JMIR FORMATIVE RESEARCH

Siste et al

Original Paper

Relapse Prevention Group Therapy in Indonesia Involving Peers
via Videoconferencing for Substance Use Disorder: Development
and Feasibility Study
Kristiana Siste1*, MD, PhD; Youdiil Ophinni2,3,4*, MD, PhD; Enjeline Hanafi1*, MD; Chika Yamada3,5*, PhD; Reza
Novalino6; Albert P Limawan1, MD; Evania Beatrice1, MD; Vania Rafelia1, MD; Peter Alison1, MD; ToshihikoMatsumoto5, MD, PhD; Ryota Sakamoto3, MD, PhD
1

Department of Psychiatry, Faculty of Medicine, Universitas Indonesia – Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia

2

The Hakubi Center for Advanced Research, Kyoto University, Kyoto, Japan3

Department of Environmental Coexistence, Center for Southeast Asian Studies, Kyoto University, Kyoto, Japan

4

Ragon Institute of Mass General, MIT, and Harvard, Cambridge, MA, United States

5

Department of Drug Dependence Research, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan

6

Karisma Foundation, Jakarta, Indonesia*

these authors contributed equally

Corresponding Author:
Chika Yamada, PhD
Department of Environmental CoexistenceCenter for Southeast Asian Studies
Kyoto University
46 Yoshidashimoadachicho
Sakyo Ward
Kyoto, 606-8304
Japan
Phone: 81 757537351
Email: chika128@cseas.kyoto-u.ac.jp

Abstract
Background: Substance use disorder (SUD) is a major health issue in Indonesia, where several barriers to treatment exist,
including inaccessibility to treatment services, stigma, and criminalization of drug issues. Peer involvement and the use oftelemedicine to deliver psychotherapy are promising approaches to overcome these barriers.
Objective: This study aims (1) to describe the development of a new group psychotherapy coprovided by a health care worker
and a peer and (2) to evaluate the acceptability, practicality, and preliminary outcomes of the program delivered via
videoconferencing in Indonesia.
Methods: Building upon an established relapse prevention therapy in Japan, we developed a 3-month weekly group therapy
module in the Indonesian language. Adjustments were made via focus group discussions with local stakeholders in terms of
substance types, understandability, inclusive language, and cultural relevance. A pilot study was conducted to test the new module
provided by a peer and a psychiatrist via videoconferencing, termed tele-Indonesia Drug Addiction Relapse Prevention Program(tele-Indo-DARPP), with a pre- and postcontrolled design. We analyzed data from semistructured feedback interviews andoutcome measurements, including the number of days using substances and quality of life, and compared the intervention(tele-Indo-DARPP added to treatment as usual [TAU]) and control (TAU only) arms.
Results: In total, 8 people diagnosed with SUD participated in the pilot study with a mean age of 37 (SD 12.8) years. All weremen, and 7 (88%) used sedatives as the primary substance. Collectively, they attended 44 of the 48 tele-Indo-DARPP sessions.
A total of 3 out of 4 (75%) preferred telemedicine rather than in-person therapy. Positive acceptability and practicality wereshown from qualitative feedback, in which the participants who joined the tele-Indo-DARPP reported that they liked the convenienceof joining from home and that they were able to open up about personal matters, received helpful advice from peers, and received
support from other participants. Providers reported that they feel the module was provider-friendly, and the session was convenient
to join without diminishing rapport-building. Meanwhile, troubles with the internet connection and difficulty in comprehending
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Siste et alsome terminology in the workbook were reported. The intervention arm showed better improvements in psychological healthand anxiety symptoms.
Conclusions: Group psychotherapy via videoconferencing coprovided by health care workers and peers was acceptable andpractical for participants with SUD and service providers in this study. A large-scale study is warranted to examine the effectivenessof the newly developed module in Indonesia.
(JMIR Form Res 2024;8:e50452) doi: 10.2196/50452
KEYWORDS
substance use disorder; cognitive behavioral therapy; telemedicine; peer involvement; Indonesia; substance use disorders; digitalintervention; COVID-19; psychotherapy; drug; mobile phone

Introduction
Substance use disorder (SUD), defined as the uncontrollable
use of psychoactive substances that disrupt daily living, remains
a significant health problem worldwide. The burden is especiallyhigh in low- and middle-income countries (LMICs), where theabsolute mortality due to SUD is higher than in high-income
countries [1], and the number of affected individuals exceeds
the capacity of accessible, formal care services [2]. This
treatment gap seems especially pronounced in Indonesia, thethird most populated LMIC worldwide. In 2019, the proportionof people who currently use drugs in Indonesia was estimatedto be 1.8%, with marijuana (68%) and amphetamine-type
stimulants (ATS, 42%) as the most used substances andunprescribed benzodiazepines and new psychoactive substances(NPS) on a recently increasing trend [3,4]. While the actual
SUD prevalence remains unreported, based on the ratio used in
global estimates—35 million SUD cases out of 269 million
people using drugs [5]—it is estimated that nearly 430,000
Indonesians have SUD. In contrast, there is a severe paucity ofavailable mental health care provisions in the country. Even
according to the most recent data, the rate of psychiatrists andmental health nurses was only 0.32 and 2.52 per 100,000
residents, respectively [6]. There is poor personnel
decentralization outside of Java island, where the country’s
capital is located, and poor facility distribution throughout thecountry’s 32 provinces, with 7 of them not having a mental
hospital [7]. Only a third of all public hospitals and a fifth of
all primary health care centers (Puskesmas) nationwide provide
mental care services [7,8]. In the Puskesmas, methadone
maintenance therapy is available, but implementation issues
persist, such as low coverage (5% in 2012) [9], short-lived
adherence (61% after 6 months) [10], high prevalence of
psychiatric problems, and lower quality of life [11]. Methadone
itself is strictly controlled and recipients need to come to
Puskesmas nearly every day to take their doses.
Although the existence of standardized therapy for SUD could
substantially help close the treatment gap in Indonesia, currently
there is none. Here, we would like to propose cognitive
behavioral therapy (CBT) as a feasible and scalable therapeutic
method for SUD. CBT approaches include motivational
interviewing by discussing clients’ ambivalence and efforts torectify it, as well as relapse prevention by identifying personal
triggers and safe methods to quell cravings. The clinical efficacy
of CBT in treating SUD has been proven in numerous
large-scale studies and meta-analyses [12-14]. In LMICs, 5
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randomized clinical trials (RCTs) testing CBT for drug use
disorders have been conducted so far [15-19]. Only 2 of themwere outpatient-based, 1 in China for opiate dependence [18]and 1 in Iran for methamphetamine use [19], both of which
reported positive outcomes in reducing the frequency of use.
The provision of CBT is low cost, does not necessitate mental
health care specialists, and can be delivered in group therapy,
which could thus counterbalance the numerical discrepancy
between SUD care providers and recipients. In particular, we
would like to elevate the role of peer counselors—people withlived experiences of SUD and recovery who now provide
experience-based knowledge as part of the counseling for clientsin need—as key CBT providers in formal service care settings.
Involvement of peers (also referred to as peer recovery support
or involvement of recovery coaches) in SUD care has beenshown to be effective in increasing abstinence rate and duration[20-22], increasing outreach in harm reduction programs andefficacy to suppress transmissible infections [23,24], andalleviating societal stigma to drug use [25]. However, based ona recent meta-analysis [26], empirical evidence in LMICs ismuch more limited. Only 4 studies have been reported so far
on the goal of abstinence, including an RCT in Iran [27], acohort study in Vietnam [28], a pilot mixed method study in
Malaysia [29], and a feasibility study in Indonesia, which tested
a family-based educational approach for adolescents with SUD
delivered by peers [30].
Finally, a telemedicine platform is assumed to further enhance
the accessibility and reach of the CBT program. Internet
communication would overcome the geographical barriers of
the Indonesian archipelago, being beneficial not only inconnecting intercities, that is, facilitating connections between
providers in central areas and clients in peripheral regions (orvice-versa), but also in connecting intracities, for instance by
cutting transportation time in traffic-heavy metropolitan areas,such as Jakarta, or allowing more flexibility in schedulingmultiple clients in a group. Privacy is also better protected asclients can receive therapy remotely from their residences,whereas visiting clinics or Puskesmas in person may reveal their
SUD diagnosis—a heavily stigmatized health condition—to
their social environment. While therapeutic approaches withtext messages or web-based applications have been developed
for relapse prevention [31], synchronous telemedicine via live
videoconferencing may improve rapport, including client
engagement with providers and group cohesion, which may all
facilitate adherence to therapy. Although videoconferencing
has been shown to be effective in delivering psychotherapy for
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JMIR FORMATIVE RESEARCHSUD [32-37], recent reviews [38-43] have highlighted 2
important knowledge gaps. First, existing intervention reports
have only addressed alcohol and opioid use [32,35-37]. Second,
there have been no studies conducted in LMICs that evaluate
psychotherapy for SUD delivered via videoconferencing. The
number of internet users has been rapidly growing in LMICs
including Indonesia. Over 74% of the Indonesian population
used smartphones in 2019, a number that is estimated to reach
89% in the next 3 years [44]. Moreover, teletherapy has become
an essential approach ever since the COVID-19 pandemic [45].
Its accessibility and effectiveness, even among people withSUD [46,47], may sustain telemedicine as the postpandemic“new normal” for SUD management [48].
Considering the current challenges and opportunities, it would
be beneficial to develop a therapeutic program in Indonesia for

Siste et alpeople with SUD where peers and conventional health care
workers work together to deliver the program throughvideoconferencing. This paper aims (1) to describe thedevelopment of a new group psychotherapy for SUD provided
by a health care worker and a peer; and (2) to evaluate theacceptability, practicality, and preliminary outcomes of the
program delivered via videoconferencing in Indonesia.

Methods
Our course of action in this study can be divided into 2 phases:
module development and pilot study (Figure 1).
Tele-Indo-DARPP: tele-Indonesia Drug Addiction Relapse
Prevention Program

Figure 1. Flowchart describing the processes undertaken in this study.

Module Development
Reference Program
The reference program, the Serigaya Methamphetamine Relapse
Prevention Program (SMARPP), and the reasons for choosing
it to base our new module were briefly explained previously[49]. Besides its efficacy and scalability, SMARPP has beenshown to reduce the stigma held by health care workers [50],as SMARPP is designed to be coprovided by a health care
worker and a peer. Thus, the positive interaction between thehealth care worker and peer might have improved the attitudeof health care workers toward people with SUD.

Translation and Workbook Development
We first translated the SMARPP module into the Indonesianlanguage. Indonesian addiction psychiatrists reviewed andrevised the module to better reflect the local contexts. The
module was then named the Indonesia Drug Addiction Relapse
Prevention Program (Indo-DARPP). We then held focus group
discussions with Indonesian peer counselors (n=6), generalpractitioners (n=4), psychiatrists (n=3), addiction psychiatrists(n=2), and Japanese researchers (n=2) to further revise themodule. All of the members had extensive experience ranging
from 2 to 20 years in the addiction field.
Focus discussions led to various adjustments to make thecontents of the workbook more locally relevant. Modifications
were made to the substances discussed in the module, with theaddition of opioids, especially heroin and opioid substitution
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therapy; the discussions on marijuana and benzodiazepines wereextended; the details on antialcohol medications, which areunavailable in Indonesia, were reduced; and the types ofprescribed medicines, NPS, and illegal alcohol were adjusted
to better reflect popular substances locally. These changes
increased the amount of content from 24 chapters or 151 pages
in SMARPP to 26 chapters or 200 pages in Indo-DARPP. The
content can be divided into 4 separate themes: basic principles
of recovery, for example, the definition of addiction, triggers,
cravings, and stages of change (chapters 1-8), effects ofsubstances on physical and mental health and the characteristics
of each substance (chapters 9-18), and finally, social
relationships, relapse cycle, and its prevention (chapters 19-26).
Sample pages of the module book can be viewed in Multimedia
Appendix 1. The module text is formatted in large 14-point
fonts with spacious paragraphs to increase readability andaccompanied by both schematic and decorative illustrations toenhance comprehensibility and appeal. A total of three elements
were blended (Figure S1 in Multimedia Appendix 1) as follows:(1) user information, which comprises basic information,
medical details, evidence-based data, and practical facts, (2)self-assessment queries, which are specific or multiple-choicequestions to invite readers in recognizing their situations, and(3) motivational interview, which are open-ended questions to
help readers analyze themselves deeper and explore toward asolution and increased motivation. Fonts were enlarged andillustrations were inserted to almost all pages to increase
readability, and “take-home messages” were added every 2 to
3 chapters. Colloquial street expressions were incorporated, andJMIR Form Res 2024 | vol. 8 | e50452 | p. 3
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stigmatizing terms were replaced with inclusive language, as
advised by peer counselors, for example, “people with substanceuse disorder” instead of “people with addiction,” where thelatter has a negative connotation in Indonesian.
The adapted workbook also incorporated cultural concepts. For
instance, Ramadan and Christmas were named as long holidays
with an increased risk of substance use. Another example is that
wudhu—the Islamic practice for body purification before
prayers—was introduced as a means to cope with cravings for
drug use. Information regarding first-aid response to overdose
cases was also added. In contrast, cultural nuances from Japan
were omitted such as the gambling device pachinko and thewidespread selling of alcoholic beverages in convenience storesand vending machines.

Tele-Indo-DARPP Sessions
The basic group structure, session phases, 12-week schedule,
and the tele-delivery method via web videoconferencing (hencetele-Indo-DARPP [tele-Indonesia Drug Addiction Relapse
Prevention Program]) were explained previously [49].
Importantly, efforts were made to increase the autonomy ofclients and create a safe and comfortable space within thesessions. This was reflected in the main principles that werecreated specifically for Indo-DARPP and written on the firstpage of the workbook, namely that (1) clients can freely joinregardless of their substance use status; (2) providers should
guarantee clients’ safety and comfort (physical wellness,emotional comfort, and privacy) so that they can tell the truth;(3) providers should not judge or negatively react to participants
even when they have been using substances; and (4) providers
should not put heavy expectations or force behavioral changes
on clients. These principles were read aloud by providers at the
beginning of each tele-Indo-DARPP session in front of theclients. In contrast, the clients were asked to recite promises torefrain from (1) sharing private information of other clients toany external parties (except by obligation of law or trial); (2)taking photographs or recording audio or video during sessions
without permission of everyone pictured; (3) bringing substances
into or showing them during the sessions; (4) using substances
during the sessions; (5) conducting transaction of substancesor handing or receiving substances to or from others; (6) sharing
information relating to the session such as schedule, URL
address, or meeting access password, among others, to any
external parties without permission of the providers; and (7)harassing others, offending others’ identity (gender, race, tribe,and religion), inciting violence or threatening for any reason
other clients, providers, or any parties, both during sessions andout of sessions.

Providers
One of the most important features of Indo-DARPP is that thesessions were provided by a peer counselor and a health care
worker side-by-side, each with their specific roles [49]. Such
psychotherapy coprovisioning is a novel concept in Indonesia,
especially in the presence of peer counselors who haveexperience with SUD themselves. While health care workers
mainly oversaw the sessions, peer counselors were expected toactively share their own experiences related to the sessions.

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Pilot Study
Design and Setting
We conducted a pilot study, using a nonrandomized controlled
before-and-after design. The location was Cipto Mangunkusumo
General Hospital, the university hospital of Universitas
Indonesia, which is located in Central Jakarta, Jakarta province.

Recruitment
Convenience sampling was done at the outpatient psychiatricclinic. The inclusion criteria were the following: (1) age between
18 and 65 years, (2) diagnosed with drug or alcohol use
disorders as per the Diagnostic and Statistical Manual of Mental
Disorders, fifth edition, (3) have used primary drugs at least
once in the past year, (4) have a device capable of video callingwith internet access, and (5) proficient in Indonesian. Exclusion
criteria were the following: (1) have a severe physical or mental
disability that hinders informed consent or data collection or(2) use inpatient or residential services. The minimal sample
size was set at 8, referring to previous online intervention pilot
studies [51,52]. We approached 9 participants for recruitment
and all of them provided informed consent. One retracted his
consent prior to the completion of the pretreatment assessment.

Treatment
Participants were allocated to either the intervention or thecontrol arm. Participants in the intervention arm received
tele-Indo-DARPP in addition to treatment as usual (TAU), while
the control arm received TAU only. The providers oftele-Indo-DARPP were 1 psychiatrist from the Department of
Psychiatry at the University of Indonesia and 1 peer counselorfrom a peer-run nongovernmental organization providing
services for people with SUDs. TAU varied among participants
and included symptomatic pharmacotherapy (eg, anxiolytics
and antidepressants), opioid substitution therapy withmethadone, and brief individual psychotherapy with a treating
psychiatrist if they are undergoing any treatment with a
psychiatrist. The psychotherapy is conducted monthly at most,with each session lasting up to 15 minutes. Structured
psychotherapy, such as motivational enhancement therapy or
relapse prevention, was not provided to the TAU participants,
and there were no group therapy sessions held either. While thepsychotherapy uses a motivational interviewing approach incases of relapse or nonimprovement, the sessions were relatively
unstructured, without using any established treatment module
for SUD, as there are currently no standardized guidelines
available for SUD treatment in Indonesia.

Data Collection
Semistructured interviews were conducted after the end oftreatment to inquire about the acceptability and practicality oftele-Indo-DARPP and audio recordings were made with theparticipants’ permission. Structured interviews were also
conducted to assess participant characteristics and outcome
measurements before and after the treatment provided.

Feasibility Measurement
This study defines feasibility as to whether the intervention,
tele-Indo-DARPP, can be shaped to be relevant and appropriate
to our purpose and sustainable to be tested further in a larger
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clinical trial [49]. We show the feasibility of tele-Indo-DARPP
by quantitatively measuring relevant outcomes and qualitatively
examining the feedback from participants after undergoing 12
intervention sessions. We can further identify that the study
results fulfill 5 out of 8 areas of focus generally defined in afeasibility study in the context of public health research [53],namely acceptability—how the intended recipients, which inthis case are people with SUD, react to tele-Indo-DARPP;
demand—viewed from the actual attendance of participants intele-Indo-DARPP sessions; practicality—the extent to which itis practical for participants and the service providers to join
tele-Indo-DARPP sessions; adaptation—focusing on theadaptation to the main changes brought by the tele-Indo-DARPP
compared with prior modalities, which are (1) the use of astructured workbook module in group therapy sessions, and (2)the use of video teleconferencing to hold the session and deliver
psychotherapy; implementation—whether tele-Indo-DARPP
service can be implemented as planned by service providers;integration—theexperienceoftele-Indo-DARPP
implementation vis-à-vis the providers’ familiarity withcounseling or psychotherapy service provision; andlimited-efficacy testing—comparison of outcome measurements
at pre- and posttreatment between the tele-Indo-DARPP+TAU
and the TAU-only arms.
The focus on expansion is irrelevant to this study, as
tele-Indo-DARPP is not an expansion from a priorpsychotherapeutic modality for SUD available in Indonesia.

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Outcomes
The outcomes, measurements, and corresponding hypotheses
are listed in Table 1. The timeline followback was assessed for
30 days [54]. Second, health-related quality of life was measured
by the World Health Organization Quality of Life Brief Version(WHOQOL-BREF) [55,56]. The WHOQOL-BREF has 4
domains: physical health, psychological health, social
relationships, and environment. Using a standard formula, eachdomain yields a continuous score that ranges from 0 (impaired
health) to 100 (full health). This study hypothesized that thetele-Indo-DARPP arm would show a greater increase in
WHOQOL-BREF domain scores than the TAU-only arm. Other
outcomes included the Addiction Severity Index [57], University
of Rhode Island Change Assessment [58], Brief-Coping
Orientation to Problems Experienced (Brief COPE) [59],Symptom Checklist-90 Revised [60], Rey Auditory Verbal
Learning Test [61], and internalized stigma of mental illness[62].
While we acknowledge confounding factors potentially affecting
the outcomes, such as pharmacotherapy, treatment ofcomorbidities, and social factors, the current pilot design would
not be able to adequately address them [63]. Therefore, we
refrain from making any inferences on the efficacy oftele-Indo-DARPP for now and aim to eliminate confounders ina definitive RCT to be done soon [49].

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Table 1. Outcomes and measurements.
Outcome

Measurement

Data for analysis

Type and score range

Hypothesis for intervention (vs control)

TLFBa for the past 30
days

Number of days using primary substance Continuous, 0 (no use) to 30(used every day).

Lower

Quality of life

WHOQOL-BREFb

4 domains: physical health, psychological Continuous, 0 (impaired health)health, social relationships, and environ- to 100 (full health)ment, each calculated using a standard
formula.

HigherAddiction
severity

ASIc

7 composite scores: medical, employment, Continuous, 0 (no problems) toalcohol use, drug use, legal, family or so- 1 (severe problems)cial, and psychiatric status. Each composite score is calculated using a standard
formula.

Lower

Motivation tochangeURICAdAction stage subscale, the sum of 8 items. Continuous, 8 (not active in behavioral change) to 40 (highly
active in behavioral change).

Higher

Coping strategies

Brief COPEe

1 subscale: substance use coping. The sum Continuous, 0 (not using) to 10
of 2 items.
(frequently using)

Lower

Psychiatric
symptoms

SCL-90-Rf

GSIg, an average of 90 items.

Continuous, 0 (no symptoms) to Lower
4 (severe symptoms)

3 test results; immediate, learning, andrecalling.

Continuous, 0 (low functioning) Higher
to 15 (high functioning)

Primary outcome
Primary substance use
Secondary outcomes

Cognitive func- RAVLTh
tion
Internalized
stigmaa

ISMIiTotal score and 5 subscales: alienation,
Continuous, 0 (low internalized
stereotype endorsement, perceived discrim- stigma) to 4 (high internalized
ination, social withdrawal, and stigma re- stigma)
sistance (reverse score), an average of 29
items (for total score), 6, 7, 5, 6, and 5
items, respectively (for subscales)

Lower

TLFB: timeline followback.

b

WHOQOL-BREF: World Health Organization Quality of Life Brief Version.

c

ASI: Addiction Severity Index.

d

URICA: University of Rhode Island Change Assessment.

eBrief COPE: Brief-Coping Orientation to Problems Experienced.

f

SCL-90-R: Symptom Checklist-90 Revised.

g

GSI: Global Severity Index.

h

RAVLT: Rey Auditory Verbal Learning Test.

i

ISMI: Internalized Stigma of Mental Illness.

Data Analysis
The interview recordings were transcribed verbatim, translated
into English, and then subjected to thematic analysis to identify
positive and negative aspects of acceptability and practicality.
Descriptive statistics were calculated to describe participants’characteristics and changes in outcomes. Changes in outcomesfrom pre- to posttreatment were compared between thetele-Indo-DARPP+TAU and TAU-only arms using the
Wilcoxon signed rank test. The statistical significance level was
set at .05. Data analysis was conducted with Stata (version 17.0;
StataCorp).

participation, the voluntary nature of consent, and that consent
could be withdrawn at any time. Participation was only
acknowledged if informed consent was obtained. All study
participants were asked to sign a pledge regarding group therapy
participation including the commitment to keep discussions
confidential and to not share any information about otherparticipants with any third party. This study protocol wasapproved by the ethics review committees of the Faculty of
Medicine, Universitas Indonesia (approval number
KET-1175/2019) and the Graduate School of Medicine, Kyoto
University (approval number C1483).

Ethical Considerations
Potential participants were informed of the purpose of the study,
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Results
Study Participants
Among the 8 participants who participated in the study, 4
declared their preference for and were thus allocated to thetele-Indo-DARPP+TAU arm, with the remaining 4 participants
being allocated to the TAU-only arm. One of the participants
allocated to the TAU-only arm did not complete theposttreatment assessment due to lost contact; the participant
was determined as “dropped out” and thus not included in theoutcome analysis.
The demographics of the participants at pretreatment are shownin Table 2. The mean age was 37 (SD 12.8) years, and all

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participants were male. The majority of the participants hadcompleted high school or higher education (7/8, 88%), had apart-time job (6/8, 75%), were widowed or separated or nevermarried (6/8, 75%), lived in a household with 3 persons or more
(6/8, 75%), were Muslims (7/8, 88%), and belonged to an ethnic
group rooted in Java island (6/8, 75%). The mean time and costneeded for one-way transportation to the nearest health carefacility were 80 (SD 39.6) minutes and 36,900 (SD 18,300)
rupiah (US $1=14,760 rupiah), respectively. Half of theparticipants had been arrested due to drug charges. Sedatives
were reported by 7 participants (87.5%) as their primary drugof concern, while 1 reported ATS. Sedatives, alcohol, andmethadone were reported to have been used in the past 30 days.

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Table 2. Participant demographics at pretreatment.
Demographics

Total (n=8)

Tele-Indo-DARPP+TAUa (n=4)

TAUb-only (n=4)

Age (years), mean (SD)37.0 (12.8)

39.3 (5.5)

34.8 (18.4)

Sex (male), n (%)

8 (100)4 (100)4 (100)Junior high

1 (12)

1 (25)

0 (0)

High

4 (50)

2 (50)

2 (50)

Vocational

3 (38

1 (25)

2 (50)

Full-time job

1 (12)

1 (25)0 (0)Part-time job

6 (75)

2 (50)

4 (100)

Disabled

1 (12)

1 (25)0 (0)Married2 (25)

1 (25)

1 (25)

Widowed or separated

2 (25)

1 (25)

1 (25)

Never married

4 (50)

2 (50)

2 (50)

Living alone

0 (0)

0 (0)

0 (0)

2 persons

2 (25)0 (0)2 (50)

3 persons or more

6 (75)

4 (100)2 (50)Islam

7 (88)

3 (75)

4 (100)Christianity

1 (12)

1 (25)

0 (0)

Jawa

3 (38)

1 (25)

2 (50)

Sunda

2 (25)0 (0)2 (50)

Betawi1 (12)

1 (25)0 (0)Minang1 (12)

1 (25)0 (0)East Nusa Tenggara

1 (12)

1 (25)0 (0)Education completed, n (%)

Employment status, past 3 months, n (%)

Marital status, n (%)

Household size, n (%)

Religion, n (%)

Ethnicity, n (%)

Transportation to the nearest health care facility, one-way trip, mean (SD)Time in minutes

80 (39.6)

81.3 (37.5)

80 (46.9)

Cost in thousands of rupiah (US $1=14,760
rupiah)36.9 (18.3)

32.5 (20.6)

41.2 (17.5)

Never

4 (50)

1 (25)

3 (75)

1-2 times

2 (25)

2 (50)0 (0)3 times or more

2 (25)

1 (25)

1 (25)

Sedatives

7 (88)

4 (100)3 (75)

Amphetamines

1 (12)0 (0)1 (25)

Alcohol

3 (38)

2 (25)

1 (25)

Heroin

0 (0)

0 (0)

0 (0)

Methadone

2 (25)

1 (25)

1 (25)

Number of arrests due to drug charges, n (%)

Primary drug of concern, n (%)

Drug type used in the past 30 days, n (%)

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Total (n=8)

Tele-Indo-DARPP+TAUa (n=4)

TAUb-only (n=4)

Other opioids

0 (0)

0 (0)

0 (0)

Barbiturates

0 (0)

0 (0)

0 (0)

Sedatives

8 (100)4 (100)4 (100)

Cocaine

0 (0)

0 (0)

0 (0)

Amphetamines

0 (0)

0 (0)

0 (0)

Cannabis

0 (0)

0 (0)

0 (0)

Inhalants

0 (0)

0 (0)

0 (0)

DemographicsaSiste et al

tele-Indo-DARPP: tele-Indonesia Drug Addiction Relapse Prevention Program.

b

TAU: treatment as usual.

Indo-DARPP Session Attendance
Among the 4 participants allocated to thetele-Indo-DARPP+TAU arm, 2 participants joined all 12
tele-Indo-DARPP sessions, with 1 participant attending 11
sessions and the other attending 9 sessions. Collective attendance
was 92% (44 sessions).

Results of Feedback Interviews
The participants who joined the tele-Indo-DARPP reported that,in general, the module had a good acceptability in terms of being
able to open up and disclose personal matters, receiving helpful
counselor’s advice, learning new things, feeling support fromother participants, and broadening their view by listening to andsharing with other participants at various stages of recovery
from SUD. In contrast, participants expressed complaints
regarding the tele-Indo-DARPP contents, finding that some ofits terminologies were confusing and did not adhere to the actual

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colloquial terms commonly used in the streets (eg, nicknames
for substances) and that some of the medical information was
too complicated for lay people and not sufficiently accessible.
The interview data are provided in Textbox 1.
In terms of practicality, the participants reported the convenienceof joining from home, without having to waste any time ormoney on transportation, and felt that the pacing between
sessions was good. However, participants sometimes felt
frustrated with technical issues and unstable internet connection
and wanted more time to share their stories. In the end, 75%(n=3) of participants expressed their preference for web
telemedicine over face-to-face meetings.
No adverse effects of tele-Indo-DARPP were reported. We
confirmed with participants that they did not perceive that
tele-Indo-DARPP negatively affected any of their physical,
psychological, or social conditions.

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Textbox 1. Themes and illustrative interview raw data on the acceptability and practicality of tele-Indonesia Drug Addiction Relapse Prevention Programfrom the point of view of participants and service providers.
Acceptability: well accepted•Able to open up on personal matters: “Talking about my meth use reminded me of all the things, like my ex-girlfriend and my old friends whodied of AIDS. I had never talked about it with anyone before. I never thought of sharing it because nobody would understand me anyway. But
in the program, others also shared similar things and I felt accepted.”•

Found the advice from peer counselors relatable: “I learned the meaning of [taking] one day at a time from him [the peer counselor]. Even if I
used drugs yesterday, it’s important to start another new day [from] there and try to live better at least on that day. Repeat and build on it. That
sort of thinking helps a lot.”•

Learned new things from texts: “Making a schedule was new to me. Keeping myself busy can distract me from things I want to forget.”•

Felt supported by others: “I thought no one would care about me, but that’s not true when I was in the program. I could complete the program
because everyone, I mean other clients too, supported me.”•Learned mutually among clients: “It was very interesting to hear the various viewpoints from the others here, some of whom have already battled
addiction for 20 years. I am eager to join future sessions so I can hear more and more stories from anyone [at] different stages in their path torecovery, including new clients, whom I can help by teaching my own experiences as well.”•(Providers) module is provider-friendly: “As a psychiatrist, I am familiar with the concept and methodologies in CBT (cognitive behavioral
therapy). However, for general practitioners and nurses who do not have CBT experience, by closely following this module and the workbook,the service has become exactly like CBT.”

Acceptability: poorly accepted•

Terminologies used in the workbook are not close enough to reality: “Sometimes the workbook content felt a bit distant from the reality in thestreets. I hope there can be content revision to make us feel more familiar [with the workbook], such as adding brand names for prescription
drugs, and street names for illicit drugs.”•

Explanations of medical and statistical information are not accessible enough: “Sometimes I couldn’t really understand the medical explanation
or study graphs, and tend[ed] to just skim them.”•(Providers) lengthy materials in the workbook: “We had to hurry because there was too much material for a 2-hour session. At the same time, I
was afraid if the session became too long, the client may lose focus.”

Practicality: practical•

Convenient to join the session from home: “I really like that I could join it from home, even right after taking a nap. Going to the hospital is sucha hassle.”•

No wasted time or cost for transportation: “If I go to the hospital, it will take up my half-day because of the terrible traffic jam and I need to take[time] off from my job.”•

Good pacing between sessions: “One session per week was the best frequency for me. I could remember what we learned in the last session.”•(Providers) convenient to join while still making rapport with clients: “[Ever since the pandemic] I am already getting used to providing
teleconference services. My concern was that I couldn’t make proper rapport with clients, but as it turns out, they seemed comfortable in sharing
their experiences and opinions. Probably because they already felt comfortable by participating from their home; their own comfort zone.”

Practicality: impractical•

Frustrated with technical issues: “I could not use my video sometimes, which was so frustrating. I couldn’t keep up with the discussion becauseof the technical problems, and then I lost the motivation I had before.”•

Wanted more time to share: “I wanted more time to share. Because it’s a group session, time for each of us is more limited compared to one-on-one
sessions.”•(Providers) unstable connection: “One of the participants could not have a stable connection, and his voice kept getting interrupted; probably hishouse had a bad (telecommunication) signal. At that time, I asked him to turn off the video (to improve bandwidth) for a moment or write what
he wanted to say in the chat box.”

Outcome Changes
Figure 2 shows the mean and SD of the outcome measurements
atpreandposttreatment,
stratifiedbythetele-Indo-DARPP+TAU arm and the TAU-only arm. The
corresponding details can be found in Table S1 in Multimedia
Appendix 1. The score in the psychological health domain of
WHOQOL-BREF increased by a median of 12.5 points among

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the tele-Indo-DARPP+TAU arm, contrasting with the TAU-onlyarm whose scores decreased by a median of 8.3 (P=.03), also,
the anxiety domain score of the Symptom Checklist-90 Revised
showed a decrease with a median of 0.3 among thetele-Indo-DARPP+TAU arm participants, while that of the
TAU-only group increased with a median of 0.2 (P=.05). We
did not observe statistically significant differences in the otheroutcomes.

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Figure 2. Differences between pre- and postintervention measurements of primary (primary substance use) and secondary outcomes (ASI,
WHOQOL-BREF, URICA, Brief COPE, RAVLT, ISMI, and SCL-90-R scores) in the pilot study. The mean and SD (error bar) are shown for eachmeasurement. Results of the tele-Indo-DARPP+TAU group are shown in red, and the TAU-only group in green (*P<.05). ASI: Addiction Severity
Index; Brief COPE: Brief-Coping Orientation to Problems Experienced; ISMI: internalized stigma of mental illness; RAVLT: Rey Auditory Verbal
Learning Test; SCL-90-R: Symptom Checklist-90 Revised; TAU: treatment as usual; tele-Indo-DARPP: tele-Indonesia Drug Addiction Relapse
Prevention Program; URICA: University of Rhode Island Change Assessment; WHOQOL-BREF: World Health Organization Quality of Life Brief
Version.

Discussion
Principal Findings
In studies testing tele-psychotherapies for SUD,
tele-Indo-DARPP is only the second intervention formed asgroup therapy on a videoconferencing platform after a 2009
study [36] and is the first to be implemented in an LMIC. While
all prior intervention modules only focused on a single substance(alcohol or opioids) [64], the tele-Indo-DARPP addresses 6
groups of substances: opioids, ATS, benzodiazepines, alcohol,
marijuana, and NPS. Nevertheless, this pilot study did not recruit
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participants using various substances, and we hope to recruit
more variable and representative participants in the RCT(protocol outlined by Yamada et al [49]) which we started
several months after the conclusion of this pilot study and is
now ongoing.
Outcome measurements showed that participants who received
tele-Indo-DARPP+TAU exhibited improvements in their
psychological health and anxiety symptoms, compared withthose receiving TAU only. As shown in the interviews,
participants were able to disclose private issues during thetele-Indo-DARPP sessions to the extent that they shared about
their illegal activities and the bereavement of persons significant
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to them. It could be inferred that tele-Indo-DARPP nurtured a
supportive group environment, which alleviated anxiety andenhanced psychological health. Such a finding is noteworthy
given that previous studies have shown that online
psychotherapies face difficulties in rapport building [65].
Building rapport has also been reported the most as a challenge
in group therapy settings [66]. Our success in building a safeand private environment for clients in an SUD treatment setting
may partly be owing to the involvement of peer counselors andthe establishment of a common understanding of group rules
as listed in Methods.

is also the first trial for tele-psychotherapy for SUD in Indonesia,
where any standardized guideline for SUD psychotherapy isnonexistent. Indo-DARPP may become the first structured
therapeutic module focusing on substance craving and relapse
prevention in Indonesia. Moreover, it is the first trial of
psychotherapy coprovision by a peer and a health care worker
in Indonesia. We showed the feasibility of tele-psychotherapy
and peer involvement in formal SUD care, which has not been
well investigated not only in Indonesia but also in LMICs, andreported preliminary positive results of outcome changes
following therapy.

Our interview data showed that, in general, tele-Indo-DARPP
had good acceptability and practicality. Tele-Indo-DARPP wasperceived as time-efficient by the participants of our pilot study
whose residence was in Jakarta, the world’s second-largest
urban area, where traffic is inconvenient and heavily congested.
Indeed, tele-Indo-DARPP could save over 2 hours of round-triptransportation time to visit an outpatient clinic. The increased
time efficiency allowed participants to join tele-Indo-DARPP
sessions weekly without having conflicting schedules for theirjobs or childcare. In contrast, in a face-to-face TAU, SUD
patients typically cannot visit clinics more than once a monthdue to time and cost restraints. This is important as the frequencyof therapy attendance is known to improve health outcomesamong SUD clients. This finding is in line with previous studies
reporting that the top reasons for SUD outpatients preferring
telehealth care included the ability to receive it from home andnot needing to spend time commuting [36,66].

As this pilot study is of an exploratory and preliminary nature,with a limited sample size, and was not intended to determine
clinical effectiveness, the results should be interpreted withcaution. Nonetheless, we observed significant improvementsin psychological health and anxiety symptoms, as well as
encouraging outcomes in the Addiction Severity Index medical
domain, substance use coping, and several subscales related tointernalized stigma, despite the lack of statistical significance.
Further limitations were that the study participants were all
male, most reported sedatives as their primary substance, andwere recruited in urban areas in the capital city of Jakarta.
Although being male and urban residency are predominantcharacteristics in people who use drugs in Indonesia [3], theobserved acceptability, practicality, and preliminary outcomechanges might not be generalizable to different populations inIndonesia. We hope to improve the demographic variability ofparticipants and expand recruitment from many distinct islands
nationwide in the future tele-Indo-DARPP RCT.

Nevertheless, the interview results revealed several issues
regarding the practicality and acceptability of tele-Indo-DARPP.
The participants reported that they were not familiar with someterminologies, such as the substance chemical names, and had
difficulties in comprehending medical and statisticalinformation. The workbook contents were carefully developed
to increase comprehensibility, but further considerations arenecessary due to the relatively low educational backgrounds ofpeople with SUD, such as adding the colloquial street namesof substances, explanatory pictures, and presenting complex
knowledge more simply. Also, the participants felt frustrated
when having technical issues related to unstable internet
connections or smartphone devices, which is another obstacle
to the widespread implementation of telemedicine.

Strengths and Limitations

Conclusions
The preliminary results of our pilot study gave someencouraging insight into how peer counselors can be involvedin formal psychotherapeutic sessions for clients with SUD andhow such therapy can be delivered via videoconferencing inIndonesia. Future effectiveness studies should explore the best
recruitment place and source of providers for such
community-based therapy, that is, whether it should be run byrehabilitation centers, Puskesmas, or hospitals. Currently, weare conducting a clinical trial recruiting participants in different
outpatient settings [49]. Future implementation studies should
also make sure to include diverse populations, especially interms of gender and location within the vast archipelago ofIndonesia.

A key strength of this study is that this is the first trial oftele-psychotherapy using videoconferencing in an LMIC. This

Acknowledgments
The authors would like to extend our deepest gratitude to all participants who have participated in the pilot study. The authors
appreciate Bonike Danne, Carlamia H Lusikooy, Deasy Nathalia, Gemelly Nurhidayat, Inoe Nugraha, Ira Oktora Dwi Artati,
Irfan Anas, Putri Nugraheni, Putri Shareefa Madina Algamar, Satya Joewana, and Zulvia Oktanida Syarif for their valuablecomments on the module development. This work was supported by the Japan-ASEAN platform for Transdisciplinary Studies
project of the Center for Southeast Asian Studies of Kyoto University, the Research Unit for Development of Global Sustainability
of Kyoto University, and the Japan Society for the Promotion of Science (JSPS) Grants-in-Aid for Scientific Research (KAKENHI;
grants JP19K24256 and JP22H03839).

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Authors' Contributions
KS, YO, EH, and CY conceptualized the study and developed the treatment program. KS, EH, and RN provided and supervisedinterventions. APL, EB, VR, and PA collected data. TM and RS supervised the development of the treatment program and overall
study. CY and YO conducted the analysis and drafted the manuscript. All authors edited the manuscript.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Supplementary Figure 1 and Supplementary Table 1.
[PDF File (Adobe PDF File), 519 KB-Multimedia Appendix 1]

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Abbreviations
ATS: amphetamine-type stimulant
CBT: cognitive behavioral therapy
Indo-DARPP: Indonesia Drug Addiction Relapse Prevention Program
LMIC: low- and middle-income country
NPS: new psychoactive substance
RCT: randomized clinical trial
SMARPP: Serigaya Methamphetamine Relapse Prevention Program
SUD: substance use disorder
TAU: treatment as usual
tele-Indo-DARPP: tele-Indonesia Drug Addiction Relapse Prevention Program
WHOQOL-BREF: World Health Organization Quality of Life Brief Version

Edited by A Mavragani; submitted 01.07.23; peer-reviewed by WR Apha, ID Yucel; comments to author 29.12.23; revised version
received 30.03.24; accepted 24.04.24; published 18.06.24
Please cite as:
Siste K, Ophinni Y, Hanafi E, Yamada C, Novalino R, Limawan AP, Beatrice E, Rafelia V, Alison P, Matsumoto T, Sakamoto R
Relapse Prevention Group Therapy in Indonesia Involving Peers via Videoconferencing for Substance Use Disorder: Development
and Feasibility StudyJMIR Form Res 2024;8:e50452
URL: https://formative.jmir.org/2024/1/e50452
doi: 10.2196/50452
PMID:©Kristiana Siste, Youdiil Ophinni, Enjeline Hanafi, Chika Yamada, Reza Novalino, Albert P Limawan, Evania Beatrice, Vania
Rafelia, Peter Alison, Toshihiko Matsumoto, Ryota Sakamoto. Originally published in JMIR Formative Research(https://formative.jmir.org), 18.06.2024. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete
bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license
information must be included.

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