and Stevenson, 2014).

Method
(i) Design
This was a semi-structured qualitative interview study with service users and staff at CRI, a social
care and health charity working with people affected by drugs, alcohol, crime and other issues.

(ii) Participants
Participants were adults service users and staff at CRI. A total of 18 participants were
interviewed for the study, comprising three service managers, three practitioners, five peer
mentors and seven service users.

(iii) Procedure
Qualitative interviews explored how BFO had been implemented within CRI services, staff and
service user attitudes towards CAT as a recovery-oriented tool for substance misuse, and any
perceived benefits of BFO. All interviews were conducted within CRI services and recorded
using a digital recording device before being transcribed verbatim. Transcription was conducted
by the lead author (SE) and transcription accuracy was checked in 20 per cent of the audio files
and their corresponding transcripts by a second researcher not associated with the study.
After all interviews were fully transcribed in Word, documents were imported into QSR NVivo 10
(NVivo 10, 2012). Recommended procedures for thematic analyses in the social sciences were
then followed (Braun and Clarke, 2006), which are described below.
The process of thematic analysis was guided by the theoretical framework of Rogers Diffusion of
Innovation Theory (Rogers, 1995, 2002, 2004). Using the key components of the theory, which
describe the various phases of diffusion and implementation of innovations, interview transcripts
were explored for themes and sub-themes that described key processes or features of each
phase of diffusion and implementation. This process was facilitated via the identification
of quotes that illustrated each theme and sub-theme. All transcripts and their themes and
sub-themes were checked three times in order to check accuracy of coding and search for
possible further themes and sub-themes that had not originally been identified.

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 This process was continued until no new themes or sub-themes were identified from the data
and theoretical saturation had been reached indicating no further data were required to be
collected. Any discrepancies in data coding were discussed until consensus had been reached.
All transcripts were found to be accurate representations of audio data. As this was an
exploratory service evaluation within social care settings, no formal ethical approval was
required, although local approvals were sought from managers of services included in the
evaluation.

Results
Themes are conceptualised using appropriate components of Rogers Diffusion of Innovation
Theory (Rogers, 1995, 2002, 2004).

(iv) Characteristics of social system

Characteristics of social system are defined as lying at the level of the social system within
which a new innovation is being adopted. The principal social system characteristic with
adoption of BFO was IT infrastructure, with some interviewees reporting that prior to
implementation of BFO, some CRI services did not have IT equipment:
[y] we didnt have the computer facilities before, but weve got the iPads now, so were moving it
forward (Practitioner 2).

It was also reported that due to the wide range of interventions available to service users, it was
sometimes difficult for staff to keep BFO high on their agendas with the programme not always
being made available as an option:
I think its about that momentum thing and we have a lot of new developments, we have a lot on offer
[y] so unless you keep it on the agenda constantly, its one of those things that staff kind of forget to
offer [y] (Practitioner 2).

One suggested solution to this was staff being provided with protected time to explore the BFO
programme themselves so that they could familiarise themselves with the benefits of it:
[y] we had the idea about giving the time to staff for them to actually go through the programme
themselves [y] to deal with elements of our own lives, so enabling us [y] the protected time to go
through the programme themselves (Practitioner 1).

Finally, the way in which the recovery agenda has affected power distribution within the
substance misuse field was also reported as being associated with adoption. Staff interviewed
reported that one of the advantages of adopting BFO was that it facilitated the transference of
some control over treatment to the recovery community:
[y] we do have control and think were aware of that [y] and we covered power imbalances,
but I think its about us realising we [staff] still hold a lot of power, but its about how you use it.
And if we have power, we have to give it back, and this [BFO] is a way of giving it back
(Service Manager 3).

(v) Characteristics of users

Characteristics of users relate to staff and service user opinions and attitudes around CAT for
substance misuse recovery and also computer literacy amongst staff and service users. One of
the user level influences around adoption that was raised was prior assumptions about the BFO
programme and how it could be implemented. One service manager reported that at first there
was an assumption that service users would be able to access and use BFO without much staff
support, given that it was online programme that could be used as self-help:
[y] you think that when you give someone something they will access it, and although we can tell
them about the benefits of it, its whether they feel able to do that (Practitioner 3).

However, despite these prior assumptions, staff reported that they understood that service users
may need support from staff in accessing the programme, particularly if IT skills were limited:
I know some people who are not computer literate so you almost have to take a back step and
almost, like, make them computer literate [y] (Service Manager 1).

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However, anxiety amongst staff about their own IT skills was also reported as a potential barrier
to implementation:
[y] weve got a lot of staff, well not a lot, but several members of staff that arent great with IT and
immediately thats a barrier for them: Well if I cant use it, how am I supposed to get a service user to
use it? So I think thats been a barrier (Service Manager 2).

But despite anxieties around IT skills, these life skills were reported as being important, not only
for accessing BFO, but for life more generally:
[y] in between people can come in and out setting up e-mail addresses and all that sort of stuff cos
they need that sort of stuff for the Job Centre, and they also need that setting up on Breaking Free
(Peer Mentor 4).

One service user who was due to start working as a peer mentor reflected on his own
experiences of overcoming anxiety around IT skills:
I had to learn to do an e-mail cos Id never done it! But Im ok with it now, I help other people now, its
not a problem (Service User 2).

And another described how once he had developed his IT skills he found it easy using the
programme:
I found it easy. I did loads and loads in hours, I did 3 or 4 hours I was just skirting through it, it was easy
(Service User 1).

In addition to issues around IT skills, interviewees reported other factors associated with
adoption of BFO, including staff perceptions of workload:
I think workers have competing priorities in their own heads, so as much as youd like to promote this
thing youre doing, youll be thinking, have I done that risk assessment, have I done that plan, have I
done those notes. So you have competing priorities [y] (Practitioner 3).

Despite concerns over workloads, staff reported that they understood the potential benefits
of the programme and how it complements their own working practices:
Its [BFO] so forward thinking though, isnt it? So in terms of moving forward its [BFO] really good, cos
not everyone can access services due to work commitments. And some people, you can do it in your
own time. Thats the beauty of it, you can do it as and when youve got the time. So I think its a brilliant
idea, we just need to promote it and really push it forward (Practitioner 2).

(vi) Knowledge of innovation

Knowledge of innovation refers to how users of the innovation understand the purpose of it
and how it might best be implemented. First, interviewees reported that they understood how
BFO fits with the recovery-oriented ethos of CRI:
[y] were very recovery focused here, like five ways to wellbeing, recovery capital [y] cos Breaking
Free is about those coping skills and removing the [focus on] substances from it is a real kind of selling
point for people (Service Manager 2).

Both staff and service users reported having an understanding of the fact that the programme
did not address solely substance use and that anyone could benefit from using the techniques in
the programme for personal development. For example, one peer mentor who had been
abstinent for a significant period said:
[y] thats what made me go on and do it all, even though I wasnt even using drugs, like I had a lot of
red areas even though I wasnt using drugs, just because youve always got your underlying
problems. Thats the thing, isnt it? (Peer Mentor 1).

In addition to understanding the philosophy and purpose of BFO, interviewees also reported
having an understanding of why providing PSI on an online digital platform is beneficial.
One service manager reported that if someone came into service and decided they did not want
to access the support on offer, they could use BFO at home:
[y] even if someone comes in and they dont want the Tier 3 service, theyve got the option of taking
BFO home and using that at home instead of coming into recovery worker appointments
(Service Manager 3).

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 And staff and services users alike discussed specific groups of service users that might benefit
from the programme:
I think itll be good for women if Im honest, married women with children, or people fearful of coming
into service, perhaps the harder to reach clients, or maybe the more restricted clients like the disabled
clients (Service User 4).

Another service user echoed these views on the ability of BFO to increase accessibility and
commented:
[y] if people struggle with accessibility, so if theyre a parent, and maybe they cant get in on school
holidays, cant get to mutual aid groups in the evening cos theyve got child care responsibilities, its
another intervention another option, if accessibility is a bit of an issue (Service User 7).

However, some staff reported that amongst some of their colleagues, a lack of understanding of
the programme was causing some anxiety around how introduction of the programme may
affect professional roles. One service manager describes this:
This is my job, this is what I do, this is what I provide, which is now being provided by a computer.
And I dont know whether thats something that people feel, that if everyone goes onto this option
[BFO], thats it putting them out of a job! (Service Manager 3).

Despite this anxiety, staff interviewed did recognise that BFO was not designed to replace
practitioners, but instead to complement and enhance their work, for example, by providing
service users with additional, continued access to support and interventions between
key-working sessions:
[y] it [BFO] complements the one-to-one work, and it continues it when you might have an hour with
your Recovery Worker once a month, it continues it in the meantime, doesnt it? (Practitioner 2).

(vii) Perceptions of innovation

Perceptions of innovation refers to ways in which users of the innovation perceive it, and
its potential benefits and costs. Perceptions of innovation are distinct from knowledge of
innovation as they refer less to knowledge about concrete facts about the innovation and refer
more to opinions about the innovation, and therefore are more subjective. Generally, perceptions
of the BFO programme were positive, with staff and service users describing perceived general
benefits to adopting the programme throughout CRI. One practitioner said:

I was saying to the staff today, its an absolutely fantastic package, in terms of CAT, and just moving so
much forward so that service users can access treatment at home [y] Its just taken every bit of
technology and used it to support someone in their recovery (Practitioner 3).

Additionally, a service user reported that for him, two and a half years into recovery, there were
potential benefits to using the programme:
Its another option, even for me two-and-a-half years down and a Recovery Champion and Im having
it for me personally (Service User 4).

However, another service user who was also in recovery reported that she did not feel the
programme was as relevant to her considering she had not been using substances for some
time:
[y] a year ago itd have been really useful, but now there needs to be an aftercare bit to it,
then it would have been more relevant. Cos I dont think the questions were as relevant to me
as they could have been. Like I say a year ago it would have been really good, the way my life
was then, but then when I went through it I thought this isnt really where Im up to now [y]
(Service User 3).

In addition, interviewees also discussed perceptions of more specific aspects of the

programme, such as particular strategies contained within it. For example, one service user who
was in the early stages of their recovery described how the initial assessment helped them to
understand their main difficulties:

[y] what stood out for me is how you plan and you input on the assessment and it tells you where
youre up to [y] (Service User 6).

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Additionally, both service users and staff reported that the strategy within the programme which
helps people to plan their time effectively was useful for service users who perhaps might be at
risk of relapse through boredom. So one service manager said:
[y] theres those diaries isnt there, like the activities and filling peoples time. So you can do a
recovery session on a one-to-one basis, based on well, what are you going to fill your time with over
the next fortnight, what activities are you going to do? (Service Manager 1).

And a service user reported that he thought the programme could relieve boredom more
generally:
[y] it relieves a lot of boredom does that, and its confidential. I wouldnt say this ordinarily but Im
quite excited about it to be honest (Service User 5).

The goal setting strategies within the BFO programme were also reported as being useful,
particularly early on in recovery, helping people to plan achievable goals from week to week to
reach stability:
Goal setting as well, people have used it for goal setting. Ive got a client who prints out his goals and
says Ive been on Breaking Free, this is what Im doing this week, this is what Ive done, this is what
Im doing next week, and the week after. And well use them and review them [y] (Practitioner 1).

Another service user reported using the goal setting strategy not just for reaching her goals with
regards to her substance use, but to reach goals in her daily life more generally:
Service User 2. The best bits Ive found are the one with the mountains [y].

Researcher. Oh right, where youre setting your life goals?

Service User 2. Yeah, and I use that not just for drug stuff, but also for everyday things like housing or
whatever.

Staff and service users also reported that the multi-media mindfulness based cognitive therapy
and relaxation techniques were well received by those using the programme, with mindfulness
also being an intervention approach that was a focus for the holistic recovery-oriented ethos
of CRI:
[y] you can just zone out, it gives you time to relax. And mindfulness is something were working on
as a project [y] its something Im personally interested in, its something thats quite evident in the
Breaking Free interventions as well [y] (Peer Mentor 4).

For those service users whose substance use was stabilised, dealing with underlying mental
health difficulties was more a focus when using the BFO programme. One peer mentor
describes how the cognitive restructuring or mind traps strategy within the programme was
helping her with this:
What comes to mind myself is the mind traps, I thought that was good. Cos for me, the sort of
person I am, that was really useful cos Ive had mental health problems as well, like anxiety and one
thing and another. So those mind traps are traps I go into anyway, never mind with the drugs
(Service User 3).

Staff and service user perceptions of how the BFO programme supports relapse-prevention
were also discussed during the interviews. Interviewees reported that they could see ways that
the programme might be beneficial for this. For example, one practitioner said:
I think for relapse prevention, and as part of an aftercare plan, knowing that theres something that you
dont need to come back into a service for (Practitioner 3).

(viii) Persuasion and decision to adopt

Persuasion and decision to adopt refers to the reasons why staff and service users in CRI
decide to adopt and use the BFO programme. First, staff described the ways in which they were
persuaded to adopt BFO in their daily practice with service users. One practitioner describes
that staff had to go beyond gaining knowledge of the philosophy underpinning it and the
content within it, and process this knowledge to a deeper level by actually experiencing some
change in their own lives as a result of using the strategies within the programme. A member of

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 staff described how using the programme to instigate change in their own life might then make it
easier for them to provide a more authentic rationale to service users who might benefit from the
programme:
[y] the first couple of times I spoke to clients about it I wasnt so convincing, but then after I used it
myself I could explain the benefits of it, and explain the progress I made and what I was trying to
achieve. But mine wasnt with drugs (Practitioner 1).

Once staff had been persuaded of the efficacy of the intervention content, they then had to
persuade service users of the benefits of using the programme. One member of staff described
using rhetorical techniques when engaging in discussion with service users about the benefits of
using the programme to address their substance dependence:
I tell them its [BFO] not just a CRI programme, its written by people who know what theyre talking
about [y] if you want to go to a top psychologist on Harley Street and pay them whatever, well youre
going to do the same interventions here on this programme (Service Manager 1).

Staff also described using more practical techniques to persuade service users of the benefits of
using the programme, such as providing support with using IT:
Im not convinced that just having a drop in where people just us it for themselves, for some people
thatll work but treatment nave people, hand holding, group, a bit of education, a bit of preparation for
it as well (Practitioner 3).

A peer mentor also described that in addition to demonstrating to service users how the
programme may benefit them, any sessions that were run had to be enjoyable in order to
encourage sustained service user participation:
But its got to be enjoyable, it has to be enjoyable. And the groups have to be run by someone who is
going to make it a bit of fun, you need a bit of fun in there you know? (Peer Mentor 4).

(ix) Adoption
Adoption refers to the process whereby an innovation is adopted within an organisation and
the practical structure and systems put in place to facilitate this. One service manager described
the way in which service users initially entering treatment were informed of the BFO programme:
[y] when people come into service, theyve got a menu with all the services we offer. And then
the service user will just tick which ones they want, and BFO is one of those interventions
(Service Manager 3).

Other staff interviewed described additional methods of increasing service user awareness of
the programme by giving out cards that provide access to the programme in induction or
welcome packs that all service users receive when entering the service:
[y] at the first point of contact when they come in, and we give them the welcome pack outlining all
the services on offer, BFO will be given in that, as an option (Practitioner 3).

Staff also reported that in their services, peer mentors and recovery champions, individuals
who had themselves been through recovery, were taking the lead on promoting and facilitating
the BFO programme and that this worked well:
[y] it was actually our Recovery Champions that were put in the lead of carrying it [BFO] on and
because theyve been through treatment themselves, they were really, really passionate about it
(Service Manager 2).

A peer mentor also described how this method of implementation was particularly effective:
I like the idea of the POD working and the peer mentors actually using the programme themselves
and then acting as facilitators (Peer Mentor 5).

The peer mentor in the previous quote described POD working, which is a method of mutual-aid
facilitation that was reported by both staff and services users as being effective. POD is an
acronym for positive outcome discussion. One practitioner described how this format worked
well when they included group discussion of the multi-media strategies within BFO:
[y] the way I would run it is youd watch the video, then thered be a discussion, then youd get
people to think about sharing some experiences, not just watching the video. It was more interactive,

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 there was interactive video and information giving. And then wed discuss it and get people to relate it
back to their experience [y] (Peer Mentor 3).

(x) Continued adoption

Continued adoption refers to the perceived benefits or costs of continuing to adopt the
innovation, and the proposed methods that will facilitate this process. Reflections on lessons
learnt through initial adoption were discussed with staff and service users during interviews
at CRI, and these reflections provided insights into how the successful adoption of the BFO
programme at CRI might continue. A key means of successful continuation of adoption of BFO
was suggested to be sustained peer mentor facilitation of BFO groups, which one service
manager envisioned becoming the principal means of implementation:
Within the next year Id like to see us with lots of volunteers and peer mentors who have done the
programme who want to then facilitate every client coming in: Come on in, sit down, this is brilliant,
lets get you logged on, and move it on that way. So theyre actually facilitating it (Service Manager 2).

This particular method of implementation, though considered as beneficial to staff and service
users, was also reported as requiring some support from staff to help with this. Another service
manager said:
[y] I think you do need that balance. I think you still need the governance. Its about being objective
about things and about having the right forums and things but managing them (Service Manager 3).

Indeed, staff involvement was also reported as being important by service users, who suggested
that the programme could also be used in one-to-one key-working sessions in addition to group
sessions:
I personally think it could be used more by the key workers, in one-to-one sessions, doing specific
interventions that are in your care plan (Service User 5).

However, despite the practicalities around continuation of adoption, one peer mentor described
how it was attitudes towards change more generally that was most important in achieving lasting
and continued adoption of BFO within CRI. He said very succinctly:
Well, for things to change, people need to change. Mindsets need to change, so its just getting over
those first hurdles, thats all it is (Peer Mentor 1).

Discussion
This paper reported on findings from a qualitative study exploring adoption and diffusion of CAT
for substance dependence (BFO) throughout a social care and health charity, CRI. This study
was the first of its kind as never before has this process been conceptualised using Rogers
Diffusion of Innovation Theory (Rogers, 1995, 2002, 2004). A narrative has emerged from the
data that describes the processes by which staff and services users at CRI have responded to
the introduction of BFO within the organisation. These processes involve perceptions of costs
and benefits of using the programme, and adjustments that have been made on an individual
and organisational level to accommodate this technology-enhanced approach to recovery-
oriented interventions for substance dependence.
Even though perceptions of BFO were positive, the introduction of the programme was still
perceived as disruptive. This finding concurs with previous research around disruptive
innovations that has demonstrated that even when benefits of innovations are recognised,
when adjustments have to be made in order to accommodate the innovation, this process may
be perceived as being disruptive (Schmidt and Cohen, 2010). This disruption is largely due to
changes that have to be made in terms of daily working practices, with this being something that
was reported by those interviewed for the present study. Additionally, changes at a wider
organisational level may also be perceived as disruptive, with this theme again emerging from
the data collected with participants at CRI. Organisational level disruption was mainly due to the
necessity for the introduction of new IT equipment that previously was not present.
Although staff and service users reported that the introduction of BFO was disruptive, this finding
could be indicative of how large organisations respond to the introduction of new technology

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 more generally. For example, previous research has demonstrated this effect in relation to the
introduction of electronic health records (Ford et al., 2006). This is likely to be an ongoing
difficulty over the next decade as more public services move online (Christensen and Remler,
2009). This has caused some concerns that already marginalised groups, such as those living in
areas where there are high levels of social and economic deprivation, may become yet more
marginalised due to lack of access to, and skills in, IT (Fuchs, 2009). Efforts are now being made
to close this digital divide by providing IT skills training to those who need it, and opening up
access to IT through public spaces such as libraries. In the case of CRI, a lack of IT equipment
was initially perceived as being a barrier to implementation. However, the introduction of BFO
stimulated improvements to the organisations IT infrastructure, resulting in a positive outcome.
Organisational level disruption in this study also referred to more intangible factors, such as the
movement away from practitioner-provided interventions into mutual-aid peer and recovery
community-led approaches. This shift was described by interviewees as something happening
across the substance misuse field more generally and was relevant not only to the
implementation of BFO but many treatment approaches. Indeed, a recent UK Government
report has stated this shift as being a major priority given its potential to advance substance
dependence treatment (HM Government, 2010), although it is likely that many staff and service
users may at first experience this change in treatment ethos as disruptive, despite the potential
benefits.
One key finding from the study was that although there were a number of perceived benefits of
interventions such as BFO being implemented in a peer-led way, some staff support and
guidance was still required in order to ensure that service user access to and effective delivery of
BFO was optimised. This could prove to be a useful learning outcome that might inform
a number of peer-led interventions that have recently been introduced as options for those
accessing support for their substance dependence.
As with any research, this study did carry limitations that should be considered. First,
participants interviewed were self-selecting, so it is possible that proponents of BFO were those
who volunteered to participate, meaning that the opinions of staff and service users either
indifferent to the programme or critical of it may not have been adequately accessed. This may in
part explain why on the whole, views on BFO that were expressed by participants were largely
positive. A second limitation lies in that perceived benefits of BFO were anecdotal, with no
objective measures of recovery capital, mental health and substance use being collected.
Further research is now underway to explore longer-term diffusion and implementation of BFO
throughout CRI, to examine how this process may change over time as such an innovation
becomes more firmly embedded within the organisational culture. Additionally, this work is exploring
the diffusion and implementation of BFO across the whole organisation, rather than focusing on
a small sample of representative services. This research is utilising a mixed-methods approach
incorporating both quantitative data and also qualitative data such as those reported here.

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Corresponding author
Dr Sarah Elison can be contacted at: selison@breakingfreegroup.com

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