Addiction Recovery in a Rural Minnesota Community: Piloting "Positive Peer Journaling" Part II
Phase: NA
Conditions: Addiction
Sponsor: University of Minnesota

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
Page 1 of 67 
Revised: 6/20/2019 
PROTOCOL COVER PAGE 
 
 
 
 
Protocol Title 
Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
Principal 
Investigator/Faculty 
Advisor 
Name: Amy R. Krentzman 
Department: Social Work 
Telephone Number: 612-625-2312 
Email Address: akrentzm@umn.edu 
Student 
Investigator 
Name: N/A 
Current Academic Status (Student, Fellow, Resident): N/A 
  
Department: N/A 
Telephone Number: N/A 
Institutional Email Address: N/A 
Scientific 
Assessment 
Not required, Minimial Risk Study 
Version 
Number/Date: 
Version: 11 
Date: 20 June 2019 
 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
Page 2 of 67 
Revised: 6/20/2019 
REVISION HISTORY 
 
Revision # 
Version Date 
Summary of Changes 
Consent Change? 
2 
10.11.18 
Miscellaneous small changes 
required as part of pre-review 
process 
Yes 
3 
11.12.18 
7 changes itemized in 10/30/18 
letter from the IRB. 
Yes 
4 
12.20.18 
Numerous revisions to screening 
consent, consent form, flyer, and 
protocol that adapt the study to 
the treatment center setting and 
finalize the details of study 
implementation 
Yes 
5 
2.3.19 
Revisions to the protocol that 
clarify research assistant duties 
and content of treatment group 
sessions. 
No 
6 
2.12.19 
Numerous minor revisions to 
screening consent, regular 
consent, screening check sheet, 
and protocol. 
Yes 
7 
2.26.19 
Minor revisions to informed 
consent document, HIPAA 
Authorization form, and a footnote 
describing that in addition to 
counting the journal entries 
uploaded to Qualtrics we will 
additionally manually count the 
journal entries in the paper 
journal, to obtain a more accurate 
count. 
Yes 
8 
3.18.19 
Now we are ready to recruit the 
second set of 5 women. Therefore, 
we submit changes to various 
study documents. We will offer the 
group sessions over three weeks 
instead of over four weeks. Minor 
changes to informed consent and 
screening consent documents. 
Minor changes to protocol. Now 
Yes 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
Page 3 of 67 
Revised: 6/20/2019 
Revision # 
Version Date 
Summary of Changes 
Consent Change? 
that we have finished the first 8-
session group, we upload a 
detailed list of contents for all 8 
sessions and submit the handouts 
we used during group. During 
screening we will have participants 
sign a release of information with 
the host setting, so we can return 
their phone calls. We will also 
teach them a few iPad basics 
during screening, to spend more 
time in group on the therapy and 
not on teaching the technology. 
We added three standardized 
measurement instruments and 
some single-item assessment 
instruments. We will revise the 
actual journal. Now, we include 
the content of handouts that we 
have used in group in the journal 
pages (see attachments). Details 
are described herein. 
9 
3.25.19 
Responding to required 
modifications from the IRB. 
Regarding our use of a trauma 
assessment instrument at baseline: 
in this revision, we clarify that we 
use the first item of the trauma 
instrument only to assess trauma 
exposure and not trauma 
symptoms, we ask this question to 
enable us to describe the 
characteristics sample. Wayside 
already screens all clients for 
trauma, but we will notify Wayside 
if any participant in the study 
seems to be having difficulty with 
study activities because of trauma 
or any other reason. 
 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
Page 4 of 67 
Revised: 6/20/2019 
Revision # 
Version Date 
Summary of Changes 
Consent Change? 
10 
6.3.19 
Protocol revised to include an 
electronic survey to be sent to the 
staff of the host treatment center 
(“Wayside”). The purpose of this 
staff survey is 1) to gather 
information about the 
implementation of the study 
logistics at Wayside to optimize 
logistics before we recruit for the 
third cohort and 2) to gather staff 
perspectives of client experiences 
of study participation. 
No 
11 
6.20.19 
Miscellaneous changes to protocol 
as we prepare to recruit for the 
third and final cohort: changes to 
exit interview questions; minor 
changes to protocol; minor 
changes to questionnaires.  
No 
 
 
 
 
 
 
 
 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
Page 5 of 67 
Revised: 6/20/2019 
Table of Contents 
 
1.0 
Objectives................................................................................................................. 7 
2.0 
Background ............................................................................................................ 10 
3.0 
Study Endpoints/Events/Outcomes  ...................................................................... 15 
4.0 
Study Intervention(s)/Interaction(s) ...................................................................... 15 
5.0 
Procedures Involved .............................................................................................. 20 
6.0 
Data Banking .......................................................................................................... 37 
7.0 
Sharing of Results with Participants ...................................................................... 38 
8.0 
Study Duration ....................................................................................................... 38 
9.0 
Study Population .................................................................................................... 39 
10.0 Vulnerable Populations .......................................................................................... 44 
11.0 Number of Participants .......................................................................................... 46 
12.0 Recruitment Methods ............................................................................................ 46 
13.0 Withdrawal of Participants .................................................................................... 48 
14.0 Risks to Participants ............................................................................................... 49 
15.0 Incomplete Disclosure or Deception ..................................................................... 52 
16.0 Potential Benefits to Participants .......................................................................... 52 
17.0 Data Management ................................................................................................. 52 
18.0 Confidentiality ........................................................................................................ 53 
19.0 Provisions to Monitor the Data to Ensure the Safety of Participants ................... 54 
20.0 Provisions to Protect the Privacy Interests of Participants ................................... 56 
21.0 Compensation for Research-Related Injury ........................................................... 57 
22.0 Consent Process ..................................................................................................... 57 
23.0 Setting .................................................................................................................... 58 
24.0 Multi-Site Research ................................................................................................ 59 
25.0 Resources Available ............................................................................................... 59 
26.0 References ............................................................................................................. 60 
 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
Page 6 of 67 
Revised: 6/20/2019 
ABBREVIATIONS/DEFINITIONS 
 
12-step programs = Community-based mutual-aid groups (such as Alcoholics 
Anonymous) comprised of individuals in recovery from a SUD and/or AUD 
that follow the 12 suggested steps of recovery. 
 
AA = Alcoholics Anonymous 
 
AUD = Alcohol Use Disorder 
 
In recovery = Maintaining abstinence from addictive substances in order to 
address an AUD and/or SUD and place the AUD and/or SUD into remission.  
 
PPJ = “Positive Peer Journaling”  
 
SMART goals = Goals that are Specific, Measurable, Achievable, Realistic, and 
Timely. 
 
Sponsor = A member of a 12-step program who often has more experience 
with recovery than another member who is selected by the less experienced 
member to serve as that person’s guide and to take a special interest and 
spend additional time with that member.  
 
SUD = Substance Use Disorder 
 
TGT = The gratitude practice called the “Three Good Things” exercise. 
 
WFO = The daily practice where wishes for others are listed. 
 
 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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Revised: 6/20/2019 
1.0 
Objectives 
1.1 Purpose: Citizens across Minnesota suffer from substance use disorders 
and their consequences. Nearly 9% of Minnesotans met diagnostic criteria 
for a substance use disorder (SUD) in 2010.1 Negative consequences from 
substance use disorders suffered by Minnesotans have included death, 
arrest, incarceration, homicide, and suicide.2 The economic cost of alcohol 
use in the State was estimated at $5.06 billion, or $975 per taxpayer, in 
2007.3 However, the citizens of Minnesota residing in the rural parts of the 
State are likely to be at greater risk.  
Sociologists have identified the classic features of rural life. These features 
include population dispersion, physical distance, absence of services, and 
“the larger territory over which people travel to meet their needs.”4 These 
features could make recovery more difficult to sustain in rural areas, 
because successful recovery involves distancing one’s self from former 
drug using friends, making new non-drug using friends, and initiating 
recovery-oriented social activities.5 These tasks are facilitated by access to 
a wide range of social connections and multiple options for recreational 
activity—things that are sparse in rural life.  
The current study is the second part of a two-part program of research on 
recovery from addiction in rural southeast Minnesota. The first part of this 
program of research is an active study entitled, Addiction Recovery in a 
Rural Minnesota Community: Piloting “Positive Peer Journaling,” IRB ID 
#1611S99341. 
This research protocol describes the second part of the study. In this study, 
Addiction Recovery in a Rural Minnesota Community: Piloting “Positive Peer 
Journaling” Part II we focus on developing, refining, and enhancing the 
logistics of an intervention we developed (called Positive Peer Journaling, 
“PPJ”). All aspects of PPJ are described in detail in this protocol (specifically 
in section 4.1, below). However, in order to clarify the sections of this 
protocol that precede 4.1, a brief description of PPJ is provided here. 
Brief description of PPJ. Many spiritual and religious traditions involve the 
practice of moral inventory or moral self-examinination.6 These practices 
involve conducting a review of the day, spirituality, gratitude, and striving 
for self-knowledge and self-improvement.6  The 10th step of Alcoholics 
Anonymous (AA) recommends that members conduct such a daily 
inventory.7 While this practice may benefit AA members, not everyone 
seeking addiction recovery joins AA. Even for those who do, it can take 
time to work steps 1-9 to reach step 10 and begin deriving benefits from it.  

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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We developed PPJ as a simple 10-minute daily practice which reviews the 
past 24 hours on the left hand side of an open-page spread and plans the 
upcoming 24 hours on the right hand side of the open-page spread of any 
standard journal.  
Two primary sources inspired PPJ. The first is AA’s 10th step which 
recommends a regular “personal inventory” where the day is reviewed and 
what went well and what went poorly is identified and acknowledged.7 The 
second source of inspiration for PPJ is the daily action plan recommended 
in some 12-step programs where the upcoming day is planned with health 
and balance in mind, including activities related to “recovery, recreation, 
and relationships in addition to work….”8 The AA 10th step practiced on the 
left hand page and the action plan practiced on the right hand page 
together affirm the value of each sober day and strengthen the odds of 
learning from the day’s events and planning a successful, balanced, and 
healthy upcoming 24 hours, which should strengthen quality of life in 
recovery.  
While each element of PPJ is explained in detail in this protocol (in section 
4.1), we provide a visual snapshot of what a completed daily PPJ entry 
might look like in Figure 1 below. 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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Figure 1. Positive Peer Journaling (PPJ) Example 
Objectives. The main objective of this study is development of the PPJ 
intervention and the feasibility, acceptability, and logistics of treatment 
delivery.  
One primary output of this work is to produce a PPJ treatment manual that 
specifies number of sessions, content for each session, clinician scripts and 
instructions, and group activities. This treatment manual can then be used 
in a future randomized controlled trial.  
A second objective is to observe whether PPJ is associated with 
improvement in hypothesized outcomes. The primary outcomes we will 
examine are enhanced treatment retention and reduced recurrence of 
substance use. We will also explore the association between the 
intervention and a set of hypothesized mediators of the effect of the 
intervention on outcomes, e.g., satisfaction with recovery and improved 
mood. A complete list of hypothesized mediators is outlined in the 
measures section 5.2 of this protocol. While our sample sizes will limit 
quantitative analysis, we will also employ qualitative exit interviews as will 
be described below to meet these research objectives. 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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Revised: 6/20/2019 
2.0 
Background 
2.1 Significance of Research Question/Purpose: Many scholars in the addiction 
field have made the case that clients with alcohol use disorders (AUD) and 
substance use disorders (SUD) should be helped to build an abstinent 
lifestyle that is positively reinforcing and more appealing than active 
addiction.9–12 Many current interventions focus, reasonably and 
necessarily, on reducing pathology,13 i.e., identifying triggers, reducing 
cravings, managing thoughts about alcohol, and coping with relapse.14 
Pathology-based treatments by themselves miss an opportunity to aid 
clients in building a positively reinforcing life in recovery that will make the 
hard work of abstinence worth the effort.  
PPJ is designed to support the construction of a positive, affirming sober 
lifestyle. PPJ emphasizes expressing gratitude and savoring what is positive 
about sober life and making plans to support recovery based on each 
person’s prized values. If satisfaction with recovery is increased, risk of 
relapse should decrease.  
2.2 Preliminary Data: Relevant Study #1. We conducted a qualitative study in 
which we gathered opinions of PPJ from 33 individuals residing in rural 
southeast Minnesota who have knowledge of SUD and AUD treatment and 
recovery. The sample was comprised of 61% people in recovery, 15% 
treatment providers, and 24% treatment providers in recovery. We 
conducted in-depth semi-structured interviews with participants to 
ascertain their perspectives of PPJ. PPJ was presented and practiced one 
time by participants. We asked, “What are your observations and thoughts 
about this journaling practice?” “How can this practice be helpful to 
individuals in recovery, if at all?” and “What might be a downside to this 
practice, if any?” Interviews were audio recorded, transcribed, and 
analyzed for themes.15  
Overall, PPJ was perceived to be feasible and acceptable. The majority 
(79%) stated the practice was feasible, e.g., “nothing too difficult,” “faster 
than I thought it would be,” and “a really easy way to journal.” The 
majority (82%) offered favorable impressions, e.g., “This is just a marvelous 
piece” and “I love it.” A quarter (27%) initially had objections to 
“journaling” but liked the practice after thorough introduction where they 
learned that PPJ involves bullet-pointed lists and not lengthy written 
narratives. One participant said: “That’s my kind of journaling. Just a 
phrase.” A fifth (21%) were ready to get started with the practice right 
away, e.g., “I’m so pumped, I’m going to buy a notebook after this.” A fifth 
(18%) expressed more moderate positive intentions, e.g., “I should show 
this [to the sober house manager],” “I could see using this [for my 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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treatment group],” and “I can talk to my sponsor…and see how we could 
put it in play.”  
Participants stated that the practice would aid recovery by increasing 
awareness of “what is,” e.g., it might aid becoming “more aware of 
themselves, and more aware of what’s going on in their life day to day.” 
The practice would help them to focus their attention on both the positive 
and the negative in a day of recovery, which was identified as helpful. 
Tracking the positive would draw attention to what is going well and help 
give one’s self credit for things going right. It would increase awareness of 
positive changes and provide an opportunity to express gratitude. Tracking 
the negative would help identify issues that need attention, put negative 
things into perspective, and inspire improvement. 
There were two exceptions where people interviewed were hesitant about 
PPJ and in the current study we will take steps to address both of these 
concerns.  
First, people had concerns about a practice that involved writing. Some felt 
writing was beneficial, e.g., “get it out of your head” and “write it down, 
you’ve released it.” Some stated they felt they were not good at “writing 
and all that kind of stuff.” Others said they had “a hard time 
concentrating.” A practitioner recognized that clients often have low levels 
of education, stating, “some of my clients only made it to 3rd grade so they 
get embarrassed to write stuff.” To address this concern, we will explain 
that the practice involves short bullet-pointed lists and not long pages of 
writing. We will explain that grammar and spelling are not relevant for this 
practice. We will explain that while the researchers will review a snapshot 
of a daily entry in the course of research activities, and participants will be 
invited to verbally share aspects of their entries, no other person will be 
shown their entries and no one will critique them. 
Second, some participants of our pilot study expressed concern about 
activity scheduling and planning. Many had positive things to say about 
planning, e.g., it would help them to prioritize tasks and it would provide 
reminders of important tasks. However, for others, planning might 
engender burdensome thoughts, e.g., “I hate remembering what I have to 
do in my home” or could cause feelings of disappointment, “my fear would 
be, I’d start it and then wouldn’t follow through… it would feed into my 
negative thoughts.” To address this concern, we will invite participants first 
to identify sober aspects of life that align with their values, and then 
identify tasks that flow from these values, as is recommended in the 
behavioral activation therapy LETS ACT.16–18 To build confidence and 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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success, participants would aim to achieve zero tasks per day (planning 
only) and then one task a day at first.  
Relevant Study #2. A component of the left side of the page in PPJ is the 
“Three Good Things” gratitude exercise to aid the review of the past 24 
hours. PI Krentzman conducted a randomized controlled pilot test of the 
“Three Good Things” gratitude intervention among AUD patients.19 In the 
study, adult AUD outpatients were randomized to a gratitude intervention 
or active control group. All who were assigned to the treatment group 
completed the 14-day gratitude intervention. The majority (91%) of 
participants completed the gratitude intervention each day and, on 
average, 91% of participants completed all gratitude interventions over 14 
days. The gratitude group rated the exercise as highly satisfying, pleasant, 
helpful, and moderately easy (averages of 8, 8, 8, and 6, respectively, on a 
scale of 0 “not at all” to 10 “extremely”). In multi-level models to detect 
change in the slope of affect over the 14-day treatment, unactivated 
positive affect increased and negative affect decreased. Qualitative results 
depicted that the exercise became easier over time. On days when things 
did not go well for individuals, participants found it harder to name three 
good things; however, they reported that with effort they could do so and 
that the practice helped disrupt negative thoughts and feelings. 
Participants found that the exercise affirmed recovery. On day 14, the 
majority of participants (82%) reported they would continue the practice 
but at 14-week follow-up, few had continued the practice and only one 
continued written recording. Improvements in mood were not sustained at 
14-week follow-up, presumably because individuals did not continue with 
the practice. To address this concern, we will take steps to improve 
teaching and learning of PPJ which we believe will foster success and 
encouragement. We will provide small group sessions that involve coaching 
and modeling to help people with all PPJ activities including the “Three 
Good Things” activity. The later stages of learning PPJ includes an exercise 
(“each one teach one”) where each participant will teach PPJ to another 
person in recovery, to cement learning and improve success and 
confidence. 
Our preliminary work has demonstrated 1) high rates of treatment 
retention for the “Three Good Things” study, 2) high acceptability among 
AUD patients for the “Three Good Things” exercise and for PPJ, 3) 
significant impact of the “Three Good Things” exercise on improvement in 
mood, and 4) revelation of important considerations to address as we 
implement the intervention moving forward. 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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2.3 Existing Literature: PPJ is a novel intervention, but it draws most strongly 
from two bodies of research: 1) the research on gratitude and its 
relationship to addiction recovery (PPJ includes two gratitude exercises on 
the left hand side of the page) and 2) the research on activity scheduling 
and behavioral activation to support addiction recovery (featured on PPJ’s 
right hand side page). 
Research on Gratitude and Addiction Recovery. Anecdotally we know that 
gratitude is a strong component of addiction recovery in 12-step programs 
such as Alcoholics Anonymous. It is a common theme in AA meetings20 and 
is a prevalent theme in AA literature.21 Recent empirical investigations into 
this phenomenon suggests that trait gratitude correlates positively with 
recovery supportive factors and negatively with factors that might 
challenge recovery.20 Research also suggests that gratitude practices are 
associated with improvement in mood, which should make recovery more 
positively reinforcing.19 Supporting recovery and improving mood should 
reduce relapse risk. In the paragraphs that follow, this body of research is 
described in detail. 
In a cross sectional study of 105 men in treatment for substance use 
disorders while incarcerated, frequency of drug use in the 12 months 
before incarceration was negatively correlated with trait gratitude during 
treatment.22 In the only study we are aware of that explored the role of 
gratitude specifically as it occurs in 12-Step programs, LaBelle and 
Edelstein20 surveyed 184 members of Alcoholics Anonymous and Narcotics 
Anonymous in a cross sectional study. The authors found that trait 
gratitude was positively associated with wellbeing outcomes (post-
traumatic growth and social support) and 12-step factors (12-step practices 
and AA promises). Trait gratitude was negatively associated with number of 
physical health symptoms.  
Three studies explored change in trait gratitude before and after SUD 
treatment. Charzyńska23 found that trait gratitude increased among 
women but not men between baseline and treatment completion, five to 
seven weeks later. Krentzman24 found that trait gratitude did not change 
between treatment entry and 6-month follow-up. Charzyńska and 
colleagues25 built on their earlier study23 by increasing the number of 
participants from 112 to 358 and using latent class growth analysis and 
three time waves to form latent class trajectories of gratitude from pre-
treatment to 6-month follow-up. They found four heterogeneous classes. 
Individuals with high gratitude at baseline maintained high gratitude, two 
classes of individuals with low gratitude at baseline showed increases in 
gratitude, and a class with moderate gratitude at baseline showed 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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decreases in gratitude. These classes were different by baseline education, 
religiosity, and age, but not by gender. 
Krentzman24 found a significant interaction between current drinking 
status and trait gratitude on future abstinence. Trait gratitude was 
positively associated with abstinence among those abstinent at 6 months, 
and negatively associated with abstinence among those drinking frequently 
at 6 months. 
Studies of gratitude as an intervention to improve mood have been 
conducted among individuals with substance use concerns. An 8-week 
positive-psychology intervention was constructed to include gratitude and 
other interventions to boost positive emotion and supportive behaviors 
and tested among adolescents with substance use problems. The 
intervention showed increases in happiness, optimism, and positive affect 
relative to a comparison group.26 A 5-session positive-affect intervention 
was conducted with men who were methamphetamine users and who had 
sex with men. The intervention included gratitude exercises as well as 
other strategies to induce positive affect such as noticing positive events, 
mindfulness, positive reappraisal, strengths, and altruism. Individuals 
randomized to this treatment showed a trend toward increases in positive 
affect. Qualitative data indicated that participants found the intervention 
to support their recovery. However, the comparison condition showed 
significant reductions in negative affect, compared to the treatment 
group.27 A gratitude intervention, the “Three Good Things” exercise28 was 
piloted in a small sample of adults in treatment for alcohol use disorders. 
The gratitude intervention increased feelings of ease and calm and 
decreased negative affect.19 
Research on Activity Scheduling and Behavioral Activation to Support 
Recovery. Behavioral activation therapy is another powerful strategy for 
making abstinence more positively reinforcing, and activity scheduling is a 
key component of behavioral activation. Activity planning comprises the 
right hand side of the page in PPJ. The Life Enhancement Treatment for 
Substance Use (LETS ACT) is behavioral activation treatment29,30 modified 
for individuals with substance use disorders. Three randomized controlled 
trials showed that compared to comparison groups, LETS ACT participants 
demonstrated lower levels of depression17 and anxiety,17 greater 
enjoyment of activities,17 higher activity levels,18 decreased dropout from 
treatment,18 and increased abstinence at 3-, 6-, and 12-month follow-ups.16 
This work is similar to what we are proposing herein, i.e., daily activity 
scheduling that is aligned with an individual’s values for a sober life. We 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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hypothesize that the benefits of PPJ will approximate the similar benefits 
found from LETS ACT therapy.  
Rationale for PPJ. Why combine daily life review (including gratitude 
interventions) with planning for the future (activity scheduling) in a daily 
exercise? Gratitude interventions and activity scheduling should reinforce 
and extend each other’s impact. A positive correlation between higher 
levels of gratitude and greater behavioral activity have been reported.31,32 
This association may be causal: in previous research, gratitude has been 
shown to improve affect19,33 which has been shown to encourage more 
frequent and more diverse types of activity.34 Therefore, gratitude 
intervention should encourage positive, abstinent behavior. Conversely, 
activity scheduling will enhance gratitude by guiding individuals to shape 
their own positive experiences rather than to passively notice them. 
Positive behaviors will produce content to populate the next day’s 
gratitude inventory.  
This study will add to the existing knowledge base because we will be able 
to determine PPJ’s feasibility and acceptability and we will produce a PPJ 
treatment manual.  
3.0 
Study Endpoints/Events/Outcomes  
3.1 Primary Endpoint/Event/Outcome: The primary outcome is empirical data 
on the feasibility and acceptability of PPJ. We will also assess rates of 
substance use and treatment retention as primary outcomes. At the end of 
this study, we will develop a treatment manual to use in a future study to 
test the intervention in a randomized controlled trial.  
3.2 Secondary Endpoint(s)/Event(s)/Outcome(s): These include hypothesized 
mediators of the effect of the intervention on outcomes. These include: 
environmental reward, mood, satisfaction with life, perceived stress, 
recovery capital, wellbeing, commitment to sobriety, alcohol and drug 
craving, anxiety, and depression. For a complete list, see the measures 
section 5.2.  
 
4.0 
Study Intervention(s)/Interaction(s) 
 
4.1 Description: In-Depth Description of PPJ Intervention. PPJ encourages past 
24 hour review and upcoming 24 hour planning to improve quality of life in 
recovery and reduce relapse. PPJ uses standard lined journals with column 
headings under which individuals make bullet-pointed lists. On the left 
hand page, past 24 hours is recalled, itemizing “good” and “bad” things 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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that happened and things for which one is grateful. Wishes for others are 
also expressed on this page. On the right hand page, activities for the 
upcoming 24 hours are planned via headings representing valued life 
domains, such as “recovery,” “work/school,” “spirituality,” “home and 
household,” and “health.” 
 
PPJ invites participants to open to a page in a journal we developed which 
has column headings representing the different categories on the left and 
right of the fold. See the figure below, which is a snapshot of the journal. 
The pages on the far left and far right fold in and serve as bookmarks. The 
far left and right pages provide helpful hints for what to include under each 
column heading. 
 
 
 
Please note, the image above has been updated in the June 2019 protocol 
revision. The far left and far right pages have been updated to include 
some of the kinds of daily life events, goals, and experiences our research 
participants in cohorts 1 and 2 have written about in their journal entries. 
For example, on the left flap we added under examples of good things, 
“had a good meal.” Under examples of things to be grateful for, we added, 
“good food” and “sunshine.” On the right flap we added, for example, the 
goal, “look for jobs” under “work/education” and the goal “go outside” 
under “joy.” The left and right flaps (far left and right panels on the image 
above and also uploaded to Ethos) offer suggestions for what participants 
will list in their own daily PPJs (the middle two panels).  
 
On the bottom of the third panel “plan upcoming 24 hours” we added 
along the footer the following words: “observable measurable (where 
when how often how long how much) smallest pieces possible” to help 
participants to articulate tasks that are small and achievable. We have 
included updates to these documents in ethos. 

PROTOCOL TITLE: Addiction Recovery in a Rural Minnesota Community: Piloting 
“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
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The left hand page is devoted to a structured review of the past 24 hours, 
and includes evidence-based gratitude interventions including making a 
gratitude list35,36 and the “Three Good Things” exercise.28 The “Three Good 
Things” exercise involves past 24 hour recall, identification, and recording 
of three positive events that occurred that day (e.g., “warm exchange with 
cashier at dollar store”). The “gratitude list” involves listing items for which 
one feels thankful (e.g., “roof over my head”). Gratitude list items are more 
global in nature. These two exercises approach gratitude content via 
different prompts to expand access to good things in life. The two exercises 
are distinct, but it is acceptable if they overlap (e.g., a “good thing” is listed 
on the “gratitude list.”)  
 
The journal will also feature pages on which the participants will write 
about their values for important life areas and identify small, actionable 
items to move toward their values. Here is what that page will look like: 
 
 
 
Please note, for the June 2019 protocol revision, there are two edits to the 
“Important Life Area” page, above. First, we add the citation. Second, 

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“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
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removed a question that was confusing to participants: “What are the 
qualities of this life area that are important to you?” has been removed. 
 
Instead of providing a handout with instructions for “each one teach one,” 
one of the final group exercises, we will include these instructions inside 
the journal, these journal pages will look like this: 
 
 
 
The reasons we have included these pages (the values exercise pages and 
the each one teach one pages) is so that the women will have access to this 
information within their journal, instead of miscellaneous pieces of 
notebook pages or handouts that can be separated from the journal itself. 
These materials might have lasting value as reference material for the 
participant. 
 
Based on participant feedback, we added approximately 10 pages of the 
journal that are lined pages with the word “notes” in the upper left corner 
of the double page spread. Participants told us they wishes the journals 
had space to capture additional thoughts and observations. It will also be a 
good place to take notes during journaling group. The notes page is 
uploaded to this ethos modification. 
 

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“Positive Peer Journaling” PART II 
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We will engage in several strategies to enhance participants’ success with 
gratitude interventions. Based on feedback from participants in our 
previous gratitude research, individuals will be coached that items on the 
“Three Good Things” list need not be monumental in scope but that small 
things count.19 Based on participant feedback from previous research, 
individuals will be coached that items on the gratitude list can include 
things often taken for granted.19 Based on published gratitude research, 
participants will be provided with suggested areas in which to look for 
gratitude content in their lives, i.e., circumstances, relationships, objects, 
qualities, events, sensations, opportunities, and capabilities37,38 and will be 
taught different types of gratitude, e.g., micro gratitude (gratitude for small 
things), macro gratitude (gratitude for large things), gratitude savoring 
(reflecting on something positive), interpersonal gratitude (grateful for 
someone), and redemptive gratitude (when something good has come 
from something stressful).39 Gratitude interventions will be modeled by the 
therapist and other group members39 until participants are able to produce 
a minimum of three items for each gratitude intervention each day. In 
keeping with the 10th step from AA, the past 24 hour review will also 
include a bullet-pointed list of what did not go well in the past 24 hours. In 
our pilot qualitative work, we learned that participants with expert 
knowledge of addiction recovery described that listing what did not go well 
in a day was useful.40 Listing what did not go well should be useful in 
forming plans for the upcoming 24 hours to address the negative 
circumstances from the previous day. For example, one category heading 
on the right hand page in PPJ is “repair/amends” which offers a venue for 
setting things right and can reference items from the left hand page. The 
left hand page will also have a column wherein participants can express 
well-wishes for someone else that they know is suffering or struggling. We 
will refer to this component as Wishes For Others (WFO). This too can 
inform plans for the upcoming 24 hours, e.g., it might prompt reaching out 
to that person to express support and thereby strengthen interpersonal 
bonds. Expressing well wishes for others is an act of kindness, and acts of 
kindness interventions have been studied as positive psychology 
interventions to improve mood.41 
 
In PPJ, the right hand page is devoted to a structured plan for the upcoming 
24 hours, and includes activity scheduling.17,42 Activity scheduling prompts 
action toward work-related and personal goals, positive activities, and self-
care behaviors each day. This work will focus on identifying important life 
areas, values, and activities. First, participants will be guided to select areas 
in life that are of most value to them (choosing from, e.g., mental health, 

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“Positive Peer Journaling” PART II 
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NCT03903159 
 
 
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physical health, education/work, hobbies/recreation, relationships, and 
spirituality). Next, participants will be guided to articulate their values and 
activities for chosen life areas. For example, in the life area “physical 
health” a value could be “feel good in my body” and a corresponding 
activity could be “walk outside for 20 minutes.” Participants will start with 
zero items each day (planning only) and build to achieving one item a day 
to avoid feeling overwhelmed and build a track record of success.  
 
5.0 
Procedures Involved 
5.1 Study Design: In this mixed-methods study we will collect quantitative and 
qualitative data. Questions related to feasibility and acceptability as well as 
hypothesized outcomes (increased treatment retention and decreased 
recurrence of substance use) and hypothesized mediators will be assessed 
quantitatively via self-report questionnaire instruments and participant 
treatment record, as described below. Qualitative data will focus on 
subjective experiences of PPJ and logistics of study implementation. The 
spoken words of participants during group and the written content of their 
journals also comprises qualitative data that we will study. This has been 
outlined for the participant in the informed consent document. Qualitative 
and quantitative data will be combined using integrative strategies 
recommended by Caracelli and Greene43 and Li, Marquart, and Zercher.44 
In this integrative process, convergence across different data sources will 
be documented, and divergence will be examined further to elucidate 
deeper understandings.45,46 Who will administer these measures? The 
quantitative measures will be assessed via electronic Qualtrics survey that 
the research participants will access and complete themselves. (In the 
event there are technological difficulties, we might administer these 
surveys as paper questionnaires). At baseline, research staff will hand the 
participant the iPad (a computer can be used as back up) to complete the 
electronic Qualtrics survey. During group, the research staff conducting the 
group will hand out the iPads and participants will use them to upload a 
picture of their journal entry and answer Qualtrics questions. Outside of 
group sessions, Wayside Staff will make the iPads available for this same 
purpose. During the screening interview, we will provide some information 
about how to use the iPads. When will these measures be administered? 
Please see Table 2 “Schedule of Assessments” below for the timeframe 
indicating when these measures will be assessed. Please note we might 
make minor changes to the wording of the Qualtrics survey, for example, 
to improve the wording of some instructions to aid clarity or to correct 
typos and other small errors. 

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“Positive Peer Journaling” PART II 
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The study is being conducted at Wayside Women’s Treatment Center in St. Louis 
Park, MN.  
 
Wayside staff participate in many aspects of study implementation. Wayside 
staff assist with recruitment, they provide us access to the treatment rooms and 
offices, they help us locate participants and prospective participants who have 
appointments with us, and they disseminate the iPads among other duties. 
Therefore, in addition to existing study activities, we also wish to survey the 
Wayside staff. The purpose of the survey will be to ascertain our operations and 
whether we can do anything to improve study logistics and implementation. We 
want to make sure Wayside staff feel considered and appreciated.  
 
In addition, Wayside counselors have residents who participate in study 
activities. These residents likely describe to their counselors how the group is 
going for them and what it is like to be in the study. We would like to capture 
the counselor’s perceptions of how the study is going for their clients. 
 
We will administer this survey via email link. The clinical director at Wayside will 
send the survey out to all staff members using email. 
 
We are requesting waiver of documentation of consent for the staff only. Staff 
can choose whether or not to answer the questions, but we will not be 
documenting their consent anywhere. Our rationale for this request is that 1. 
We will provide information with all elements of consent disclosure, this text 
will be included in the body of the email sent to staff (the text is included as an 
ethos attachment), 2. The questions are minimal risk.  
 
We will have a lottery and will give out four $25 Target gift cards to four people 
who complete the survey and who choose to provide their email address. 
Providing the email address is optional but necessary for being in the pool to 
win a Target gift card. 
 
Attached to ethos, please find the questions we will ask in the survey. The 
survey is brief and asks 14 questions. Sample questions include: Are you okay 
with continuing to assist with the Positive Peer Journaling study? What are 
some things we can do to make this experience better for you? Please share any 
feedback about the journaling practice that you have received from participants 
or others.  
 
 
 
 
 

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“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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5.2 Study Procedures: The purpose of this study is to further develop PPJ, test 
its acceptability and feasibility, and write a treatment manual using an 
iterative process of testing, feedback, and revision. We will focus on the 
logistics of treatment delivery and research feasibility including 
recruitment, subject remuneration, instructions for the intervention, 
therapist scripts, group processes, and data collection. We will focus on 
feasibility, acceptability, and potential impact. These purposes govern 
study procedures.  
Procedures. There are three phases to this intervention: the Group Phase 
(2-3 50- to 60-minute groups meeting each week for 3 weeks), the 
Independent Practice Phase (2 week duration after the group terminates in 
which participants practice PPJ 2-7 times per week), and the Qualitative 
Exit Interview, which features the final quantitative Qualtrics questionnaire 
and an in-depth semi-structured exit interview to ascertain satisfaction 
with and criticism of PPJ, study logistics, and participant’s opinion of 
relevance to recovery in rural communities. Participants continue with 
treatment as usual during PPJ study activities. We will begin with one set of 
3-5 women, make any revisions (including IRB amendments) and then 
begin again with a second set of 3-5 women. We will repeat that process at 
least one more time. See Figure 2 below for a description of the three 
phases which are described further in the text after the diagram. 
 
 
 
 
Figure 2. Study Flow Diagram 
The Group Phase. Three consecutive small groups of 3-5 residents at a 
substance use disorder treatment program (specifically, the Wayside 
Recovery Center Women’s Treatment Center; see section 23.1 below for a 
detailed description of the study site) will be recruited and will meet for 50- 
to 60- minute group sessions 2-3 times per week for 3 weeks to learn PPJ.  
 

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“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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The optimal number of group meetings needed to teach and learn PPJ will 
be determined by this intervention development process (e.g., we may 
ultimately determine that 3 weeks is sufficient for this phase and if so we 
will make an IRB amendment or we may determine that the groups should 
meet 3 times per week). PI Krentzman will conduct these intervention 
therapy groups. The primary aim of the groups is to teach the elements of 
PPJ. Groups will be audio recorded to aid treatment manual development. 
Audio recorded sessions also serve as qualitative data for analysis. PPJ is 
taught by a counselor or group facilitator who themselves uses PPJ on a 
daily or near daily basis and the facilitator will practice PPJ along with 
participants in the group setting.  
 
A Wayside staff member will sit in on all group sessions. Study staff 
(research assistants) may also sit in on group sessions and may lead group 
sessions in the unlikely event of any absence of Amy Krentzman, primary 
investigator, who would provide supervision and instruction in such an 
event. Wayside staff or research staff will also practice PPJ. Please note the 
study protocol has already stated that Research Assistants RAs will be 
involved in all aspects of the research. Journals and pens will be provided 
by the study to the study participants. Notebooks or paper for taking notes 
may also be provided. Journals will have pre-printed category headings 
listed on the pages (see the figure, above). The study will provide lap desks 
for participants to use to lean on when writing their journal entries unless 
we use a room with a table to lean on. An additional journal will be 
provided if the original journal is lost or stolen during the group sessions. 
An additional journal will be offered to each participant who attends an 
Exit Interview. 
 
Participants will complete PPJ during group and will be invited to share 
some aspects of PPJ in a group process that will include modeling and 
coaching to support learning. During the sharing part of group, the 
facilitator and the Wayside staff member and the Research Assistant will 
also (judiciously) share their own PPJ entries. In between group sessions, 
participants will be given homework to continue to practice and therefore 
learn the elements of PPJ. Group participants are also encouraged to share 
journal content judiciously as some content may feel private. Group 
participants are also encouraged to protect their privacy by writing some 
journal items using brief words or initials that would not be meaningful to 
another person. 
 
See Table 1 below for a detailed plan for each group session.  

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“Positive Peer Journaling” PART II 
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Table 1. PPJ Group Phase Daily Session Content. Please note: this represents a general 
idea of content for each session. We will follow this general plan but the details 
(activities, PowerPoint slides, topics, exercises) might be modified week by week. 
Preparation of detailed group session plans, handouts and PowerPoint slides (if used) 
might be conducted the day before or the morning of group sessions. Therefore, there 
would not be time to gain approval for these details from the IRB in advance of the 
group session. However, we will submit detailed group session plans, PowerPoints and 
handouts to the IRB as soon as they are ready and we are able to submit them in a 
modification to the study. 
 
Also, one objective of the current study is to ascertain how many sessions will be 
required for this content. For the first group, we will use 2 sessions per week for 4 weeks. 
For the second group, we will also use 8 sessions but over 3 weeks instead of 4 weeks. 
Exactly what is covered in each session may vary based on pacing of different groups but 
this sequence will be followed approximately.  
 
Week and 
Session # 
Session Content 
Week 1, 
Session 1 
Ice breaker, establish group rules, describe rationale for PPJ 
Introduce “Three Good Things” exercise (TGT) 
Provide tips for success 
Practice TGT exercise 
Sharing about the exercise 
Introduce listing of what did not go well in the past day 
Homework: Continue to practice TGT exercise 
Week 1, 
Session 2 
Debrief: How did homework go? 
Practice TGT exercise 
Introduce gratitude list 
Provide tips for success 
Practice gratitude list 
Sharing about the exercise 
Introduce “Wishes for Others” list 
Sharing about the exercise 
Homework: Continue to practice TGT exercise and gratitude list exercise 
Week 2, 
Session 3 
Debrief: How did homework go? 
Practice TGT exercise, gratitude exercise, and wishes for others (WFO) 
WFO, “advanced moves”: find someone in your “good things” and “bad things” lists 
and add their name to send them well wishes. For the right hand page: think of any of 
the people on your wishes list who you would like to reach out to extend your kind 
wishes. 
Provide tips for success 
Sharing about the exercise 
Introduction to the right hand side of the page, discussion of each life area. 
Homework: Continue to practice what we have learned so far. 

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“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
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Week and 
Session # 
Session Content 
Week 2, 
Session 4 
Debrief: How did homework go? 
Practice TGT, gratitude list, what did not go well, and WFO 
Provide tips for success 
Sharing about the exercise 
Rank order each life area. Write about what makes your top life area valuable and 
meaningful to you. 
Write about values for this life area. 
Teach how to identify a SMART goal for each valued life area 
Generate a SMART goal for three life areas, one at a time 
Homework: Continue to practice what we learned so far. 
Week 3, 
Session 5 
Debrief: How did homework go? 
Practice left and right sides of the page 
Have participants choose other life areas important to them 
Write about values, develop SMART goals. 
Homework: Continue to practice left hand and right hand side of the page 
Week 3, 
Session 6 
Debrief: How did homework go? 
Practice left hand and right side of the page 
Choose more valued life areas 
Write about values for this life area 
Generate SMART goals for each valued life area 
Practice right hand side of the page 
Homework: Continue to practice left hand and right hand side of the page 
Week 4, 
Session 7 
Debrief: How did homework go? 
Practice left and right hand side of the page 
Choose more valued life areas 
Write about values for this life area 
Generate SMART goals for each valued life area 
Practice right hand side of the page 
Homework: Continue to practice left hand and right hand side of the page. 
Homework: Each One Teach One: Find a person supportive of your recovery. Teach 
them the journaling practice. Journal alongside them. Share content you wish to with 
each other. 
Week 4, 
Session 8 
Debrief: How did the Each One Teach One and homework go? 
Practice left hand side of the page and right hand side of the page 
Sharing about the journaling practice 
Group closure exercise, such as, the “What you got and what you brought” activity 
where each group member writes down what they got out of the group and all other 
group members write down what each other member “brought” or contributed. 
Homework: Move on to The Independent Practice portion of the study where PPJ 
continues over the next 14 days. 
 
When we address values, we will pay special attention to the life areas 
selected by participants and will help them identify small, action steps that 
are measurable and observable that they can take toward their goals in 
every life area. 
 

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When we talk about recovery as an important life area, we will present to 
the group the research that has shown that mutual aid (for example, 
Alcoholics Anonymous) meeting involvement has been more strongly 
associated with abstinence than mutual aid attendance. We will describe 
small action items that can improve mutual aid involvement, such as 
helping to set up the chairs or greeting the newcomer. In the 
questionnaires, we will determine whether individuals have enacted these 
action items (see Hypothesized Mediators in the Measures section, below) 
if they have attended a mutual aid meeting in the past 24 hours.  
 
If we don’t have time to use the iPads to capture journal entries completed 
during group, participants might be asked to borrow the iPads from 
Wayside staff later in the day to complete the survey questionnaires for 
that day. 
 
If a group member misses group, we will ask for a volunteer from group to 
fill that person in on what we did in group that day. 
 
If someone misses group or other study activity for 2 days or 2 sessions in a 
row, we will reach out to them and gently encourage continued 
participation, or inquire whether they wish to drop out of the study. 
 
 
The Independent Practice Phase. This phase begins when The Group Phase 
ends. During this phase, participants will continue the journal practice on 
their own over the next 14 days. Participants are encouraged to complete 
PPJ a minimum of 2 times a week during this phase but they can feel free 
to complete PPJ daily if they would like to (they are compensated for up to 
5 entries each week).  
 
 
Qualitative Exit Interview. At the end of the Independent Practice Phase, 
participants will be invited to participate in an individual (one-on-one) 
semi-structured qualitative exit interview to ascertain their experience of 
being in the study and any potential impact or downsides of PPJ. This 
interview will also involve administration of the final quantitative 
questionnaire that we are calling the “end of group and independent 
practice phase” questionnaire, administered via Qualtrics and iPads (see 
pdf attached to ethos). Ideally, these interviews will not be conducted by PI 
Krentzman but will be conducted by research staff or perhaps by the 

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“Positive Peer Journaling” PART II 
VERSION DATE: 20 June 2019 
NCT03903159 
 
 
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University of Minnesota Office of Measurement Services in order to 
diminish socially desirable responses. 
 
Every effort will be made to conduct the exit interviews in person, but 
when that is not possible, we will offer the opportunity to complete the 
exit interview via telephone or in writing through email. 
 
Data Capture. Participants will take a snapshot of their journal entries and 
upload this image to a Qualtrics survey to affirm that assignments are 
completed; this skill will be taught and practiced during the screening 
meeting and Group Phase and practiced during the Independent Practice 
Phase. Participants will learn how to do this using Qualtrics and iPads 
during group and will be able to continue to use study-issued iPads to 
continue this practice during The Independent Practice Phase. After 
uploading the image of their journal, participants will answer psychometric 
questionnaires in Qualtrics (see the question items checked under the 
column heading, “At Every PPJ Qualtrics Upload,” in Table 2 below.) Study 
iPads will be physically secured when not at use in a staffed 
office/supervised cabinet at Wayside. Participants will be asked to 
complete their journal entries right before they upload them to Qualtrics. 
 
Please note we will thank Wayside staff members by citing Wayside and 
individual staff names in the acknowledgments section of academic posters 
and manuscripts that result from these data. We may make periodic 
presentations to Wayside staff about study observations and findings 
throughout the study period. When appropriate, we will offer CEUs for 
Social Workers to Wayside staff for their attendance at these 
presentations. 
 
Measures. Sociodemographic factors will be assessed at the initial baseline 
measurement (e.g., age, sex, marital status, years of education, 
race/ethnicity, employment status, and annual household income). A 
variety of psychometric scales will be used at baseline and throughout the 
study. Please see Table 2 for the Schedule of Assessments and the text 
following after Table 2 for more detail about each assessment approach. All 
surveys, scripts, and participant-facing data collection forms are uploaded 
to ETHOS. Specifically, three pdfs are uploaded to ETHOS that contain all of 
the Qualtrics questionnaire items including all Qualtrics items from Table 2: 
“PPJ_Baseline Survey, 
PPJ_after_Group_and_Independent_Practice_Phases, and 
PPJ_After_Each_Upload Survey. 

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“Positive Peer Journaling” PART II 
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Please note: in the June 2019 protocol change, we are making some small 
changes to our assessment protocol to reduce response burden on 
participants as follows: 1) we are removing the Gratitude Adjectives 
Checklist items from the PANAS. These covary at high levels with the Trait 
Gratitude measure so they are not necessary; 2) We are removing the Life 
Orientation Test from the every upload assessment. Updated versions of 
the three surveys will be uploaded to ethos. 
 
Table 2. Schedule of Assessments. 
 
 
How long 
does it 
take to 
complete 
each of 
these 
measures
? 
Baseline 
At Every 
PPJ 
Qualtrics 
upload 
Asked or 
Tallied 
after 
Group 
Phase 
Ends 
Asked or 
Tallied after 
Independent 
Practice 
Phase Ends 
Final 
Study 
Activity 
Baseline characteristics 
 
 
 
 
 
 
Sociodemographics 
3 minutes 
X 
 
 
 
 
Hospital Anxiety and Depression Scale 
3 minutes 
X 
 
X 
X 
 
10-item SIP-AD, addiction consequences 
5 minutes 
X 
 
 
 
 
Perceived Stress Scale 
2 minutes 
X 
 
X 
X 
 
World Health Organization Wellbeing Index 
1 minute 
X 
 
X 
X 
 
Satisfaction with Life 
1 minute 
X 
X 
X 
X 
 
Recovery Capital 
2 minutes 
X 
 
X 
X 
 
Commitment to Sobriety (full scale) 
2 minutes 
X 
 
X 
X 
 
Life Orientation Test (optimism) 
2 minutes 
X 
 
X 
X 
 
Trait gratitude 
2 minutes 
X 
 
X 
X 
 
Reward probability index 
2 minutes 
X 
 
X 
X 
 
AA Affiliation Scale 
2 minutes 
X 
 
 
 
 
Demoralization Scale 
2 minutes 
X 
 
X 
X 
 
Exposure to trauma 
1 minute 
X 
 
 
 
 
Using Medication Assisted Treatment? 
½ minute 
X 
 
 
 
 
Legal issues? 
½ minute 
X 
 
 
 
 
Satisfaction with treatment 
2 minutes 
 
 
X 
X 
 
Social Desirability Scale 
4 minutes 
X 
 
 
 
 
Open ended questions: history living in / 
plans to return to rural areas/small towns, 
12-step experience including experience 
working the 4, 5, and 10th steps. What have 
you already heard about this study? 
3 minutes 
X 
 
 
 
 
Hypothesized Mediators 
 
 
 
 
 
 
Positive and Negative Affect Schedule, 
including three items comprising the 
serenity subscale (calm, relaxed, at ease)  
2 minutes 
X 
X 
X 
X 
 
Abstinence Self Efficacy Question (single 
item) 
1 minute 
X 
X 
X 
X 
 
Commitment to Sobriety (single item) 
2 minutes 
 
X 
 
 
 

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How long 
does it 
take to 
complete 
each of 
these 
measures
? 
Baseline 
At Every 
PPJ 
Qualtrics 
upload 
Asked or 
Tallied 
after 
Group 
Phase 
Ends 
Asked or 
Tallied after 
Independent 
Practice 
Phase Ends 
Final 
Study 
Activity 
Alcohol craving (single item) 
½ minute 
X 
X 
X 
X 
 
Drug craving (single item) 
½ minute 
X 
X 
X 
X 
 
Satisfaction with Recovery (single item) 
½ minute 
X 
X 
X 
X 
 
Individual items to assess specific impact of 
PPJ journaling practice 
3 minutes 
X 
X 
X 
X 
 
Behavioral activation to increase depth of 
involvement in mutual aid meetings 
2 minutes 
X 
X 
X 
X 
 
Effort, Feasibility, and Acceptability 
 
 
 
 
 
 
# of Qualtrics surveys completed 
 
 
 
X 
X 
 
Ease, helpfulness, satisfaction, effort 
2 minutes 
 
X 
X 
X 
 
# group sessions attended 
 
 
 
X 
 
 
# homework assignments completed 
 
 
 
X 
 
 
# journal entries completed1 
 
 
 
X 
X 
 
Eligibility rate and consent rate 
 
 
 
 
 
X 
Open Ended Survey Question 
 
 
 
 
 
 
What are your thoughts about Positive Peer 
Journaling (PPJ) so far? 
2 minutes 
 
 
X 
X 
 
Outcomes 
 
 
 
 
 
 
Recurrence of Substance Use 
 
 
 
X 
X 
 
Treatment Retention at Wayside center 
 
 
 
X 
X 
 
Qualitative Exit Interview 
30 
minutes 
 
 
 
 
X 
 
Baseline characteristics. 
 Sociodemographics 
Exposure to trauma. Women who have experienced addiction have high 
rates of exposure to trauma. We will ask about exposure to trauma in order 
to describe the sample, that is,  to report what percentage of the sample 
has been exposed to trauma. To determine exposure to trauma, we will use 
the first question from The Posttraumatic Diagnostic Scale.47 The first 
question of this instrument asks if the participant has ever experienced life 
threatening illness, physical assault, sexual assault, military combat, child 
abuse, accident, natural disaster, or other trauma. Participants will be 
informed that we will be asking about this in the informed consent 
                                                 
1 The number of journal entries completed will be counted using the iPad entries and it will also be counted 
by Research Staff examination of the written journals or by asking participants to examine their own 
journals. We will count the number of journal entries and the dates journal entries will be made. We will do 
this because participants create a new journal entry for the iPad uploads, but in addition to these, they also 
make new journal entries that are not captured in the iPad uploads. Therefore, if we or they manually count 
the paper journal entries, we should get a more accurate count of participation than if we count only the 
journal entries that are captured using the iPads. 

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document. Please note, we will not assess for symptoms or effects of 
trauma since our objective is to use the single item to describe the sample. 
Wayside regularly screens all residents for trauma. However, if any 
participant has difficulty with study activities because of trauma or any 
other reason, we will inform Wayside. If participants experience distress 
related to this trauma question or any other element of the baseline 
questionnaire or screening interview, we will refer them to Wayside staff.  
  
 Legal involvement. Women with severe addiction histories such as 
those in our study have greater rates of involvement with the legal 
system. Therefore, to better define our population, we will ask, 
“Are you currently involved in a civil legal case or criminal court 
case?” 
 Medication Assisted Treatment (MAT). Women with severe 
addiction histories are often prescribed specific medications to 
reduce substance use and cravings. Therefore, we will add two 
items to determine if women in our sample are using MAT to 
support their recovery. For the specific item, see the baseline 
questionnaire attached to ethos. 
 Symptoms of anxiety and depression will be assessed using the 
Hospital Anxiety and Depression Scale.48 
 Severity of addiction consequences will be assessed using the 10-
item version of the Short Inventory of Problems-Alcohol and Drugs 
scale (10-item SIP-AD).49 
 Perception of personal stress will be assessed by the Perceived 
Stress Scale.50 
 Participant’s positive feelings and overall sense of well-being will be 
assessed using the WHO-5 Well-being Index.51 
 Satisfaction in Life will be assessed with the Satisfaction with Life 
Scale.52 
 A participant’s resources related to recovery will be assessed using 
the Brief Assessment of Recovery Capital.53 
 Motivation to remain abstinent will be assessed by the 
Commitment to Sobriety Scale.54 
 Participant’s optimism will be assessed using the Life Orientation 
Test – Revised.55,56  
 An individual’s disposition toward gratitude will be assessed with 
the GQ-6 Gratitude Scale.57 
 Environmental Reward will be assessed with the Reward Probability 
Index.58 

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 12 step affiliation will be assessed via the AA affiliation scale59 
 Demoralization will be assessed via The Demoralization Scale.60 The 
feeling of demoralization has been shown to decrease with 
psychotherapy. 
 Satisfaction with treatment at Wayside will be assessed via a 
treatment satisfaction scale.61 In previous research, participants 
who received behavioral activation treatment for substance use 
disorders had higher treatment satisfaction than individuals in the 
control group. We will include this instrument to pilot test it since 
the current study has no control group. 
 A participant’s concern with social approval will be assessed with 
the Marlow-Crowne Social Desirability Scale.62 
 At baseline we will ask participants about their histories living in 
rural areas and plans to return to rural communities, if relevant. We 
will ask them to tell us the places they have lived to determine if 
they have lived in rural areas or small towns, defined as 
communities with census of less than 10,500. We will ask about 
their 12-step participation, especially if they have worked the 4, 5, 
and 10th steps which are relevant for life review. We will ask if they 
currently do a 10th step daily life review and if so, what form it 
takes. We will ask what they already know about this research study 
(counselors might have mentioned things about the study and the 
groups subsequent to the first group might have heard about the 
study). These will be a qualitative open-ended questions. 
 
Hypothesized mediators. 
 A participant’s current feelings of gratitude (measured through 
individual items assessing thankfulness, gratefulness, and 
appreciativeness) will be assessed with the Gratitude Adjectives 
Checklist.35 
 Affect will be assessed with the Positive and Negative Affect 
Schedule.63 
 Self-confidence in a participant’s ability to abstain from addictive 
substances will be assessed by the Abstinence Self Efficacy Scale 
Question: “I am confident in my ability to abstain from drugs and 
alcohol”.64 
 Commitment to sobriety (single item) “I am totally committed to 
staying off of alcohol/drugs” 
 Alcohol craving (single item) “Rate the strongest urge to drink you 
have experienced in the past 7 days” 

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 Drug craving (single item) “Rate the strongest urge to use drugs you 
have experienced in the past 7 days” 
 Satisfaction with recovery (single item) “In general, I am happy with 
my recovery” 
 We developed several single items to assess change that is directly 
related to the activities of the journaling practice. These items are 
now included in the updated versions of the Qualtrics surveys 
uploaded to ethos. We ask, “in the past 24 hours…something good 
happened to me, I thought about the needs of other people, I took 
a step towards one of my goals, I took time to do something which 
made me happy, I expressed gratitude about something in my life, I 
did something to help another person in recovery, I found good 
ways to spend my time, I had unpleasant experiences (reverse 
coded), I felt able to get things done, and I had the opportunity to 
socialize with people. Some of these items are items from the 
environmental reward instrument58 that we are using, or were 
inspired by items from this instrument. 
 We ask whether the person attended a mutual aid group in the past 
24 hours (such as Alcoholics Anonymous).  
 If they attended a mutual aid meeting, they would then check all 
that apply in a list of items designed to capture depth of 
involvement in mutual aid. Previous research has shown that depth 
of involvement is a stronger predictor of lower alcohol use than 
attendance.65 Here are the items they would be able to check: “At 
that mutual aid meeting (that I attended in the past 24 hours), I did 
the following: put away chairs/set up chairs, spoke at the meeting, 
spoke to my sponsor (if I have one), read program literature out 
loud during the meeting, helped make coffee, helped a newcomer, 
shared during the meeting, reached out to a member for help, 
reached out to welcome someone new, helped to plan or run the 
meeting, announced my length of sobriety at the meeting, 
celebrated my recovery birthday, talked to someone after the 
meeting, arrived early, arrived on time, stayed after the meeting, 
sat in the front or towards the front, stayed until the end of the 
meeting, took steps to get a sponsor (if I don’t already have one), 
reached out to someone who is struggling, cleaned up after the 
meeting, helped to set up the meeting, other.” 
 
Effort, Feasibility, and Acceptability. 
 # of Qualtrics surveys completed 

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 Effort, Ease, helpfulness, satisfaction (one item to assess each: “For 
this PPJ, I would say I put forth this much effort…” Degree to which 
PPJ was difficult, helpful, satisfying, easy, rated on a 0-10 point 
scale) 
 # of group sessions attended 
 # homework assignments completed 
 # journal entries completed 
 Eligibility rate: Number eligible/total at Wayside site 
 Consent rate: Number consented/number screened 
 
Open ended survey question. 
 What thoughts would you like to share with us about positive peer 
journaling, if any? 
 
Outcomes. 
 Recurrence of substance use.  
 Retention of treatment in Wayside treatment center 
 Wayside reason for leaving 
 
Recurrence of substance use and treatment retention will be assessed via 
Wayside treatment record. Research staff will not have direct access to the 
Wayside treatment record. A Wayside staff member will meet with 
research staff at reasonable intervals to report information about 
treatment retention and recurrence of substance use for study participants 
from the Wayside treatment record. Recurrence of substance use is 
assessed at Wayside by positive urine analyses (UAs) and other drug 
screens as well as resident self-report. At this meeting, research staff will 
have a password protected electronic document which links participants’ 
real names with their study codenames/numbers. Research staff will use 
this key to record the information from Wayside staff into a de-identified 
database (e.g. excel or SPSS or google drive). 
 
Dr. Amy Krentzman, the lead investigator, will keep a log throughout the 
study, qualitatively recording observations, especially after each class 
session. 
 
Analysis Plan. The intervention will be repeatedly modified and the sample 
size too small to conduct quantitative statistical analyses, however, some 
descriptive data will be summed as follows. 
Sample characteristics. We will aggregate information about the 
demographics and baseline characteristics of the study to be able to 

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describe the psychosocial, demographic, and clinical profile of study 
participants. We will calculate means and standard deviations for 
continuous measures (e.g., age) and calculate percentages for categorical 
measures (e.g., marital status). 
Primary feasibility and acceptability measures. We will aggregate 
information designed to assess feasibility and accessibility such as number 
of Qualtrics surveys completed, group sessions attended, journal entries 
completed, as well as participant assessment of the difficulty, ease, 
helpfulness, satisfaction, and effort expended on PPJ. We will sum these 
items and calculate means and standard deviations. We will use this 
information to inform intervention modifications. 
Secondary measures: outcomes and mediators. We will compare rates of 
treatment retention and recurrence of substance use to the general rates 
reported by Wayside. We will also examine pre-post treatment means and 
standard deviations of hypothesized mediators (affect, satisfaction with 
recovery, individual items theoretically related to PPJ) to determine if 
change is in the expected direction. We will also study these constructs to 
determine if there is reasonable variability in the data we collect or if floor 
or ceiling effects are present. We may also use single-subject designs66 to 
depict change over time in key constructs by study participant. Qualitative 
data will be thematically analyzed using the techniques recommended by 
Braun and Clarke.15 Here, the researcher examines transcripts of texts and 
identify key themes and how themes relate to one another. These data will 
inform intervention development and study implementation procedures. 
Data Collection Methods. The University of Minnesota allows faculty and 
researchers access to Qualtrics software. Qualtrics is an online software 
survey program which collects survey data. We, along with the University 
of Minnesota Office of Measurement Services, will program Qualtrics to 
administer the self-report measurements discussed in the Measures 
section at baseline, throughout group, during the independent phase, and 
at the exit interview. At baseline, we will provide participants with an 
electronic tablet (iPad) (if necessary we will use a computer at baseline or 
at other measurement occasions) so they can access the baseline 
assessment via Qualtrics. Study staff will sit unobtrusively in the same room 
with participants as they complete the baseline assessment. This will take 
place in a quiet and private setting after screening and informed consent. 
Participants will be invited to ask questions of study staff as they complete 
the survey. Once the Group Phase begins, participants will take a snapshot 
of their PPJ entries and upload them to Qualtrics during group and 
independently during the Independent Practice Phase. Study therapists will 

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teach participants how to do this during The Group Phase. During the 
independent practice phase, study iPads will be kept in a staffed or locked 
office at the Wayside residence; participants will ask staff for access at 
appointed hours (there will be appointed hours scheduled every day, 7 
days a week) and will photograph their journal pages and answer survey 
questions using that iPad. The iPad will access the internet via existing 
Wayside wireless service.  
The specific procedural steps that we will take to conduct this study 
include: 
 Present PPJ to clinical staff at Wayside to gain setting-based insights 
and situate the intervention successfully in context. 
 Train Wayside staff on their participation in the study, that is, 
identification of prospective participants. This includes reviewing 
the study with the prospect to determine interest, having the 
prospect sign up for a meeting with study staff, providing study 
fliers and the informed consent document to interested persons. 
Wayside staff will take no further action if the prospect is not 
interested. Wayside staff will also sit in on group sessions, and lend 
out the iPads. 
 Work with U of M (Office of Measurement Services) Qualtrics 
survey developer to use Qualtrics to capture data. 
 Teach PPJ to a small group of 3-5 clients. 
 Assess feasibility, acceptability, and hypothesized treatment 
outcomes such as increased treatment retention and decreased 
recurrence of substance use. Assess hypothesized mediators such 
as satisfaction with recovery and improved mood. For a complete 
list, see the measures section 5.1. 
 Assess feasibility and acceptability of The Group Phase and The 
Independent Practice Phase. 
 Determine optimal number of group sessions and optimal length of 
group sessions to adequately teach PPJ. 
 Determine script for describing steps of PPJ, e.g., instructions for 
the “Three Good Things” gratitude practice, instructions for the 
gratitude list practice, and all other elements of the treatment 
intervention. See Table 1 for an outline of what will be covered in 
each session and the attachment to ethos for a more detailed 
description. 

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 Conduct qualitative exit interviews to ascertain participants’ 
subjective experiences of the intervention, logistics of delivery, 
relevance to recovery in rural communities, and feasibility and 
acceptability of the intervention. The final quantitative Qualtrics 
survey will also be administered at this meeting. 
 Study and refine recruitment processes, retention ability, 
functioning of Qualtrics surveys, and feedback about feasibility and 
acceptability. Create IRB amendments as needed. 
 Revise PPJ and study procedures based on data acquired, test PPJ 
again with a second group of 3-5 clients.  
 Repeat process one final time with a small group of 3-5 clients to 
finalize the treatment manual. 
 Repeat process additional times with small groups of 3-5 clients as 
time and resources permit to capture as much data as possible to 
answer the research questions. 
 Produce the treatment manual which then can be tested in a future 
randomized controlled trial. 
5.3 Follow-Up: After The Group Phase and The Independent Practice Phase 
participants will be invited to participate in a qualitative exit interview with 
research staff. There will be no other follow-up after the exit interview.  If 
the resident has moved out of Wayside on good terms during the course of 
the study, we will reach out to them at their new residence and invite them 
to an exit interview. We would contact the person at the forwarding 
information kept by Wayside when women move out and at other contact 
information they left with Wayside. The participant will have given 
informed consent for this in the informed consent document. We will meet 
with participants at Wayside or in their new home or at a local library or 
other reasonable location that offers privacy. The research study will pay 
for a taxi for the participant to meet us for the Exit Interview. Participants 
will also be encouraged to call us to schedule the Exit Interview. 
If participants leave Wayside on good terms during the study period, they 
may still be able to continue to be in the study because it is possible to 
continue study activities from outside of Wayside for the independent 
practice phase. Any smartphone can be used to continue to participate in 
the independent practice phase. We may reach out to participants who 
continue to participant in this way to encourage them to continue in the 
study or ask if they wish to remain in the study using the contact 
information they provide to use through Wayside. 

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5.4 Individually Identifiable Health Information: Research study staff will meet 
with Wayside staff at reasonable intervals to collect data on our primary 
outcomes: 1) treatment retention and 2) recurrence of substance use. At 
these occasions we will go through our list of study participants and ask 
Wayside staff if: 1) that person has left treatment or been asked to leave; 
2) that person has had a positive urine analysis screening indicating 
recurrence of substance use. We will mark down the replies in our 
deidentified data file. To facilitate this work, study staff will use a password 
protected file linking participants’ real names with study IDs 
(codenames/numbers). 
 
[Please note: we called the IRB to consult on the question of whether this 
information represents PHI. I was advised that HIPCO will be brought on 
board as an ancillary reviewer for this study to make the determination of 
whether this study involves PHI. In the meantime, we have completed the 
University’s Privacy Office online application and attached the pdf entitled 
“HIPCO Survey” under “other attachments” under question #3 in ETHOS.]  
 
6.0 
Data Banking 
6.1 Storage and Access: Quantitative data will be stored in a spreadsheet or 
data analytic software file and this data will be de-identified. Qualtrics will 
be used to collect data prior to download. Qualtrics is HIPAA compliant. 
Cases will be identified by code name or number only. Using a successful 
strategy we have used in the past, at baseline, participants will be asked to 
provide a “codename or number” that does not contain identifiers such as 
real name or birthday. Examples from the past have included “Rusty” or 
“007.” An electronic key linking participants’ real names with 
codenames/numbers will be held on the PI’s and research staffs’ laptops in 
a password-protected file. This file will be deleted one year after the 
manuscripts based on this research are accepted for publication. Only the 
PI and research team will have access to the data. Codenames and real 
names are also listed on the “codename” sheet that individuals fill out at 
baseline when choosing their codename. These pages are kept in a locked 
file box or filing cabinet. 
Qualitative data will be stored in several formats. Audio recordings of 
group sessions and of exit interviews will be stored only on the secure U of 
M School of Social Work Shared Drive server. Uploaded pictures of PPJ 
entries will be shared on this same server. Transcripts of the audio 
recorded sessions will also be uploaded here and will be de-identified 
before qualitative data analysis. The Shared Drive Server at the School of 

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Social Work is an access control list (ACL) controlled file server. This means 
that each user has different access depending on which Active Directory 
Groups they are in. The folder on the drive where the data would be saved 
would have its own Active Directory group, and only research team 
members (and the server administrators) would have access to the files in 
the folder. We have been advised by Information Technology professionals 
at the School of Social Work that these security provisions are in line with 
the University of Minnesota data security provisions including the storage 
of research study data. De-identified transcripts of these sessions will be 
kept on the U of M server and/or the PI’s and research teams’ laptops. 
Transcripts are created by an outside vendor, Datagain 
(datagainservices.com). Datagain is a transcription service for research. 
Datagain offers data encryption on all stored data, secured data transfers, 
compliance with ISO 9001 and HIPAA standards, and regular security 
audits. If needed, we will use a different company than Datagain but one 
with all of the same protections and security provisions. 
6.2 Data: The data elements to be collected and banked for future use in a de-
identified data set include all those listed in the measures section under 5.2 
of this protocol. We will also store jpg files representing the snapshots of 
the uploaded PPJs.   
6.3 Release/Sharing: N/A 
7.0 
Sharing of Results with Participants 
7.1 Participants will be encouraged to email or call the PI in about a year’s time 
to obtain study results in the form of academic posters or academic 
manuscripts. Upon such requests, the PI will email or send via regular mail 
these products as well as an easy-to-understand fact sheet summarizing 
the results to date, to improve accessibility to study findings for lay 
readers. This opportunity is mentioned in the informed consent document. 
In general, the PI will share research findings at community-based, local, 
regional, and international conferences and will publish study findings in 
academic journals. We will also make a presentation of findings to Wayside 
staff when the study is over and throughout the study, as requested by 
Wayside.  
8.0 
Study Duration 
8.1  
 
The duration for an individual participant’s participation in the study 
is anticipated to be five to nine weeks as follows: Up to 8 group 
sessions over 3 weeks, 2 weeks of independent PPJ practice (bringing 

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participation to 5 weeks), and a qualitative exit interview to take 
place as soon as possible at the 6 week mark but perhaps up to 4 
weeks later depending on scheduling and research staff availability. 
 
The duration anticipated to enroll all study participants: Enrollment 
will be rolling during this iterative process, we are planning for this 
study to last approximately 9 months. Typically, we plan to screen 
and consent and enroll participants during the week before group 
starts. 
 
The duration anticipated to complete all study procedures and data 
analysis: Including manuscript production and publication, 
approximately three years. 
9.0 
Study Population 
9.1 Inclusion Criteria: 1) minimum 18 years of age, 2) meet DSM-V criteria for 
past-year SUD as primary or secondary diagnosis, 3) English literacy 
sufficient to make short written lists needed to complete PPJ and 
homework assessments, 4) minimum 2 weeks sustained abstinence, 5) 
completed first 2 weeks of treatment at Wayside (approximately 2 weeks), 
a residential substance use disorder treatment program and the 
recruitment site, 6) priority will go to participants who are from or moving 
back to a rural area or small town  defined as a population less than 
10,500, 7) agree to be audio recorded in group meetings and in individual 
meetings with research staff, 8) currently are clients in the Wayside 
residential program, 9) participants must be English speaking and literacy 
must be strong enough to write short lists and to understand the questions 
asked in the Qualtrics survey. Priority will go to women who will be residing 
at Wayside for the duration of the study activities (and not moving out 
after one week, for example). 
 
The women in treatment at Wayside are individuals with low or no income 
and histories of severe substance use disorder. Therefore in the list below 
we checked that they are “disadvantaged in the distribution of social goods 
and services such as income, housing, or healthcare” and, as individuals 
with addictive disorders, we also checked that they are from an 
“undervalued or disenfranchised social group.” 
 
All participants will be 18 or over. Wayside on occasion will have a 17 year 
old resident, but they will not be eligible for this study. 
 
9.2 Exclusion Criteria: 1) presence of a psychotic disorder, psychiatric condition 
(e.g., suicidal ideation), or cognitive impairment (e.g., severe dementia, 

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traumatic brain injury) limiting ability to give consent and/or participate in 
the study; 2) severe psychiatric illness (current schizophrenia, major 
depression with suicidal ideation); 3) personality disorders that would 
interfere with satisfactory participation in or completion of the study 
protocol, 4) inability to give informed, voluntary consent to participate, 5) 
lack of sufficient English literacy to participate, defined as inability to make 
a list of 5 things they did yesterday and inability to understand Qualtrics 
survey questions, 6) any impairment, activity, or situation that in the 
judgement of the research staff would prevent satisfactory participation in 
or completion of the study protocol.  
See the attached document “PPJ inclusion exclusion questions.” This 
document shows how each of the inclusion/exclusion criteria will be 
assessed during the recruitment and screening phase of the study. This 
document also shows who will make the determination for each criteria 
(Wayside staff or Research staff) and how they will make the determination 
(e.g., chart review, screening activity, screening questions, the GAIN SS 
instrument,67,68 the GAIN cognitive impairment screener,69 the UCSD Brief 
Assessment of Capacity to Consent (UBACC).70 Each of these screening 
instruments and the screening procedures are described in detail below in 
section 9.3. 
 
9.3 Screening: The screening process will proceed as follows. 
1) Wayside staff will conduct chart reviews to determine items 1, 2, 4, 5, 6, 
7, 9, 10 of the “PPJ Inclusion and Exclusion Questions” uploaded to Ethos. 
Prospective participants who meet these criteria (e.g., English speaking, 
resident at Wayside) will be given a study flyer (see attached), a copy of the 
regular informed consent document, and will have the opportunity to sign 
up to have an appointment with Research Staff at Wayside to continue the 
screening and informed consent process. Prospective participants will be 
encouraged to read the informed consent document before their 
scheduled meeting with researchers, and to bring any questions they have. 
2) When prospective participants meet with Research Staff, Research Staff 
will follow the recruitment, screening, consent, and baseline script 
(uploaded to Ethos). During this interview, prospective participants will 
complete a set of questionnaires and consent forms, specifically: the 
Screening Consent Form, Informed Consent Form, UBACC quiz to 
determine capacity to consent,70 the HIPAA Authorization form, the GAIN 
SS67,69,69 instrument to determine presence of a psychotic disorder, 
psychiatric condition (e.g., suicidal ideation), severe psychiatric illness, and 
personality disorders, the GAIN Cognitive Impairment Questionnaire. In 

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addition, prospective participants will be asked questions about their 
experience growing up in, living in, or moving to or returning to, small 
towns or rural areas with census <10,500. See “Recruitment, screening, 
consent, and baseline script” document uploaded to Ethos for details. All of 
these instruments and documents are attached. Please note, the Screening 
Consent Form and Informed Consent Form were created using University 
of Minnesota templates, but some of the language was modified to reduce 
the reading grade level of the documents from approximately 10th grade 
reading level down to 7th grade reading level, which is more appropriate for 
this research sample.  
3) When prospective participants meet with Research Staff, they will also 
do one activity: they will be asked to write a list of 5 things that happened 
yesterday. Research staff will examine this list to determine if the 
individual has adequate literacy and writing skills to be part of the study 
since PPJ requires writing of short lists. 
4) The screening interview will take place as follows: 
1. Participant will have been given the study main consent form in 
advance by Wayside staff, ideally, and will have been asked to read 
it. They will have the chance to ask any questions. 
2. Screening consent form will be read, described, and signed. 
3. Participants and research staff will review the HIPAA consent 
document. 
4. Research staff will double check the inclusion criteria that Wayside 
staff determined via treatment records before referral to the 
research team, using the “Recruitment, screening, consent, and 
baseline script” document to guide the questions. 
5. Please note, that this study seeks to enroll women from rural areas 
and small towns of census less than 10,500. If women are from 
towns/cities, or will return to towns/cities, of greater census, then 
10,500, then they will be offered the opportunity to be placed on a 
waiting list for admission into the study, giving women from small 
towns or rural areas first priority. This is stated in the screening 
consent form and regular consent form and will be described 
verbally to participants in the “Recruitment, screening, consent, and 
baseline script.” 
6. Participants may also be placed on the waiting list if: a) they will not 
be at Wayside for the duration of the study, b) research staff is not 
sure if the person is eligible based on results of screening tests. In 

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this case, Wayside counseling staff are consulted to make sure the 
participant is eligible (e.g., if the person is adequately stabilized 
psychiatrically for participation). 
7. Participant will be asked to write a list of 5 things that happened 
yesterday, research staff will evaluate this list and determine 
whether or not it is adequate for study inclusion. If not adequate, 
screening procedure will stop. 
 
8. Research staff will administer the GAIN Cognitive Impairment 
Screener.70 This instrument uses 6 items to determine cognitive 
impairment. It uses questions such as “What year is it now?” and 
“Please count backwards from 20 to 1.” Participants earn points for 
correct answers. Cognitive impairment is considered to be present 
if the total score is greater than 10. If the participant scores 14 or 
greater, they will be excluded from the study. Screening procedure 
will stop. 
Research staff will ask participants each of the items of the GAIN SS. 
The GAIN SS is a short instrument designed to determine whether 
individuals should be assessed more comprehensively for 
internalizing disorders (6 items), externalizing disorders (7 items), 
and criminal or violent behavior (5 items). The instrument also asks 
5 items about substance use, but since all of the individuals in this 
study will have met criteria for a substance use disorder, we will not 
ask these questions. The response format determines how recently 
the individual had the symptoms or the behavior. We will used the 
modified response format adapted by Wayside. Wayside uses this 
instrument at baseline to screen participants, so the items will have 
been asked of the individuals before. Wayside’s response format is 
0=never, 1=in lifetime, 2= last year, 3=last month, 4=last week. We 
would change all the questions and prompts that say “when was 
the last time that you did the following things two or more times” 
to “when was the last time that you did the following things” so 
that even one instance would count. We would modify any 
question that asks about behavior at “school, work or home” so 
that it reads “school, work, home, or here at Wayside.” We would 
add this phrase to the instructions: “I will now ask you some 
questions about your experiences. Please answer “as of today” so 
“in the last week” would mean in the week that ends today. Please 
know I will not be asking you any follow up questions for any of 
these next questions. Depending on some of your answers, I might 

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need to let Wayside staff know of your replies.” We would consider 
a high score to be two or more past-week symptoms for each 
subscale: internalizing disorder, externalizing disorder, or 
criminal/violent behavior. Exclusion from the study based on these 
items would include endorsing “last week” for certain items such 
as: “thinking about ending your life or committing suicide,” “lied or 
conned to get things you wanted or to avoid having to do 
something,” having a hard time “paying attention at 
school/work/home” in combination with having a hard time 
“listening to instructions at school/work/home,” “were a bully or 
threatened other people,” “started physical fights with other 
people,” “had a disagreement in which you pushed, grabbed, or 
shoved someone,” and “purposely damaged or destroyed property 
that did not belong to you.”  In the event of high scores in any of 
the three subscales or a single score of “last week” for any of these 
selected items, the person would not be eligible for the study. 
However, in each of these cases, we would discuss the results with 
Wayside staff before determining final eligibility for the study. 
9. The requirement of 2 weeks continuous sobriety before enrollment 
in the study may be waved based on clinical judgement.  
10. Participant would read/review/discuss with study staff the 
informed consent document. Participant would read/review/discuss 
with study staff the HIPAA consent document.  
11. Research staff would ask the participant the questions from the 
UBACC quiz to determine capacity to consent.70 A score of 15 or 
higher is needed for inclusion in the study. The prospective 
participant can review the study details and return to re-do the quiz 
another day if this is possible given the study timeline.  
12. If they score over 15 on the UBACC and meet all other study 
inclusion/exclusion criteria, or if they are eligible for the wait list,  
they will they sign the main informed consent document and the 
HIPAA consent document. Sign these forms in duplicate, provide 
one copy for staff, one for participant. 
 
13. If the participant is deemed to meet all study criteria, they would 
move on to take the baseline assessment instrument. If they are 
from or going to a rural area or small town of census < 10,500, they 
will be informed of the day, time, and location for the first group 
session. They will may be placed on the wait list, depending on their 

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qualifications for the study and enrollment into the study at that 
point. 
10.0 Vulnerable Populations 
10.1 Vulnerable Populations:  
☐ Children  
☐ Pregnant women/Fetuses/Neonates 
☒ Prisoners 
☐ Adults lacking capacity to consent and/or adults with diminished 
capacity to consent, including, but not limited to, those with acute 
medical conditions, psychiatric disorders, neurologic disorders, 
developmental disorders, and behavioral disorders 
☐ Approached for participation in research during a stressful situation such 
as emergency room setting, childbirth (labor), etc. 
☒ Disadvantaged in the distribution of social goods and services such as 
income, housing, or healthcare 
☐ Serious health condition for which there are no satisfactory standard 
treatments 
☐ Fear of negative consequences for not participating in the research (e.g. 
institutionalization, deportation, disclosure of stigmatizing behavior) 
☐ Any other circumstance/dynamic that could increase vulnerability to 
coercion or exploitation that might influence consent to research or 
decision to continue in research 
☒ Undervalued or disenfranchised social group 
☐ Members of the military 
☐ Non-English speakers 
☐ Those unable to read (illiterate) 
☐ Employees of the researcher 
☐ Students of the researcher 
☐ None of the above 
10.2 Additional Safeguards:  
Why we checked the “prisoner” box: 
Perhaps 5% of Wayside residents are furloughed from incarceration. These 
women are not prisoners while in residential treatment at Wayside, but if they 
were to leave treatment without approval, a warrant would be issued for them 
to return to incarceration. There are a larger percentage of Wayside residents 
who are court mandated: they are civilly committed. We would include both 
groups of individuals in this study. To ensure that such individuals are especially 

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reassured that they are free to choice to be in the study or decline to be in the 
study without legal consequence, we added this language to the informed 
consent document: 
“We want to especially emphasize something for Wayside residents who are 
furloughed from incarceration or who are court mandated or civilly committed. 
This study is optional and you can feel free to say no to this study and still remain 
in treatment at Wayside. Being in this study or not being in this study does not 
affect your legal status in any way. Return to incarceration is in no way a 
consequence of either deciding to be in the study or deciding not to be in the 
study. Please ask us if you have any questions about this.”   
We also include special language in the informed consent document to clarify 
the consequences of certain kinds of disclosures to research staff, including 
telling research staff about substance use, intent to hurt someone else at 
Wayside, and about crimes committed. Here is the language we added, under 
the category, “What happens to the information collected for the research?” 
 
We will not ask you about child or vulnerable adult abuse. If you tell us about 
child or vulnerable adult abuse or neglect, we may have to report it to 
authorities because of law or policy. This is true if you tell us in group, one on 
one meetings, or in journal entries. Also, if we learn (in person, in group, or via 
journal entries) that you are at risk for hurting yourself or others, we will inform 
Wayside treatment staff of this information as soon as possible.  
 
In general, if something worries us about what you put in your journals, one on 
one meetings, groups, your iPad surveys, or any other contact you have with us, 
we will let Wayside Staff know. This includes any time you tell us that you have 
used drugs or alcohol. Telling us that you have used drugs or alcohol will have 
the same consequences as if you told a Wayside staff member that you used 
drugs or alcohol. Wayside staff would work with you to make sure that you have 
the support you need to get back on track related to your recovery. 
 
If you tell us that you committed a crime, we would tell Wayside Staff. Telling us 
that you committed a crime would have the same consequences as if you told a 
Wayside staff member that you committed a crime. If you are on probation or 
parole, Wayside staff would need to report this to your probation or parole 
officer. 
 
If you tell us that you intend to hurt yourself or someone else at Wayside, we 
would tell Wayside staff. 
 

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Some of these things that you might tell us might have consequences related to 
your stay at Wayside.  
 
In general, the Wayside Staff will not find out your answers to the iPad surveys.  
 
 
11.0 Number of Participants 
11.1 Number of participants to be consented will be a minimum of 9 and 
maximum of 35.  
12.0 Recruitment Methods 
12.1 Recruitment Process: Wayside counselors will inform clients who have 
completed 2 weeks of treatment of the possibility to participate in this 
research study by providing them with a study flyer and by discussing the 
opportunity with them. Counselors will emphasize that participation is 
entirely optional and that clients may choose to participate or not, and may 
drop out or continue with the study as they wish. Prospective participants’ 
relationships with Wayside or the University of Minnesota will not be 
negatively compromised whatever choice they make, and this point will be 
emphasized.  
Wayside staff will approach clients who appear to meet study criteria. 
Clients will receive the recruitment flyer, which may also be posted on 
bulletin boards or made available in group rooms or lounge areas. 
Interested clients will make an appointment with research study staff. At 
this appointment, prospective participants will be screened by research 
staff (see screening document attached). Those who meet inclusion criteria 
will go through the informed consent procedure and take the baseline 
questionnaire on the iPad. They will then be scheduled to join the first 
study group. Individuals who meet criteria for the waiting list would also 
take the baseline screening instrument. 
 
We will recruit participants who are from rural areas of the state or who 
believe they will return to rural areas after treatment. As 75-100 women 
are served each year at Wayside from rural areas, Wayside staff anticipate 
we will have no problem recruiting 15 women from rural areas.  
12.2 Source of Participants: All women to be enrolled in the study will be 
concurrently in residence, receiving SUD treatment at Wayside Women’s 
Treatment Center. PPJ is offered in addition to SUD treatment as usual, but 
women may miss Wayside groups in order to instead attend PPJ groups. 
This decision will be made by Wayside staff. 

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12.3 Identification of Potential Participants: Wayside staff will initially make 
contact with potential participants. Wayside staff will be aware of the 
inclusion and exclusion criteria and will approach women who appear 
eligible. Such women, if interested, will make appointments to be screened 
by research staff. The research study team will not have access to clients’ 
Wayside treatment records. Some clients of Wayside might self-identify 
based on the recruitment flyer (see attached). The recruitment flyer will 
have instructions for the prospective participant to approach a selected 
staff member to make an appointment with research staff.  
12.4 Recruitment Materials: Recruitment materials include the screening 
document and the recruitment flyer (copies are attached).   
 
12.5 Payment: Payment will be made in the form of Target gift cards given out 
at baseline, during each weekly group session, at the end of the 
independent practice phase, and at the exit interview. Target gift cards 
cannot be replaced if lost or stolen, this is stated on the regular consent 
form. Values of the Target gift cards will be based on participation as 
follows: 
 
Participants will be compensated $15 for the baseline assessment 
instrument and $5 for attending each group session during the 3-week 
Group Phase. Participants will be compensated $5 each time they upload 
PPJ using Qualtrics outside of group. This will be practiced once per week 
during the Group Phase to teach the skills needed for the Independent 
Practice Phase. 
 
During the two-week Independent Practice Phase, participants are 
required to upload PPJ a minimum of 2 times per week but can upload a 
maximum of 7 times per week if they wish to (they will only be 
compensated up to 5 times). Each time they upload, they will be 
compensated $5, assuming all aspects are completed (successful upload of 
photograph and answering study questionnaire items). Participants can 
feel free to upload more than 5 times a week (maximum would be daily) 
but would not be compensated for more than 5 times per week. 
Participants are not compensated for uploads that take place during group 
sessions. 
 
Participants will be compensated $15 for the exit interview. Participants 
will be paid a $20 bonus for completing the baseline interview, the exit 
interview, and at least 90% of all other study activities (group participation, 
homework, and the minimum number of independent PPJ uploads). 

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Total possible compensation including the bonus is $155. 
13.0 Withdrawal of Participants 
13.1 Withdrawal Circumstances: Participants will be withdrawn from the 
research without their consent for three reasons: 1) if the participant 
leaves Wayside treatment against staff advice, 2) if the participant leaves 
Wayside treatment at the request of staff for breaking the rules (for 
example, if they instigate a physical altercation), or 3) the participant 
leaves Wayside treatment without discussion with staff and does not 
return (e.g., does not return from a pass). In these three situations, we 
would retain the person’s data to date and code them has having 
discontinued treatment, since treatment retention is one of our primary 
outcomes. Participants of course can keep any Target gift cards they have 
earned. If a participant leaves treatment and the study owes the individual 
Target gift cards, these will be left for the individual at Wayside and/or 
forwarded to their home address listed in Wayside records. 
13.2 Withdrawal Procedures: Participants can elect to leave the study at any 
time. This is emphasized in the informed consent document. If participants 
leave the study, we will still consult Wayside records to determine relapse 
or treatment departure for all study participants. We will include this 
information in the informed consent document. 
Termination Procedures: If a participant stops attending group, we will 
reach out to them once if they are still in residence in Wayside and ask 
them if they would like to leave the study. If they say no then the process 
will stop and we will pay them any Target gift cards we owe them. If they 
are uncertain, we will warmly invite them to return to group, but will then 
consider them to have left the study if they do not return. If the participant 
stops recording PPJ entries after the Group Phase, we will also ask them if 
they would like to leave the study. If they say they would like to leave the 
process stops and we will pay them any remaining Target gift cards we owe 
them. If they are uncertain we will warmly encourage them to continue 
one time. We may also ask Wayside staff to help us find out this 
information. If a person wishes to leave the study, we will note this in our 
study records. For individuals who leave the study prematurely, we will use 
data already collected and follow up data on relapse and treatment 
departure in our data analyses. Participants of course can keep any Target 
gift cards they have earned and we will pay out any additional Target gift 
cards earned upon their exit from the study.  
 

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Wayside study participants will be invited to sign a release of information 
naming research staff, so that if study participants call research staff by 
telephone, we will be able to call them back and speak to them or leave a 
message. 
 
14.0 Risks to Participants 
14.1 Foreseeable Risks: The potential risks in this study include those related to 
confidentiality, alcohol and illicit drug abstinence, and uncomfortable 
emotions when completing PPJ and Qualtrics questionnaires, which will ask 
about substance use, affect, trauma history, satisfaction with recovery, and 
other wellbeing and health indicators.  
 
Although the PPJ is hypothesized to be supportive, affirming, and 
encouraging, uncomfortable emotions may also arise when looking back 
over the past 24 hours or planning the upcoming 24 hours when 
completing PPJ.  
 
One risk to confidentiality will be if a third party (such as another resident 
at Wayside) reads the participant’s journal. We will advise participants to 
use codenames and symbols to code material that is especially private to 
them in case their journal is viewed by other people. We will also advise 
participants to keep journals stored in a safe place. Some participants may 
accidentally take a picture of their journals outside of the Qualtrics survey 
which would then be saved on the iPad until study staff deletes it. In this 
case, there is a risk that another research participant will see their journal 
entry. This is described as a risk on the informed consent document. 
 
Although our sample participants will have been in treatment for a 
minimum of two weeks at Wayside and should no longer be experiencing 
the acute physical withdrawal effects associated with drug and alcohol 
abstinence, continued abstinence from drugs and alcohol is often 
associated with irritability, restlessness, anxiety, depressed mood, sleep 
disturbance, increased appetite, and decreased concentration. Abstinence 
may also exacerbate pre-existing mental health conditions. Although these 
symptoms may be effectively treated with appropriate intervention, we 
will monitor these symptoms at each session.  
 
Individuals reporting extreme mental health issues either in the treatment 
group or in their PPJ Qualtrics entries will be referred to Wayside staff. In 
such cases, we will refer the patient to appropriate 
medical/psychiatric/counseling staff at the Wayside treatment center. 

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More specifically, individuals who indicate suicidal ideation will be referred 
to the Wayside staff. Wayside staff would then follow their usual 
procedures and refer patients with life threatening conditions to inpatient 
psychiatric programs in the Minneapolis metro area.  
 
Procedures to be performed to lessen the probability, magnitude, 
duration, or reversibility of those risks. All of the information obtained 
from subjects is entirely for research purposes and will be referenced by 
codename or number versus participant name and kept in locked 
confidential files at the University of Minnesota School of Social Work or on 
password protected University of Minnesota computers or servers. At 
baseline, participants will be invited to select a codename or number that 
they can easily remember but one that is not an identifier (e.g., real name, 
birthdate). They will use this codename or number on all study materials 
except for the informed consent document including study homework and 
PPJ entries. Their codename and real name are also listed on paper forms 
but these are always kept in a locked file cabinet or locked file box. 
 
The original PPJ entries will remain in the hard-copy paper journal which 
we will provide to participants. The research team will see electronic 
snapshots of journal entries uploaded to Qualtrics. These snapshots will 
not contain identifying information (participant name, date of birth, etc). It 
is important to see these snapshots to make sure the participant is 
authentically completing PPJ that day. 
 
Consent forms will be separated and kept in a separate locked storage 
container or drawer. All forms that include identifying information (i.e., 
consent form) will not include participant codenames or numbers. This 
information is not available to anyone except the investigators. All data 
collected are solely identified by codename or number and are not 
identifiable by any other subject information. The exit interviews and parts 
of group sessions will be transcribed. Transcriptions will be fully de-
identified.  
 
We will maintain an electronic document with a password that links subject 
number or codename to participant names, and we will delete this 
document after data analyses are complete, approximately one year after 
the last data are collected from study participants. We will also destroy 
paper forms linking real name to codename at this same time. 
 

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There may be some discomfort associated with completing questionnaires 
that ask about affect, which may be poor in early recovery, satisfaction 
with life in recovery, which may be low in early recovery, and history of 
substance use and trauma. There may be some discomfort with looking 
back over the past 24 hours and planning the upcoming 24 hours. We 
expect that any such discomfort would be temporary. We will alert 
participants to this in the informed consent document and in group. We 
will also address emotions related to past 24 hour review and planning the 
upcoming 24 hours to provide support and understanding for any 
uncomfortable feelings that may arise during the group sessions. Any 
emotions of extreme intensity or duration will cause study staff to refer the 
participant to Wayside staff.  
 
A Wayside staff member will sit in on all group sessions to monitor the 
session and participant wellbeing, as the groups will be part of participants’ 
overall Wayside experience. If an individual is in an amount of distress that 
cannot be managed by the group process, then the Wayside staff member 
can take the person out of group to address the issue. The Wayside staff 
member will also help maintain group norms, group rules, and appropriate 
group behavior which will foster an environment conducive to learning. If 
there should be a group meeting conducted without a Wayside staff 
member for any reason, and any incident of this kind takes place, research 
study staff will go down the hall to find a Wayside staff member to assist. 
 
Another risk is the privacy of journal contents. The journaling practice is 
meant to capture the person’s lived experience over the past 24 hours. 
Some of this content will be private and personal and not meant to be 
shared with anyone, which is entirely acceptable and even encouraged. 
However, to keep such information private in a written journal, we will 
encourage participants to use code names or code initials for very personal 
information, e.g., “I was upset and mad at DB” where DB are code initials 
for the individual referenced. This will protect the individual in case a third 
party (e.g., other Wayside resident) reads the person’s journal. We will ask 
all participants to respect the privacy of other people’s journals. We will 
discuss this in the group sessions.  
 
We will monitor journal entries submitted in the Group and Independent 
Practice Phases for any information about feelings about participants 
hurting themselves or others or cases of abuse of a vulnerable adult or 
child neglect or abuse. We are mandated reporters in such cases and will 
share what we see with Wayside staff and make sure that reporting 

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procedures are followed. Wayside will provide us with an emergency staff 
number that we can dial 24/7 if we see something worrisome in a PPJ 
journal entry uploaded to Qualtrics. We will describe this limitation to 
confidentiality in the informed consent document and in group sessions.  
 
14.2 Reproduction Risks: N/A 
14.3 Risks to Others: One group exercise we will employ is “each one teach 
one.” In this exercise, group members are invited to choose someone in 
their supportive network to teach the journaling practice to. This secondary 
person would be invited by the participant to try PPJ, and then the 
“teacher” and the friend will share contents of PPJ with each other. We do 
not expect that the secondary participant would face any risks beyond mild 
and temporary feelings of discomfort that might arise when reviewing the 
past 24 hours or planning the upcoming 24 hours.  
15.0 Incomplete Disclosure or Deception 
15.1 Incomplete Disclosure or Deception: N/A. Participants will be informed that 
this is a test of a journal practice that involves daily life review and planning 
for the future as a way to support recovery. 
16.0 Potential Benefits to Participants 
16.1 Potential Benefits: The hypothesized benefit of the proposed study is the 
potential of improving quality of life and increasing other wellbeing factors 
(e.g., positive emotion), which we hypothesize will support sustained 
abstinence from alcohol and other illicit drugs and sustained enrollment in 
the Wayside treatment center. However, while there is evidence that 
gratitude practices and activity planning may yield such benefits, there is 
no evidence for the benefits of the combined elements that comprise PPJ.  
 
Although potential risks include frustration, existing psychological 
withdrawal effects from alcohol and substance use abstinence, mild 
discomfort when filling out questionnaires, and adjusting to a new lifestyle, 
these are not life threatening and will subside as treatment progresses.  
 
Finally, issues of confidentiality are a high priority and will be closely 
monitored throughout the treatment study. Consequently, the risk to 
benefit ratio in the proposed study appears to be acceptable. 
17.0 Data Management 
17.1 Data Analysis Plan: Please see “Analysis Plan” under 5.2, above.  

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17.2 Power Analysis: N/A. No power analysis is needed for this pilot study that 
will enroll 9-35 participants (see sections 5.2 and 11.0). 
17.3 Statistical Analysis: N/A. No hypothesis testing will be done in this pilot 
study designed to develop, refine, and enhance the PPJ intervention. 
However, descriptive statistics of the quantitative measures will be used to 
conduct power analyses and sample size calculations for a larger controlled 
trial. 
17.4 Data Integrity: The use of Qualtrics to collect survey data will improve data 
accuracy because this allows us to avoid keystroke and other errors 
involved with manual data entry from written questionnaires. We will 
scrutinize the data produced by Qualtrics to ensure its integrity; whether 
values are within scale ranges and whether missing data is coded correctly. 
We will carefully examine and clean the data to ensure accuracy. For 
standardized instruments, we will be very careful to follow the directions 
for summing or taking the mean of scale items and reverse code any items 
as per the instructions. 
18.0 Confidentiality 
18.1 Data Security: We will safeguard against breaches of confidentiality by 
coding participant data by codename or number rather than by name and 
by keeping information linking these codenames or numbers to research 
staff via password protected electronic file. Further, no individuals will be 
identified by name nor will any identifying information be offered when 
presenting data in lectures, seminars, professional presentations, or 
papers. When qualitative data are transcribed, whether from exit 
interviews or recorded group sessions, they will be de-identified to replace 
any spoken names or identifiers with brackets, e.g., “Joan” will be replaced 
with “[Participant’s Daughter].” 
 
The Office of Measurement Services (OMS) of the University of Minnesota 
will be assisting the study by designing the Qualtrics mechanism that we 
will use for data collection. OMS has many years of experience in 
collecting, maintaining, and storing data in accordance with FERPA and 
HIPAA regulations. OMS’s internal security and safeguards go beyond the 
minimum levels established for the University of Minnesota. OMS provides 
data security and privacy protection by using a dedicated server to store 
data, by performing daily data back-ups, and by using Secure Sockets Layer 
(SSL), the industry-standard means for safeguarding web communications. 
OMS also utilizes encryption protocols for the storage and transmission of 
data which further ensures data security. Additionally, OMS recently 

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completed IT risk assessments from Berry Dunn and Deloitte to verify that 
our data handling and storage procedures are up to date and effective. 
 
A copy of the consent form will be placed in the participant’s Wayside 
hard-copy file. Wayside will make mention in chart notes that the client has 
participated in the PPJ group.  
19.0 Provisions to Monitor the Data to Ensure the Safety of Participants 
19.1 Data Integrity Monitoring:  
The job of data integrity monitoring will be conducted by PI Krentzman. She 
will oversee all study progress and ensure that the study is conducted, 
recorded, and reported in accordance with the protocol and standard 
operating procedures. In the event that changes to the protocol are 
needed, PI Krentzman will make modifications using standard IRB 
procedures. PI Krentzman has been an Assistant Professor of Social Work 
for five years. PI Krentzman has expertise in positive psychology,71,72 
gratitude,19,24 and spirituality in AUD recovery;65,73–75 as well as qualitative 
data analysis;19,76 quantitative data analysis;65,73,77 mechanisms of behavior 
change;65 and the conduct of randomized control trials to test novel 
interventions to support AUD recovery.19,78 PI Krentzman will be in ongoing 
contact with staff at Wayside, specifically Jessie Everts, PhD, Vice President 
of Clinical Programs at Wayside, who is the study’s primary contact at the 
host agency. PI Krentzman will supervise study staff including all Research 
Assistants. Supervision will involve face to face meetings at a minimum of 
once every two weeks. Study reports will be provided to the IRB according 
to the regularly scheduled requirements of such reporting. In these reports 
we will describe recruitment progress and study findings as they unfold. 
19.2 Data Safety Monitoring:  
All research staff will complete the online training modules which cover 
HIPAA, ethical research with human subjects, accuracy, record keeping, 
and confidentiality. These modules are offered by the University of 
Minnesota and include HIPAA Training; Managing Personnel Data; 
University Information Security; Assessing Capacity to Consent to Research; 
Collaborative Institutional Training Initiative (CITI) Program’s 
Social/Behavioral or Humanist Research Investigators and Key Personnel; 
and Responsible Conduct of Research Core – Social and Behavioral 
Sciences. PI Krentzman will model and extensively review this content with 
all staff. 
Safety. 

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As noted in the human subjects section of this application, we will protect 
against physical and emotional symptoms resulting from substance use 
abstinence and any other relevant psychological symptoms. Further, we 
are acutely aware of the importance of protecting participant 
confidentiality and in abiding by HIPAA guidelines.  
The baseline session will take place in a private and quiet setting at 
Wayside. The meeting begin with screening informed consent, screening, 
and then informed consent, which will include a detailed description of the 
purpose and procedure of the study, emphasizing our policy regarding 
privacy and confidentiality, and an opportunity for the individual to ask any 
questions or voice any concerns. A screening informed consent document 
will be signed before screening activities take place. A regular informed 
consent document will be reviewed and a quiz on its contents passed 
before any study data are collected. Two copies of the informed consent 
document will be signed and the participant will keep one copy and study 
staff the other copy. In addition, participants will complete a “screening 
consent” document where they will obtain informed consent and give 
permission to be screened for this study. We will invite and answer any 
questions about the study. We will make sure the participant understands 
the information and does not feel pressured to make a decision. 
Participants will understand that their participation is entirely voluntary. 
Aside from signing the consent forms, HIPAA form, and the “codename” 
form, the participant’s name will not appear anywhere on other collected 
information which instead will be marked with a codename or number that 
will be listed on all data forms; only research staff will have access to a 
document(s) that links participant number/codename and name. All of the 
information obtained from subjects is entirely for research purposes and 
quoted by codename or number and kept in locked confidential files at our 
offices at the University of Minnesota or on password protected laptops or 
university servers. This information is not available to anyone except the 
investigators. 
Although our sample participants will have been in treatment a minimum 
of 2 weeks and no longer suffering from the acute physical withdrawal 
effects of alcohol or drug abstinence, continued abstinence from drugs and 
alcohol is often associated with irritability, restlessness, anxiety, depressed 
mood, sleep disturbance, increased appetite, and decreased concentration. 
Abstinence also may exacerbate pre-existing conditions. Although these 
symptoms may be effectively treated with appropriate intervention, we 
will monitor these symptoms at each session. Individuals reporting 

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moderate or persistent concerns or problems will be referred by study staff 
to appropriate medical/psychiatric staff at Wayside. We will periodically 
evaluate the data collected regarding both harms and benefits to 
determine whether participants remain safe.  
Study Research Assistants or PI Krentzman will review the data, especially 
the pictures of the journal entries, as soon as possible after submission but 
no later than 72 hours after submission to examine the data for any safety 
concerns. Now that we have added the Demoralization scale, we will also 
check responses to this scale and report to Wayside high responses to 
items #20 or #2, which are: “I would rather not be alive” and “My life 
seems to be pointless.” If we see scores of 3 or more (3 indicates “often”) 
on either of these items, we will report this to Wayside.  
If participants experience distress related to the baseline questionnaire, 
including the question that asks about history of trauma, we will refer them 
to Wayside staff.  
 
20.0 Provisions to Protect the Privacy Interests of Participants 
20.1 Protecting Privacy: The consent documents and codename sheets will be 
the only documents that contain the participant’s name. All other 
documents in paper or electronic format will include the person’s 
codename or number only. An electronic file matching participant name to 
codename or number will be kept on a password protected computers and 
the file itself will be password protected and erased one year after the 
conclusion of data analysis. Paper copies of this information will also be 
destroyed at this time. 
We will go to great lengths to make sure participants understand the 
nature of the research study and our concern about their privacy. This will 
be made clear in the content of the informed consent document. We will 
review this information with participants in depth as we go over all 
elements of the informed consent process. We will assure the participant 
that we will do everything we can to ensure their privacy, including using a 
codename or number associated with their data and putting a password on 
the electronic file that matches their codename or number to their name. 
Limitations to confidentiality will also be described, such as whether the 
participant describes the desire to harm themselves or others, or whether 
a minor or vulnerable adult is at risk of abuse or neglect. 
20.2 Access to Participants: The research team will not have access to Wayside 
records. To determine our key outcomes, recurrence of substance use or 
discontinuation of treatment, a Wayside staff member will sit with a 

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member of the research team at reasonable time intervals to share 
whether participants have left treatment or whether they have resumed 
substance use. Resumption of substance use is confirmed at Wayside via 
urine testing or other drug screening. Results of these tests, if positive for 
substances, will be communicated to research staff at these prescribed 
meeting times (2, 4, and 6 weeks into the study or at other reasonable 
periods) and we will code this information into our de-identified data 
records. 
21.0 Compensation for Research-Related Injury 
21.1 Compensation for Research-Related Injury: N/A 
21.2 Contract Language: N/A 
22.0 Consent Process 
22.1 Consent Process (when consent will be obtained): Our consent process is 
informed by the instructions provided in HRP-090 and HRP-091. The 
consent process will take place on site at Wayside house. Research staff 
will meet with prospective participants. First, participants will complete a 
screening informed consent document then they will be screened using our 
screening document (attached to ETHOS). If the participant meets 
eligibility, we will offer the participant the choice of reading the informed 
consent document and we will verbally summarize it for them in detail. 
Participants will be administered the UBACC quiz to determine that they 
have understood the study and their role in the study. A score of 15 or 
higher is needed for inclusion in the study. An impartial witness will be 
used if necessary, for example, if the prospective participant has a visual 
impairment and cannot read the informed consent document. If an 
impartial witness is used we will follow the guidelines described in HRP-090 
for that procedure. 
22.2 Waiver or Alteration of Consent Process (when consent will not be 
obtained, required information will not be disclosed, or the research 
involves deception): N/A 
22.3 Non-English Speaking Participants: N/A 
22.4 Participants Who Are Not Yet Adults (infants, children, teenagers under 18 
years of age): N/A 
22.5 Cognitively Impaired Adults, or adults with fluctuating or diminished 
capacity to consent: N/A 
22.6 Adults Unable to Consent:  
 
Permission: N/A 

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 
Assent: N/A  
23.0 Setting 
23.1 Research Site: Four factors governed our choice of community partner. 1) 
Our analyses of existing study data indicated that many rural individuals 
migrate to more densely populated areas for substance use disorder 
treatment. 2) An important part of new intervention development is 
identification of the subpopulation with whom the intervention might be 
most successful. Our analyses of pilot data indicated that the journaling 
intervention might be more acceptable among women. 3) The earliest 
stages of intervention development require repeated and frequent site 
visits to coordinate logistics, plan, revise, and pilot the intervention. 4) A 
site that would be feasible given time and cost limitations would be located 
in the Twin Cities metro. Ideally, it would serve women from rural areas.  
 
Therefore, our partner for the study will be Wayside Women’s Treatment 
Center, a residential substance use disorder treatment program in St Louis 
Park, MN, where 25%-33% of clients come from rural areas. Wayside 
Recovery Center is a private, non-profit organization treating substance use 
disorders since 1959. Over 300 women each year are treated at the Center 
for approximately 90 days followed by intensive outpatient care. 
Treatment elements include education groups and lectures, process group 
therapy, and individual therapy. The therapeutic model uses relational-
cultural therapy, trauma-informed care, cognitive behavioral therapy, and 
motivational interviewing. PPJ is not redundant with existing aspects of the 
program.  
 
The research team in coordination with Wayside staff will identify and 
recruit potential participants from this site. Research procedures including 
screening, informed consent, baseline assessment, study groups, and exit 
interviews will be performed on this site. We will work in close 
collaboration with the staff and management of Wayside Women’s 
Treatment Center throughout. Specifically, Wayside staff will help us with 
recruitment by identifying prospective participants, Wayside staff will sit in 
on group meetings, Wayside staff might help us get messages to 
participants in between group meetings or study phases. Wayside staff will 
keep the iPads under lock and key and distribute them to participants 
during the independent practice stage of this study. We will also solicit 
input from Wayside staff before the study begins and seek consultation on 
drafts of the treatment manual after the study ends. 
 
23.2 International Research: N/A 

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23.3 Community Based Participatory Research: N/A 
 
24.0 Multi-Site Research  
N/A 
25.0 Resources Available 
25.1 Resources Available:  
Time. The Agricultural Experiment Station (AES) grant that is funding this 
study provides PI Krentzman with one course buy out each year for 2018-
2019 and 2019-2020 academic years. PI Krentzman will use this time and 
additional time to conducting and completing this research.  
Research Assistant(s) (RA). The AES grant that is funding this study allows 
for two 25% RAs for years one and two of this study (2018-2019 and 2019-
2020 when we will be writing up our results and planning next steps). The 
RAs will be involved in all aspects of the research including screening and 
informed consent, data management, data cleaning, literature reviews, exit 
interviews, attending group sessions, and general research activities. 
Facilities. The School of Social Work is home to five research and training 
centers that serve local and national educators, researchers, and 
professional social workers. The School is located at 1404 Gortner Avenue 
in St. Paul, MN. Faculty members at the School of Social Work are among 
the most productive in the nation, conducting research on a wide range of 
topics. The School produces a wide range of high-quality research relevant 
to social welfare including work in health, mental health, disability, aging, 
and methods and methodology (http://www.cehd.umn.edu/ssw). The 
School of Social Work’s research committee hosts monthly research 
colloquia to showcase the current research of University of Minnesota 
faculty.  
 
Offices. A 118 square foot office for PI Krentzman is permanently available 
in Peters Hall. The office features a desk, credenza, attached table with two 
guest chairs, two lockable large two-drawer filing cabinets, one lockable 
three-drawer filing cabinet, and high-speed internet access hardwired to a 
laptop docking station. The University’s wireless network is also accessible 
throughout Peters Hall. Project staff will be equipped with additional office 
space in Peters Hall similarly equipped with desks, chairs, filing cabinets, 
computers, and internet service.  
 
Computers. The PI has a Dell PC laptop (Windows 10) and two monitors. All 
research staff will have Dell PC workstations in their offices. The University 

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provides SPSS Statistics Software and the PI has perpetual licenses for two 
copies of NVivo software for qualitative data analysis. Annual NVivo 
licenses have been purchased for additional research staff members. 
Availability of medical or psychological resources. These currently exist at 
Wayside and will be utilized if necessary via referral of the participant to 
Wayside staff in the event of medical or psychological concerns beyond the 
scope of this study. 
Trained research staff. PI Krentzman takes responsibility to ensure that all 
persons assisting with the research are adequately informed about the 
protocol, the research procedures, and their duties and functions. Research 
assistants will be trained in data collection, data cleaning, and data 
management including recruitment activities, informed consent, and 
administration of self-report, interview, and electronic measures. All 
research staff will complete University of Minnesota training modules 
which cover HIPAA, ethical research with human subjects, accuracy, record 
keeping, and confidentiality. PI Krentzman will model and extensively 
review this content with staff. Research assistants will develop skills (e.g., 
informed consent procedures) via role-play exercises with PI. Krentzman. PI 
Krentzman will provide ongoing supervision for research staff. 
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