Psychotherapy co-provision by peers and healthcare workers
for substance use disorders in Indonesia

Chika Yamada
Youdiil Ophinni

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Psychotherapy co-provision by peers and healthcare workers
for substance use disorders in Indonesia
Chika Yamada*1, Youdiil Ophinni 2, 3

Abstract
For many decades, the infringement of the autonomy of people who use drugs has permeatedmany levels in Indonesia. Drug use has been disparaged as a moral issue, marginalised by the
public, and criminalised by authoritative governing bodies. For people who develop substanceuse disorders (SUD), healthcare services also commonly enact compulsory treatment that
disregards clients' autonomy seeking help. However, in recent decades, there has been agrowing movement of people who use drugs to regain autonomy in attaining health rights. In
this chapter, we first describe the lack of autonomy experienced by people with SUD,
particularly in regard to their health rights. We then outline roles of peer counsellors throughdirect observations of psychotherapy co-provision by both peer counsellors and healthcare
workers (HCWs) in a novel SUD psychotherapy module we designed ourselves, termedIndonesia Drug Addiction Relapse Prevention Program (Indo-DARPP). We observed various
peer counsellors’ roles, including diversification of the knowledge taught in the sessions. We
also report the preliminary results of the pilot study of Indo-DARPP, which showed thatparticipants who received Indo-DARPP for three months reported good acceptability andusability. Finally, the design of a randomised controlled trial for Indo-DARPP evaluation ispresented. Ultimately, we hope to present insights reinforcing peer involvement into formal
SUD care, with the aim of helping people with SUD to regain their autonomy in healthcare.

Keywords: autonomy, substance use disorder, peer involvement, lived experience,
psychotherapy, Indonesia.

1

Department of Environmental Coexistence, Center for Southeast Asian Studies, Kyoto University, Kyoto,
Japan *E-mail: chika128@cseas.kyoto-u.ac.jp
2
Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, USA
3
Immunology Frontier Research Center, Osaka University, Osaka, Japan2

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1. Introduction“My parents forcefully took me to a rehabilitation centre. [...] I was locked up in the isolation
room for my withdrawal symptoms, for 2 weeks. I was using heroin, so it was very hard. I felt
very sick when I (was going through) withdrawal. They didn’t understand, so they just put me
into a locked room, without any medicine or anything, for two weeks in the room with my pain.
I was so angry with that so I didn't want to listen to anything they thought about drugs.
After I came out of that place, I started using crack again. My parents then took me to a placein Kalimantan to a psychic to get hypnotised to eliminate my desire for drugs. […] In that place,they tied my arms and legs to each tree. I tried to get them to let me out because it hurts. I wasvery sad and got mad at my parents. Why did you treat me like this? I'm not a bad person. I justneed help for my addictions. But they didn't listen.
[...] My parents thought drugs were a moral issue not a health problem. This is the problem inIndonesia. Most people think that addiction is about morals, not a health problem…”
Transcript from a podcast interview with Rosma Karlina, a person recovering from substanceuse disorder, from IDPC-UNAIDS podcast, August 2020 (UNAIDS Asia-Pacific 2020).
***
The excerpt above vividly illustrates the arduous experience of people with substanceuse disorder (SUD) in Indonesia. Rosma eventually went through 17 drug rehabilitation
programmes—both formal and informal—almost all against her will, including two years inprison for drug possession. Nevertheless, she survived, and finally managed to attain recovery
for her addiction through the aid of a non-compulsory counselling program. Currently, sheheads a peer-run organisation representing people who use drugs in the criminal justice system.
Rosma’s story might have been one of the better ones. A brief observation of the daily news
program would yield many such cases of mistreatment toward people who use drugs. Evenvery recently - a private jail complex in North Sumatra was used as a 'rehabilitative treatment
centre' for people who use drugs, running openly for a decade under approval from surrounding
residents, with a total lock count of over 600 people, until being exposed by the National
Commission in Human Rights in January 2022 as a form of illegal slavery for a nearby palm
plantation (“District Head’s Private Prison Cell Claims Lives: Rights Commission” n.d.).
Indeed, people who actively use drugs in Indonesia are perpetually being put in a precarious
position: being threatened with heavy criminalisation, while at the same time facing an
infringement of their most basic human rights, i.e., the rights to health and autonomy, or the
freedom to make informed decisions regarding their own healthcare.
One form of activism aiming to represent the autonomy of those who are marginalised
from societal rights is the full and direct involvement in policy decisions of those affected by
the policy themselves—’nothing about us without us’ (Latin: ‘Nihil de nobis, sine nobis’).
Within the realm of healthcare for SUD, the slogan can be interpreted as the involvement of
individuals recovered from SUD in the care provision of people with the same condition yet
still needing help for their recovery. Autonomy is a core principle of bioethics taught tohealthcare professionals, but as has long been described in observations of physician-patientencounters (Rendtorff 2008), overemphasis on a physician’s own expertise may override theautonomy of clients or even other co-providing professionals such as nurses (Kenny andAdamson 1992). Here, it is important for medical providers to step outside of their authoritative
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zone and reach out for active participation from other disciplines. Indeed, the most complex
challenges relating to health problems necessitate a transgression over the boundaries of asingle health-related discipline, and even the scope of healthcare professionals and medical
academia. In the field of public health, transdisciplinary research and practice can be definedas ‘an integrative process whereby scholars and practitioners from both academic disciplines
and non-academic fields work jointly to develop and use novel conceptual and methodologicalapproaches that synthesise and extend discipline-specific perspectives, theories, methods, andtranslational strategies to yield innovative solutions to particular scientific and societal
problems’ (Haire-Joshu and McBride 2013). The sheer complexity of the health and societal
issue leading to the autonomy deprivation of people with SUD can be regarded as one ‘wicked
problem’ necessitating a transdisciplinary approach, involving not only clinical professionals
and academia, but also non-academia: people with SUD themselves, persons who help andadvise them, i.e., counsellors, the governing sectors, private stakeholders, and more.
In the following, we first describe the lack of autonomy experienced by people with
SUD, particularly in regard to their health rights. We then outline roles of peer counsellors
through direct observations of psychotherapy co-provision by both peer counsellors andhealthcare workers (HCWs) in a novel SUD psychotherapy module we designed ourselves,termed Indonesia Drug Addiction Relapse Prevention Program (Indo-DARPP). Finally, we will
present the preliminary results of the pilot clinical study of Indo-DARPP. Ultimately, we hopeto present insights reinforcing peer involvement into formal SUD care, with the ultimate aimof helping people with SUD to regain their autonomy in healthcare.
2. Autonomy for people with substance use disorders
2-1. Global context
Substance use disorder (SUD) is defined as an uncontrollable use of psychoactive
substances which disrupts daily living. While 5.2% of the world population have used an illicit
substance at least once in the past year (Peacock et al. 2018), around 10% of that, or 35 million
people globally, have developed SUD. In 2018, SUD contributed to 131 million years or 5.5%of all disability-adjusted life years (DALY) of all diseases (GBD 2016 Alcohol and Drug Use
Collaborators 2018), and is related to 11.8 million worldwide deaths annually (Ritchie andRoser 2019). One frequently overlooked problem is the disproportionate burden put on lowand middle-income countries (LMICs). While substance use prevalence itself is higher in highincome countries (HICs), absolute deaths due to SUD is higher in populous LMICs (Peacocket al. 2018), and merely 1% of people with SUD have access to formal treatment services(Degenhardt et al. 2017).
A long history of studies has reported that people with mental health conditions areoftentimes not treated as persons with full autonomy (Brekke et al. 2001; Hiday et al. 2001). It
is not uncommon for health institutions to enforce compulsory inpatient care toward them, withisolation, physical restraint, and sedation (Newton-Howes et al. 2020; Steinert et al. 2010;
Yamada, Ophinni, and Diatri 2020). Such treatment is even more pronounced when dealing
with people with SUD, where care services are dictated by views often unreconciled with theirown. The biomedical model of addiction (O’Brien and McLellan 1996) emphasises compulsion
and uncontrollability due to altered brain functions, which may advocate a position of nonautonomy or, at best, reduced autonomy (Koopmans and Sremac 2011). Subsequently,
healthcare workers are prone to believe that individuals under the influence of addiction are notcapable of making independent and trustworthy decisions (van Boekel et al. 2015), thus
disregarding the conditions in which the individual wants to achieve improvements.
Furthermore, healthcare professionals tend to work to stop or reduce drug use based upon a44

scientific notion that it is harmful to the body, and thus, the final goal of abstinence was imposed(Anderson, McGovern, and DuPont 1999). Objective measurements of drug concentration suchas urine tests were prioritised—often compulsorily. The context of why a person wants tocontinue using drugs is neglected.
2-2. Criminalisation of drug use in Indonesia
Even more pertinent to the infringement of rights of people who use drugs is the factthat drug use has been heavily criminalised. Public sentiment against drug use started in thecolonial period and continued to grow after Indonesian independence, greatly influenced by the
globalisation of a prohibitionist -and racially motivated- anti-drug regime born in the US(Musto 1999). Following the Single Convention on Narcotic Drugs by the United Nations,
Indonesia enacted their first-ever Narcotics Law in 1976, banning the use of opium, coca, andcannabis products. These substances were freely used and traded in Indonesia for centuries
before, even openly distributed by the Dutch regime (the Opium Regie) (Hefner and Rush 1991).
Such cultural and sociohistorical aspects of drug use were ignored. Ever since the Law
ratification, people who use drugs have been treated as ‘perpetrators of crime’, and hundredsof thousands have been sent to prison for personal drug use (Putri and Blickman 2016). The
Law revision in 1997 widened regulated substances and introduced more extended
imprisonment for drug possession, and soon after in the early 2000s, the ‘War on Drugs’ wasformally declared to ‘eradicate drug use and trafficking’ for a utopian ‘drug-free society,’leading to the establishment of the National Narcotics Board (Badan Narkotika Nasional,
BNN) (Honna 2010; Fransiska 2019). Concerningly, as shown in Figure 1, such punitive antidrug stances have been trending recently in several countries in Southeast Asia (Lindsey,
Nicholson, and Nicholson 2016).

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Figure 1. Recent trend of hardline anti-drug policies in Southeast Asia, overlaid with the nationwide
coverage of harm reduction services and drug trafficking routes through the region.

The persecutory environment surrounding people who use drugs still permeates
throughout Indonesia, and has been intensified by the current administration (Figure 2). As of
December 2021, prisons nationwide were operating at 336 per cent overcapacity, and almost
half of them (about 135,000 persons) were detained for drug offences (UNAIDS & UNODC
2021). Socioeconomically disadvantaged people are being disproportionately targeted as they
are more identifiable and ‘arrestable.’ Numerous reports have acknowledged the lack of
distinction in the judicial practice between drug use and drug possession or dealing, and eachis punished differently, either with mandatory rehabilitation to a maximum of four years prison
for the former, and four years prison to lifetime or the death penalty for the latter. Here, poor
people may find their cases being altered from drug use to possession, i.e., going to prison
instead of only rehabilitation, as they are unable to ‘offer’ anything. From the perspective oflaw enforcement, especially under the ‘War on Drugs’ directives, the number of arrests are
directly linked to performative success, that is meeting a ‘quota,’ and drug use cases areinevitably being used as exploitable sources of incentives (Mustafa, Malloch, and Hamilton
Smith 2020).

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Figure 2. Number of death sentence (blue line) and death penalty (red line) ever since the first drugrelated capital punishment was enacted in Indonesia in 1995. The current administration oversaw astriking increase in the number of death sentences, peaking to 101 in 2020.

2-3. Mandated care services in Indonesia
Nevertheless, the latest 2009 Narcotics Law revision brought a significant
improvement by introducing the eventuality of rehabilitation for people caught by the law, andelevated the roles of the health sector as well as the rehabilitative division of BNN to better thecondition of people with SUD. This also led to a new government program in 2012 called the
Mandatory Report Recipient Institution (Institusi Penerima Wajib Lapor, IPWL), launched by
the Ministry of Social Welfare together with the Ministry of Health and BNN (Ministry of
Health 2013). IPWL are government-accredited facilities, e.g. BNN-owned inpatient facilities,
hospitals, community health centres (Pusat Kesehatan Masyarakat, Puskesmas), private
rehabilitation services, as well as prisons, intended to connect people who use drugs to medicalor social rehabilitation. However, mandatory still means the absence of autonomy; people who
use drugs have to report themselves as a service recipient at IPWL or otherwise be prosecutedby law enforcement. A study reported that although the majority of IPWL users claimed thatthey joined ‘voluntarily,’ around 60% of them were not well informed of the kind of treatment
on offer (Wirya and Misero 2016). Furthermore, the IPWL system provides services inexchange for release from punishment, and thus some choose to register out of fear ofprosecution. Monetary incentives are also being used for recruitment: 14.4% of respondents
were asked to bring another person in return for money. These episodes suggest that the focus
still lies on the quantity of IPWL mandatory registrants, which may not help much to improve
the autonomy of people who use drugs in regards to which service they receive, and whether
they want to receive it in the first place.
2-4. Care system for substance use disorder in Indonesia
In Indonesia, the world’s third most populous LMIC, the national prevalence of
psychoactive substance use was estimated to be 1.8% or 3.3 million people, with the most used
substance being marijuana (Puslitdatin Badan Narkotika Nasional 2019, 2017) (Figure 3). The
past two decades has seen a substantial decrease in injecting heroin use of about 80%(Puslitdatin Badan Narkotika Nasional 2017), but otherwise a marked increase in psychoactive
medications use without prescriptions, particularly benzodiazepine sedatives and muscle
relaxant, or colloquially known as ‘koplo pills’. Alcohol consumption is comparatively low inIndonesia most likely due to its Muslim-majority population; prevalence estimate of alcohol

7 7use disorder was 0.8% in 2016, which is much lower than the average rate of that among
countries in SEA (3.9%) (World Health Organization 2019).

Figure 3. Prevalence by types of substance, based on the government national representative survey in 2019 (N=28,842 respondents).

In Indonesia, the current treatment options for SUD in formal health services include
supportive psychotherapy, symptomatic pharmacotherapy, and opioid substitution therapy(OST). OST is effective in reducing withdrawal symptoms, cravings, and the risk of bloodborne infections for people with injected heroin use disorder (Lawrinson et al. 2008), and has
been available in Indonesia from Puskesmas since 2006 under government subsidies. The
treatments are provided by HCWs, namely, psychiatrists, psychologists, general practitioners,
and nurses. The overall principle of formal medical care for SUD in Indonesia mainly follows
the perspective of evidence-based knowledge, such as basing it on international treatment
guidelines (Kleber et al. 2007). Here, SUD conditions mandated detoxification during acuteepisodes of withdrawal, and in the longer term to reduce dose or frequency of use to achieveabstinence. A typical endpoint of treatment and rehabilitation is remission, which is defined asa condition of no longer meeting the criteria for SUD, or simply abstinence, for twelve months
consecutively. Such a set of rules are closely followed as well by the Ministry of Health and
BNN, which in 2020 outlined the standard rehabilitation procedure as 3-6 months inpatient
phase and long term outpatient phase, with frequent monitoring (twice a week) and urine test
(Ministry of Health 2020).
3. Peer involvement in medical care for substance use disorders
3-1. Recovery-oriented movement at global stage
However, over the past two decades, on the global stage, a more comprehensive
approach has been adopted from care services provided for general mental conditions. Here,treatment is aimed more toward a holistic recovery, i.e., improving the health and wellbeing of
those affected, as well as their capability to strive to achieve their full potential via self-directed
processes (Whitley and Drake 2010). This recovery-oriented approach is considered to be best
served by peers—people with actual field expertise and personal experience in recovering from
SUD themselves, who truly understand the importance of holistic recovery, what path is needed
to attain it, and the various practical details and nuances encountered in their journey. Here,knowledge gained from ‘lived experience’, or experience-based knowledge, should deservedly
be held in the same regard as medical expertise or evidence-based knowledge (Byrne, Happell,and Reid-Searl 2015). People with lived experiences of a health condition are consideredexperts by experience (Vojtila et al. 2021), i.e., possessing practical know-how in how to treat
themselves based on first-hand involvement in everyday events, and thus collectively
88contribute to a constructivist paradigm on how to achieve recovery. Such experience-basedknowledge may counterpoise the positivist approach of evidence-based knowledge, i.e., how
to efficiently establish a true diagnosis and systematic treatment algorithm based on evidence
yielded from medical clinical trials. Notably, the distinction between experience- and evidencebased knowledge, particularly in the field of mental health, draws parallel to the perpetualdebate of particularism vs universalism. Indeed, the overwhelming majority of medical
evidence on mental health treatment is based on clinical trials held in industrialised countriesof the West, which commonly brought over and introduced as is to the countries of the global
South - critics have called it as a form of cultural imperialism (Sax and Lang 2021). Here,experience-based knowledge may more closely follow the local sociocultural settings,
compared to evidence-based knowledge derived from Western medical textbooks and journals.
In healthcare provision, involving peers may enable outreach to potential clients in thecommunity who tend to avoid formal healthcare. In a clinical setting, peers may alleviate power
imbalances in clinical settings between healthcare professionals and clients (as will be
discussed below in Part 4), and enhance trust and rapport between them. Peers may also conduct
knowledge transfer and act as an educator of constructivism-based approach to healthcare
professionals. At a larger level, peers may navigate the legislation, healthcare system andprograms, providing empowerment as peer workers and advocacy in regulation regarding
people who use drugs, as reflected in the slogan ‘Nothing About Us Without Us.’ Lastly,
involving peers in research can increase the appropriateness and effectiveness of treatments,
thereby improving the potential of future healthcare services.
3-2. Peer-run services for substance use in Indonesia
An appreciable number of peer-run drug-related services have been increasing inIndonesia, especially over the past two decades. The actual contributions of peers in Indonesia
may encompass many needs of the client—many peers may specialise in a specific role or
two—including but not limited to the following:● Elicit what clients want to be and help them make realistic plans to achieve it● Connect clients to community resources e.g., welfare, employment, legal, and medical
services, and self-help groups.
● Assist transitions between levels of care, especially from inpatient to outpatient● Facilitate clients’ long-term engagement with treatment services● Community outreach for those not yet connected to services● Harm reduction programs, e.g., needle distribution● Helping HIV and hepatitis C prevention, e.g., voluntary counselling and testing● Training interested clients to become addiction counsellors, and train counsellors to
improve their capability● Addiction education for the general public, e.g., information booths in schools anduniversities
The roles of peer counsellors significantly differ across facilities, even within the same
healthcare system in a country (Salzer, Schwenk, and Brusilovskiy 2010), and such differences
might be greater across countries. Concerningly, peer counsellors have been reported to havebeen misunderstood by HCWs and treated as if they were in an inferior position, as those who
were supposed to only assist HCWs’ duties (Almeida et al. 2020). Greater emphasis should be
put on the indispensable role held by peer counsellors, who can engage with clients outside thelimits of formal healthcare and fill in critical gaps within the holistic care practices for people
with SUD.
In Southeast Asia, the practices of collaborative services provision between healthcare
professionals and peers, however, are largely limited within the scope of harm reduction
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services. A recent systematic review (Satinsky et al. 2021) found 12 articles that reported about
five peer-delivered services for substance use related problems in the Southeast Asia region.
Four of these services focused on harm reduction programs aimed to reduce HIV and sexuallytransmitted infections (STI) transmission among people who inject drugs. Those programs
include peer-outreach for distribution of sterile needles and syringes, education, and advocacy
to stakeholders in Vietnam (Walsh, Gibbie, and Higgs 2008; Ngo et al. 2009) and ChinaVietnam borderland (Des Jarlais et al. 2007; Hammett et al. 2006; Des Jarlais et al. 2018;
Hammett et al. 2012), as well as peer-education small-group sessions for improving
communication skills related to sexual and injection practices in Vietnam (Go, Minh, et al.
2013; Go, Frangakis, et al. 2013) and Thailand (Latkin et al. 2009; Sherman et al. 2009; German
et al. 2012). In Indonesia, as well, PLES has been playing significant and active roles to design
and implement harm reduction services (Rigoni, Woods, and Breeksema 2019). These
programs have been reported to be effective to increase the accessibility of services, reducing
societal stigma towards people who inject drugs, and preventing HIV transmissions.
Meanwhile, only a few studies have been focusing on SUD treatment, which reported
the feasibility of training and preliminary effectiveness of peer-delivered psychotherapy in
Malaysia (Rashid et al. 2014) and Indonesia (Busse, Kashino, Suhartono, Narotama, Campello,
et al. 2021). Considering the possible competency of peer counsellors in enhancing theautonomy of clients in therapy as well as exerting influence to HCWs, as promoted in themental healthcare system in general in Indonesia (Irmansyah et al. 2020), it is of interest to
develop a therapy where peers and conventional HCWs work together in providing treatment
for people with SUD.
3-3. Psychotherapy co-provided by peer counsellors and healthcare workers in Indonesia
In 2020, we developed the Indonesia Drug Addiction Relapse Prevention Program(Indo-DARPP), which is group psychotherapy provided jointly by a peer counsellor and a
HCW (Yamada et al. 2021; Siste et al. 2021). The contents of Indo-DARPP are based on therelapse prevention model, where participants are guided to learn high-risk situations for
substance use and coping strategies. The structure of the module is group therapy, using aworkbook complete with explanations, figures, and exercise questions, in both open-ended andmultiple-choice answers. Indo-DARPP itself was based on the Serigaya Methamphetamine
Relapse Prevention Program (SMARPP), a relapse prevention therapy in Japan (Matsumoto etal. 2009) that is facilitated by HCWs, peer counsellors, and even non-healthcare professionals
such as probation officers. The adaptations from SMARPP, in particular the workbook contents,
were done via focus group discussions involving researchers, Indonesia-based psychiatrists,
general practitioners, and peer counsellors.
Indeed, the most important feature of Indo-DARPP is that the sessions are provided bya peer counsellor and a HCW working together; such co-provisioning of psychotherapy handin-hand is a novel concept in Indonesia. While HCWs are in charge of facilitating the sessions,peer counsellors are expected to actively share their own experiences related to the sessions. In
hospitals, the HCWs will be psychiatrists, and in puskesmas will be general practitioners or
mental health nurses. While the group sessions were planned to be in-person meetings, in
response to the Covid-19 pandemic, they were changed to a telemedicine-based online
psychotherapy using videoconferencing. Importantly, efforts were made to create an ‘safe space’for clients to increase their autonomy. This can be reflected in four points (out of seven) of themain principles created specifically for Indo-DARPP and are written on the first page of the
workbook:
1. Participants can freely join even if they continue substance use;
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2. Providers should guarantee their safety and comfort (physical wellness, emotionalcomfort, privacy) so that they can tell the truth;
3. Providers should not judge or negatively react to participants even if they have beenusing substances.
4. Providers should not put heavy expectations or force behavioural changes onparticipants.
3-3-1. Roles performed by peer counsellors in Indo-DARPP
To more clearly elaborate on how peer counsellors and HCWs can work hand-in-handin an SUD psychotherapy provision, we turn to our newly-developed psychotherapy module,
Indo-DARPP. Here, our specific purpose is to seek to answer the following question from aperspective of peer counsellors themselves: ‘what roles do peer counsellors perform, in aclinical setting where they co-provide psychotherapy for SUD together with HCWs?' We
qualitatively interpreted peer counsellor's roles in Indo-DARPP based on our observation ofIndo-DARPP sessions, conversations and interviews with peer counsellors, healthcare workers,
and clients who have been participating in the Indo-DARPP pilot and clinical trial studies. In
the following section, we show interpretations based on discussions between the two authors
and the peer-counsellors who joined Indo-DARPP, followed by examples of our observations
which were used as one of the bases of the interpretation.
(1) Closing the emotional distance with the clients
In this first role, peer counsellors acted to emotionally approach the clients by sympathisingwith their experiences and creating a 'soft and free' atmosphere, which also helped HCWs build
trust with them.
Sympathising toward the clients’ experiences
When clients shared their feelings, thoughts, and symptoms, peer-counsellors responded withsympathy by saying things like ‘we can understand,' reflecting and rearticulating what they
have said, and confirming if our experience resembles theirs. In response to sympathy, theclients further described their experiences in greater detail. An example of this role can beobserved in the exchange below.
Client: I used heroin on Saturday. On Sunday I tried to hold myself back. Monday was
the same, but not fully the same. I used … I don't know if it's an addiction or not but I
drank Kratom at night. All I needed was something that made me calm. That’s why I
drank that. Wednesday I still couldn't work, I fell again. Now, today, I try to endure itagain.
Healthcare provider: Bro [the client’s name] has tried. You fought it back so you did
not fall again. You already tried that. Am I right, Bro [peer counsellor’s name]?
Peer counsellor: That's right, Doc. That's right. We can understand what Bro feels.
Maybe one or two days feels like the body is in a state of chaos, right, Bro?
Client: That's right. In the afternoon, if there is still sun, it's not comfortable. Finally I
can calm down at night, when I want to sleep but I still need Kratom so I can sleep
easily.
Peer counsellor: Yes. It is indeed a very uncomfortable situation. [...] you feel destroyed.
Everything feels wrong, doesn’t it? The body feels sweaty, not good. It's not good to feelcold either.
Client: Nausea, sweating.
Peer counsellor: Nausea, sweating, tears came out. Isn't it?
Client: I’m feeling it now, honestly.
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Read and navigate the atmosphere
Peer-counsellors read the situation and momentum of the session, before flexibly managing
them to be more appropriate and comfortable for clients. If the atmosphere was too heavy, sad,or boring, peer-counsellors improvised as needed to try to break the ice and turn the atmosphereto be ‘soft’ and ‘free’, so that they gave more space for the clients to share their thoughts andfeelings. This was perceived by peer counsellors as necessary since interactions between HCWs
and clients may tend to be ‘stiff’ and ‘rigid.’ Indeed, the Indo-DARPP participants described
the overall atmosphere of the sessions as ‘light’ and ‘fun.’On the other hand, if the atmosphere was too playful or noisy, peer-counsellors tried tobring the discussion back on track. As such, peer-counsellors balanced the atmosphere,
controlled the session and directed the group to come to a fruitful discussion without having to
be too strict or tough.
(2) Showing how to handle medical knowledge
Peer-counsellors showed the clients how to handle medical knowledge through reifying
concepts into relatable stories and diversifying the taught knowledge.
Reifying abstract concepts into relatable stories
There are several abstract concepts within the module that are presented in jargon (trigger’,‘craving’, etc.). Use of these terms was intended to make the concepts applicable to manyclients. However, the more abstract a concept is, the more difficult for clients to associate itwith their everyday experiences, and thus peer-counsellors reified these abstract concepts into
relatable stories using realistic experiences to enhance the relatability of such terms.
[After a client read texts about triggers and cravings]
Peer counsellor: Now for us, maybe we don’t see the substance or the drug in front ofus, but because there are certain situations, certain people, certain objects, or certain
places that remind us of our drug use, the urge to use drugs increases. For example, inthe past, I used to be… this is like a classic Korean drama, so every time I had a fightwith my lover, the urge to use drugs increased. I fought with my lover, which made me
sad, and then I used drugs. Finally, once the situation with my lover continued to heatup a bit, or tense a bit, what came to my mind was ‘use drugs.’ I ended up using drugs.
Even though, before that, there was no thought at all to use it. Now, those situations,then the people, the location, the object, that’s what is called the trigger. Thus causing,even though we do not see it, a desire to rise within us which is called craving.
Diversifying the knowledge taught in the session
A peer counsellor can position self independently from HCWs who promote evidence-basedknowledge, which as explained above, exists alongside the experience-based knowledge
possessed by peers and clients alike. Peer-counsellors avoided over-emphasising thecorrectness of evidence-based knowledge to clients, and instead encouraged them to remain
open-minded and value their own experiences.
[After everyone discussed how they can apply certain techniques to distract oneself
from craving, such as relaxation]Peer counsellor: Actually, these techniques… These are not must-use techniques. You
actually have the right to choose which one is the most effective for you. So, do not beburdened by these techniques. Because maybe there are other techniques that have
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worked for you. These can be used as an addition for you—if the other skills suddenly
stuck or fail, this might be useful.
Knowledge diversification particularly becomes crucial when there are discrepancies
between medical evidence-based information taught in sessions and the peer counsellor's
experience. For instance, in a session, the doctor explained the effectiveness of methadone
maintenance therapy, where methadone is less addictive than heroin. The peer counsellor
followed suit to criticise the therapy, stating that people who have started it would not be able
to get out—he has seen people using methadone every day for more than a decade, and thus hedoes not believe it can alleviate addiction. The doctor then argued, referring to evidence of
methadone therapy from clinical trials in Indonesia. Their arguments remained throughout thesession. Finally, the doctor complained that the peer counsellor had spread false information,
brought negative influence to clients, and thus was not suitable to provide psychotherapy.
Meanwhile, a nurse who had observed the same discussion, opined that 'The doctor is right,
but, what the peer counsellor said is also true. Methadone is an important treatment option,
but it is far from perfect. The clients themselves are already on methadone and so they are more
likely already knew the good and the bad aspects. Hiding such facts, or being biassed, would
only erode their trust in us.’
Here, we observed that a peer counsellor’s knowledge challenged a healthcare provider’sknowledge. Healthcare providers might perceive such situations as uncomfortable, but at thesame time, peer counsellors may provide a diversified knowledge, and thus the overall
information can become more relevant for clients, whose thoughts may very well align morewith peer counsellors’ outlook.
(3) Creating a safe and comfortable environment
Peer-counsellors contributed to building a safe and comfortable environment by ensuring safety
for being honest and accommodating a comfortable platform for all.
Ensuring safety for honest disclosures
Peer-counsellors explicitly stated from the start, that the providers would never negatively react
to the clients even if they keep using drugs. They also repeatedly expressed gratitude to theclients who have honestly shared their drug use behaviours and related experiences.
Healthcare worker: Okay, yes, everyone has shared their experience this week. Maybe
Bro [peer counsellor’s name] can give some input?
Peer counsellor: Yes, thanks Doc. First of all, I want to thank you guys again, because
you were willing to share your experiences. This is very valuable information for us.
For the Doctor and for myself too. [...] My hope is to encourage you all to continue toshare if you use narcotics in the future. Because whatever the condition is, I and Doc
will still accept you all with open arms. [...] Even if there is a [substance] use, that’s
okay, that is indeed the purpose of this session.
Ensuring safety was aimed to enable clients to feel comfortable in disclosing things theywould otherwise hesitate to do. Honest disclosures were valued foremost, as it is vital forbuilding a trusting relationship with the clients.
‘One of the clients first used heroin but changed it to kratom. He tried to stop using
heroin. But then, he tried to go through the withdrawal symptoms with kratom. And hetold us he continued using kratom. In my opinion, the positive side is that he told us the1313

truth about the cross-addiction. That is a very important thing for me as a counsellor.
The client freely told us about the situation, and he admitted that he had a crossaddiction. That is the most important thing as a counsellor. He trusts us. He is
comfortable to open up.’ (Interview with a peer counsellor)
Accommodating a comfortable platform for all
Flexibility was perceived by peer-counsellors to be important; peer-counsellors adapted andcompromised with many situations, and to an extent tinker with the group rules and schedules
to accommodate everyone in the group as much as possible.
Healthcare worker: There was a question, maybe Bro [peer counsellor’s name] canalso give input. ‘Is it okay to smoke during this meeting, Sir?’
Peer counsellor: For me, Doc, since this meeting is via Zoom, and all of us are in ourown places, maybe it's okay to smoke. But if, for example, we are in the same room,
maybe that will be a problem because it can disturb others.
(4) Sharing practical knowledge
Peer-counsellors shared practical knowledge by indicating a reasonable timeframe andconnecting clients with community resources.
Indicating a reasonable timeframe
Peer-counsellors helped clients reconsider the timeframe they were in for specific situations,and thus give them ideas to reasonably adjust their perceived elapsed time. For example, clients
who relapsed after a long abstinence period tend to blame themselves. Peer-counsellors
suggested to them to widen their perception of elapsed time by saying that ‘it is part of a longprocess of recovery.’ Meanwhile, to a client who feels disheartened every time they suffer fromwithdrawal symptoms, peer-counsellors suggested focusing their time frame into a short period,so that the client would not perceive the suffering period to be too long to endure.
[To a client who are experiencing withdrawal symptoms of heroin]
Peer counsellor: I recommend trying it every two hours, Bro. Try not to use it for the
next two hours. If you keep doing that, you won’t feel the time has stopped. Suddenly it
will be already time to sleep. Tomorrow when you wake up, you realise one more day
has passed.
Connecting clients with community resources
Peer-counsellors recommended resources related to addiction recovery in the community, suchas self-help groups and addiction clinics nearby, for clients to sustain their recovery effort
especially when the Indo-DARPP sessions have come to an end.
[After reading texts about self-help group]
Peer counsellor: I just want to add a little. Maybe just a little information for you guys.
What is meant by self-help groups is, for example, Narcotics Anonymous or NA Meeting,then Alcohol Anonymous too or AA Meeting. So there really are some support groups
for AA, that’s Alcohol Anonymous, that’s for people who use alcohol. Then Narcotics
Anonymous is for people who use other substances besides alcohol. So, maybe if you
guys are interested in joining a self-help group like that, you can just contact me or ask
14

14

questions in the group. I might be able to share some information, location, or contact
person for this self-help group.
(5) Helping build self-confidencePeer-counsellors helped the clients to build self-confidence by reconstructing their experiences
as positive stories and celebrating self as what they are.
Reconstructing experiences as positive stories
When the clients shared experiences, peer-counsellors identified positive aspects within
the experiences and informed them as compliments. Such reconstruction is thought by peer
counsellors as especially important when their experience is seen as a drawback from the
medical perspective, such as continuing using drugs or changing one drug to another.
[The below is the conversation following the above-quoted conversation in‘Sympathising toward the clients’ experiences’]
Peer counsellor: Wow! What time did you use it last time, Bro?
Client: Yesterday, at seven o'clock.
Peer counsellor: Seven o’clock? That means almost twenty-four hours have passed,
right?
Client: Yes, it is true.
Peer counsellor: That’s quite a long time, Bro. You can stay clean for almost twentyfour hours. It is already cool for me. If I may tell you, in the past, I couldn't even resist
for more than two hours.
Celebrating clients as they are
No matter in what conditions the clients were, regardless of whether they showed changes ornot, peer-counsellors expressed acceptance in a delightful way. Such encouraging feedback
brightened the HCW’s way of talking as well and lightened the mood of the entire group.
Peer-counsellor: I really appreciate it even though you guys are not using drugs a day
or two and then fall again. Some have fallen even after being eight months clean, but forme, personally, I only have one word: keren [‘cool’ in Bahasa Indonesia]. It actuallyshows that you guys have real abilities to stop. That’s keren, doc. You guys are keren.
Healthcare provider: Right, even though there were difficulties, you still tried to fightback. Yes, the keyword was five letters like Bro [peer-counsellor’s name] said: keren. Is
that so Bro?
Peer-counsellor: Keren, doc. Keren. Everyone is keren.
Healthcare provider: Okay.
Peer-counsellor: Not five letters, doc. But ten. Because the last ‘e’ is long. That’s
kereeeeeen.
Everyone: [Laughing](6) Sharing the art and skills with healthcare workers
Finally, peer-counsellors shared art and skills related to care provisions with healthcare workers.
Peer-counsellors helped HCWs to look at things from the clients’ perspective and showed skills
to communicate more effectively.
Helping healthcare workers to look from clients’ perspective
Peer-counsellors showed HCWs how to empathise, get emotionally close to, acknowledge,
listen to, and enhance knowledge sharing with the clients. By observing such engagements, as
1515

well as being directly exposed to honest stories from the clients, HCWs themselves reflectedon how they had interacted with the clients before, reduced feelings of blaming and distrustwith people who use drugs, and learned to be in the position of clients.
[Interview with a nurse]“I learned so many things from the peer counsellor. One, I learned that patients want tobe appreciated, and we have to be sensitive to their feelings. Two, I personally have neverused any substances myself. So sometimes I feel as if I am a know-it-all when I try tocorrect them, like, ‘No, it’s not like that!’ But what do I know? it is them who felt thesymptoms. Sometimes, I even underestimate and blame them, like, ‘Oh, you’re lying tome right? You’re being manipulative—I don’t believe you.’ But the things that they aresaying are authentic; that is actually what they are, and we have to accept them. If we
don’t believe what they say, then how on earth could they trust us?”Showing skills to communicate with the clients
HCWs also appreciated peer counsellors as they could learn practical conversational techniques
to be applied toward clients that may be uncommon in the medical parlance. For instance, peer
counsellors commonly converse with the clients using street slang. By working together with apeer counsellor, a psychiatrist acknowledged that they learn those vocabularies and how to use
them. They stated that such communication techniques can work like a ‘glue,’ connecting
clients and providers instantly.
Through the observation of actual psychotherapy co-provisioning by peer counsellors
and HCWs it can be said that peer counsellors have the potential to positively transform theformal mental health care provision. All counsellors involved in the Indo-DARPP are BNNcertified, and we observed that in general, counsellors strove towards symmetric relationships
with clients. They also importantly diversified the evidence-based knowledge, helped HCWs
to have clients’ perspectives, which was indeed acknowledged by some HCWs as improving
their communication skills. However, we also observed when peer counsellors challenged
HCW’s knowledge, and in some cases such confrontational stances led to arguments. Previous
studies also reported that peer counsellors encountered situations that contradicted their values(Wyder et al. 2020), and they needed to ‘fit’ with existing beliefs and values in the mental
health care services to be regarded as legitimate team members (Ehrlich et al. 2020).
Nevertheless, variation in perspective, approach, and experience surely exists, either on the partof peer counsellors or HCWs.
3-3-2. Pilot test of Indo-DARPPIn the following, we report the preliminary results of Indo-DARPP. Our researchquestion here was: will such a program with peer involvement become effective, acceptableand usable for the people with substance use disorder who participate in it? Based on the results,
we aimed to refine the program as needed to increase the effectiveness and feasibility of
implementation.
Methodsa) Design and setting
We conducted a pilot study, employing a non-randomised controlled before-and-after
design. The location for the pilot study was Cipto Mangunkusumo General Hospital, the1616university hospital of Universitas Indonesia and simultaneously holds the status as the largest
nationwide referral hospital in Indonesia.
b) Recruitment
Recruitment was done in a convenience sampling from the outpatient psychiatric clinic.
The inclusion criteria were those who met all five of these: 1) age 18-65 years old, 2) diagnosed
with drug or alcohol use disorders in the Diagnostic and Statistical Manual of Mental Disorders
5 (DSM-5), 3) have used the primary drug at least once in the past year, 4) have a device capableof a video call with Internet access, and 5) proficient in Indonesian. Exclusion criteria were
those who: 1) have a severe physical or mental disability that hinders informed consent or datacollection, or 2) use inpatient or residential services.
c) Treatment
Participants were allocated to either intervention or control arms. Participants in theintervention arm received tele-Indo-DARPP, online provision of Indo-DARPP throughvideoconferencing in response to the Covid-19 pandemic, in addition to treatment as usual(TAU), those in the control arm received TAU-only. The structure of the tele-Indo-DARPP wasweekly CBT in a group (maximum 5 people) for a total of 12 sessions or 3 months, ~2 hours
per session, through an online video conferencing via the application Zoom. The providers were
healthcare workers from the Department of Psychiatry, University of Indonesia and peer
counsellors from a peer-run NGO providing services for people with substance use disorders.
d) Data collection
Structured interviews were conducted to assess participant characteristics and outcome
measurements before and after the treatment provided. Table 1 shows the outcomes and theirmeasurements. Semi-structured interviews were also conducted after the end of treatment to
ask about the acceptability and usability of the tele-Indo-DARPP, and audio recordings weremade with the participants' permission.
Table 1. Outcomes and measurements
Outcome

Measurement

Data for analysis

Type and score range

Hypothesisforintervention(vs control)

Continuous,
0 (no use) to 30 (usedeveryday).

Moredecrease

Primary
substance use

Timeline follow-back Number of days using the(TLFB) for the past
primary substance.
30 days

Addiction
severity

Addiction Severity
Index (ASI)

7 composite scores: medical, Continuous, 0 (noMoreemployment, alcohol use,
problems) to 1 (severe decrease
drug use, legal, family/social, problems).
and psychiatric status. Eachcomposite score is calculatedusing a standard formula.

Quality of life

World HealthOrganization Qualityof Life Brief Version(WHOQOL-BREF)

4 domain scores: physicalhealth, psychological health,social relationships,
environment. Each domainscore is calculated using astandard formula.

Continuous, 0 (impared Morehealth) to 100 (fullincrease
health).

1717

Motivation tochangeUniversity of Rhode Action stage subscale, sum of Continuous, 8 (notIsland Change
8 items.
active in behavioural
Assessment (URICA)
change) to 40 (highly
active in behaviouralchange).

Coping strategies Brief-Coping
Sum of substance use coping
Orientation to(2 items)
Problems Experienced(Brief COPE)

Continuous, 2 (lowsubstance use coping)to 8 (high substanceuse coping)Moreincrease

More
decrease

Psychiatric
symptoms

Symptom Checklist- Global Severity Index (GSI), Continuous, 0 (noMore
90 Revised (SCL-90- average of 90 items.
symptoms) to 4 (severe decreaseR)
9 dimension scores:
symptoms).
somatisation, obsessivecompulsive, interpersonalsensitivity, depression,anxiety, hostility, phobic
anxiety, paranoid ideation,
psychoticism, average ofitems.

Cognitivefunction

Rey Auditory Verbal 3 test results; immediate,
Learning Testlearning, and recalling.
(RAVLT)

Continuous, 0 (lowfunctioning) to 15(high functioning).

Internalised
stigmaInternalized Stigma of Total score, average of 29
Mental Illness (ISMI) items.
5 subscale scores: alienation,
stereotype endorsement,
discrimination experience,social withdrawal, stigma
resistance, average of items.

Continuous, 0 (lowMoreinternalised stigma) to decrease
4 (high internalised
stigma)More
increasee) Data analysis
Descriptive statistics were calculated for participants’ characteristics and changes inoutcomes. The interview recordings were transcribed verbatim, translated into English, andthen subjected to thematic analysis to identify positive/negative aspects of acceptability andusability.
f) Ethical considerations
Potential participants were informed of the purpose of the study, the methods, the burdens
and expected risks/benefits of participation, the voluntary nature of consent, and that consent
could be withdrawn at any time. Participation is only acknowledged if informed consent was
obtained. All study participants were asked to sign a pledge regarding group therapy
participation, such as to keep discussion confidential and not to share any information aboutother participants to any third party. This study protocol was approved by the Ethics Review
Committees of the Faculty of Medicine, Universitas Indonesia, and the Graduate School of
Medicine, Kyoto University.
Resultsa) Study participants
We approached nine participants for recruitment and all of them provided informed
consent. One retracted his consent prior to the completion of pre-treatment assessment. Amongthe eight who participated in the study, four preferred to and thus were allocated to the IndoDARPP+TAU arm and four to the TAU-only arm. One of the participants allocated to the TAUonly arm did not complete post-treatment assessment due to lost contact—the participant wasdetermined as ‘dropped out’ and thus not included in outcome analysis.
18

18Demographics of the participants at pre-treatment are shown in Table 2. The mean age
was 37 years old and all of them were male. The majority of them completed high school orhigher education (87.5%), had a part-time job (75%), were widowed/separated or never married(75%), in a household with three persons or more (75%), were Muslim (87.5%), and werebelong to an ethnic group rooted in Java island (75%). The mean time and cost needed for oneway transportation to the nearest health care facility were 80 minutes and 36.9 thousand rupiahs,
respectively. Half of the participants had been arrested due to drug charges. Sedatives werereported by seven participants (87.5%) as their primary drug of concern, while one reported
amphetamines. Sedatives, alcohol, and methadone were reported to have been used in the past
30 days.
Table 2. Participant demographics at pre-treatment
Total

Indo-DARPP+ TAU

TAU-only

n=8

n=4

n=4

Age, Mean (SD)37.0

(12.8)

39.3

(5.5)

34.8

(18.4)

Male gender, n (%)

8(100.0)4(100.0)4(100.0)Junior high1

(12.5)

1(25.0)

0

(0.0)

High

4

(50.0)

2(50.0)

2(50.0)

Vocational

3(37.5)

1(25.0)

2(50.0)

Full-time job

1(12.5)

1(25.0)

0(0.0)

Part-time job

6(75.0)

2(50.0)

4(100.0)

Disabled

1(12.5)

1(25.0)

0(0.0)

Married2(25.0)

1(25.0)

1(25.0)

Widowed/ separated

2(25.0)

1(25.0)

1(25.0)

Never married

4(50.0)

2(50.0)

2(50.0)

Living alone

0

(0.0)

0

(0.0)

0

(0.0)

2 persons2(25.0)

0

(0.0)

2

(50.0)

3 persons or more

6(75.0)

4(100.0)2(50.0)

Islam

7(87.5)

3(75.0)

4(100.0)Christianity

1(12.5)

1(25.0)

0(0.0)

Education completed, n (%)

Employment status, past 3 months, n (%)

Marital status, n (%)

Household size, n (%)

Religion, n (%)

Ethnicity, n (%)

1919

Jawa

3

(37.5)

1(25.0)

2(50.0)

Sunda

2(25.0)

0

(0.0)

2

(50.0)

Betawi1(12.5)

1(25.0)

0(0.0)

Minang1(12.5)

1(25.0)

0(0.0)

East Nusa Tenggara

1(12.5)

1(25.0)

0(0.0)

Transportation to the nearest healthcare facility, one-way trip, Mean (SD)Time in minutes

80(39.6)

81.3(37.5)

80(46.9)

Cost in thousand Rupiah

36.9(18.3)

32.5(20.6)

41.2(17.5)

Number of arrests due to drug charges, n (%)
Never

4

(50.0)

1(25.0)

3(75.0)

1- 2 times

2(25.0)

2(50.0)

0(0.0)

3 times or more

2

(25.0)

1(25.0)

1(25.0)

Sedatives

7(87.5)

4(100.0)3(75.0)

Amphetamines

1(12.5)

0

(0.0)

1

(25.0)

Alcohol

3(37.5)

2(25.0)

1(25.0)

Heroin

0

(0.0)

0

(0.0)

0

(0.0)

Methadone2(25.0)

1(25.0)

1(25.0)

Other opioids

0

(0.0)

0

(0.0)

0

(0.0)

Barbiturates

0

(0.0)

0

(0.0)

0

(0.0)

Sedatives

8(100.0)4(100.0)4(100.0)

Cocaine

0

(0.0)

0

(0.0)

0

(0.0)

Amphetamines

0

(0.0)

0

(0.0)

0

(0.0)

Cannabis

0

(0.0)

0

(0.0)

0

(0.0)

Inhalants

0

(0.0)

0

(0.0)

0

(0.0)

Primary drug of concern, n (%)

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

2020b) Indo-DARPP session attendance
Among the four participants allocated to the Indo-DARPP+TAU arm, two participantsjoined all twelve Indo-DARPP sessions, one participant attended 11, and one joined 9 sessions.
Collective attendance was 91.7% (44 out of 48 sessions).
c) Outcome changes
Figure 4 shows means and standard deviations of the outcome measurements at pre- andpost-treatment, stratified by the Indo-DARPP+TAU arm and the TAU-only arm. The
corresponding details can be found in Table S1.

2121

Figure 4. Difference between pre- and post-intervention measurements of primary (primary substanceuse) and secondary outcomes (ASI, WHOQOL-BREF, URICA, Brief COPE, RAVLT, ISMI, and SCL90-R) in the pilot study. Mean and standard deviations in error bar for each measurement are shown.
Results of the Indo-DARPP group are shown in the red line, and the TAU group in the green line.

22

22

Primary substance use
Both arms showed a mean decrease in the number of days of using the primary
substance in the past 30 days, with a greater decrease by 3 days in the IndoDARPP+TAU arm.
Addiction severity
The IndoDARPP+TAU arm showed a decrease in ASI composite scores of the
medical, psychiatric, alcohol use, drug use, and psychiatric domains. Of these, thereduction found in the medical and alcohol use domains were the most prominent, as
the TAU-only arm exhibited an increase or no change instead. The composite score of
the legal domain increased in both arms. The employment and family/social domains
among the Indo-DARPP+TAU arm showed an increase and no change, respectively,
while those among the TAU-only group showed a decrease.
Quality of life
Scores of the physical health, psychological health, and social relationships
domains of WHOQOL-BREF increased among the Indo-DARP+TAU arm, contrastingwith the results of the TAU-only arm which showed decreases or no change. The
environment domain score, however, decreased in both arms.
Motivation to change
There is an increase in the URICA action stage score in the Indo-DARPP+TAU
arm. This was in contrast with the TAU-only group, which showed a decrease.
Coping strategies
Substance use coping score of Brief COPE decreased among the IndoDARPP+TAU arm, while that among the TAU-only arm increased.
Psychiatric symptoms
The GSI score of SCL-90-R showed a decrease among the Indo-DARPP+TAU
arm, while that of the TAU-only arm increased. The scores of the Indo-DARPP+TAU
arm were reduced in the following domains: obsessive-compulsion, interpersonalsensitivity, anxiety, and hostility. Among these, the reductions observed in theinterpersonal sensitivity and hostility were noticeable as the scores in said dimensions
rose or did not change in the TAU-only arm. In contrast, the scores of the depression,
phobic anxiety, and paranoid dimensions increased and that of the psychoticism
dimension did not change in the Indo-DARPP+TAU arm. Nevertheless, these patterns
were also found in the respective dimensions among the TAU-only arm.
Cognitive function
The Indo-DARPP+TAU arm exhibited an increase in the trial 1 and 2 and adecrease in the recall trial, all of which were in line with the results among the TAUonly arm.
Internalised stigma
The total score of ISMI dropped in the Indo-DARPP+TAU arm, while itremained unchanged in the TAU-only group. All five subscales decreased among the
Indo-DARPP+TAU arm, and the decreases were noteworthy especially in the subscalesof alienation, stereotype endorsement, social withdrawal, and stigma resistance, as thescores of these subscales in the TAU-only arm rose or did not change.
2323d) Results of feed-back interviews with the participants
The participants who joined the Indo-DARPP reported that, in general, themodule had a good acceptability in terms of being able to open up on their personalmatters, receive helpful counsellor’s advice, learn new things, feel support from otherparticipants, and broaden their view by listening and sharing to other participants invarious stages of recovery from SUD. On the other hand, participants expressed
complaints regarding the Indo-DARPP contents, where some of its terminologies were
confusing and did not adhere to the actual colloquial terms commonly used in the streets,and some of the medical information was too complicated for lay people and notaccessible enough. Examples of interview data are provided in Table 3.
In terms of usability, the participants felt the convenience of joining from home,
without any wasted time or cost for transportation, and felt good pacing between
sessions. However, participants sometimes felt frustrated with technical issues andunstable Internet connection, and wanted more time to share their story. In the end, 75%(3 out of 4) participants expressed their preference for online telemedicine compared toface-to-face meeting.
No adverse effects of Indo-DARPP were reported. We confirmed withparticipants that they did not perceive that Indo-DARPP negatively affected any of their
physical, psychological, and social conditions.

Table 3. Themes and example interview raw data on acceptability and usability of tele-Indo-DARPP
Acceptability
Well-acceptedAble to open up personal matters‘Talking about my meth use reminded me of all the things, like my ex-girlfriend and my old
friends who died of AIDS. I had never talked about it with anyone before. I never thought ofsharing it because nobody would understand me anyway. But in the program, others also
shared similar things and I felt accepted.’
Found advices from peer counsellors relatable‘I learnt the meaning of one day at a time from him [Peer counsellor]. Even if I used drugs
yesterday, it's important to start another new day there and try to live better at least on thatday. 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 others supporting me‘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 patients too, supported me.’
Mutually learned‘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 hearmore and more stories from anyone among different stages in their path to recovery,
including new patients, whom I can help by teaching my own experiences as well.’24

24

Poorly accepted
Terminologies used in the workbook not close enough to reality‘Sometimes the workbook content felt a bit distant from the reality in the streets. I hope
there can be content revision to make us feel more familiar, such as adding brand names
for prescription drugs, and street names for illicit drugs.’
Explanation on medical and statistical information are not accessible enough‘Sometimes I couldn't really understand the medical explanation or study graphs, and tend
to just skim them.’
Usability
UsableConvenient to join from home
‘I really like that I could join it from home, even right after taking a nap. Going to thehospital is such a hassle.’
No wasted time/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 off from my job.’
Good pacing between sessions‘One session per week was the best frequency for me. I could remember what we learnt in
the last session.’
Poorly usable
Frustrated with technical issues‘I could not use my video sometimes, which was so frustrating. I couldn't keep up with thediscussion because of 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.’

Discussion
Our preliminary results of the pilot study showed that participants who received
Indo-DARPP+TAU were more able to reduce their number of days using primary
substance use, compared with those receiving TAU only. Among the IndoDARPP+TAU arm, the reduction was also observed in the composite scores of drug
and alcohol use domains of ASI, which measured not only the use of primary substancebut also various types of psychoactive substances. These scores also reflect how
troubled the participants were in regards to psychoactive substance use, and how
important it is for them to receive treatment for such troubles. The observed reductions
in substance use and its related troubles are in line with the positive changes of theprocess measurements among the Indo-DARPP+TAU arm, namely, the increased scoreof the URICA action stage scale and the decreased score of the Brief COPE substanceuse coping scale. These might suggest that those who received Indo-DARPP increased
their motivation to actively engage in changing their substance use behaviour, as wellas make choices of strategies other than substance use to cope with their stress ineveryday life. Indeed, the interview revealed that Indo-DARPP participants were able2525

to maintain their motivation thanks to the peer counsellor’s knowledge which was basedon his own experiences, and learned new practical skills to avoid triggers for substanceuse (e.g., schedule making).
Among those who received the Indo-DARPP+TAU, we also observed some
improvements in outcomes regarding psycho-social aspects, i.e., increase in the domainscores of psychological health and social relationships in WHOQOL-BREF, decreasein the interpersonal sensitivity and hostility dimension scores of SCL-90-R, anddecrease in the subscales of alienation, stereotype endorsement, social withdrawal, andstigma resistance of ISMI. It could be inferred that gaining a supportive group therapy
environment from Indo-DARPP alleviated psychological suffering and enhances
mutual social support. As shown in the interviews, participants were able to disclose
private issues during the Indo-DARPP sessions to the extent that they shared about theirillegal activities and bereavement of persons significant to them. Previous studies
showed that psychotherapies via online technologies faced challenges in building
rapport between clients and therapists, compared to when being provided in-person(Backhaus et al. 2012). Our success in building a safe and private environment as a
SUD treatment setting may not have been possible without the involvement of peer
counsellors, as well as the establishment of common understanding of the group rule,i.e., to not disclose any information discussed in sessions to any third party outside thegroup. The interview also showed that the Indo-DARPP worked as an interactive
platform of mutual sharing and learning, instead of a conventional treatment setting
where knowledge is unidirectionally given from therapists to clients. As reflected in theobserved reduction in internalised stigma, the format of group therapy with abundant
open discussions in Indo-DARPP might have helped lessen some negative affect,
including shame, guilt, and loneliness, and enhance self-worth and sense of belonging(Yalom 1995). Another possible interpretation is that reduced psychoactive substanceuse in itself may have led to improvement in psychiatric symptoms.
Furthermore, Indo-DARPP was perceived as time-efficient by the participants ofour pilot study whose residence is located in Jakarta, whose city traffic is inconvenientand heavily congested. Indeed, Indo-DARPP could save over two hours of roundtrip
transportation time to visit an outpatient clinic.
Nevertheless, our results also showed that people who received Indo-DARPP
did not show improvements in the employment and family/social domains of ASI.
Previous surveys reported that having a full-time job and good family relationships (i.e.
cohabitation with parents and family cohesion) were important protective factors forthe well-being of people who use substances in Indonesia (Li et al. 2014; Natakusumah
et al. 1992). More detailed field observation in Makassar, Sulawesi, reported that
employment enables young men who use drugs to gain halal (legitimate) income,acquire rewa (local masculine identity), be gaul (sociable), as well as able to rebuild
good relationships with their families and social networks with a wider community(Nasir, Rosenthal, and Moore 2011). Widening of these social networks is surely
difficult without alleviating societal discrimination towards people with SUD. Indeed,
the Indo-DARPP participants showed a relatively limited reduction in thediscrimination experience score of ISMI. In this current module, Indo-DARPP does notcomprehensively address the needs of people with SUD, especially in employment andfamily/social aspects, indicating a need for concurrent complementary programs. For
instance, local NGOs including several rehabilitation centres are providing job finding
assistance and skill training, and the national government has a welfare program ofconditional cash transfer for unemployed people with SUD (Hatta and Sarkawi 2011).
There are also ongoing efforts in Indonesia to implement family interventions for SUD
26

26

(Busse, Kashino, Suhartono, Narotama, Pelupessy, et al. 2021). Furthermore, peer-run
NGOs are playing key roles in stigma reduction, via education, story sharing, andcreation of media. It might be recommended to amend Indo-DARPP contents to meeta wide range of needs, as well as provide the program in combination with existing
resources.
The interview results revealed several other issues regarding the usability andacceptability of Indo-DARPP. For example, the participants reported that they were notfamiliar with some terminologies, especially substance names used in the workbook.
Also, some participants had difficulties in comprehending medical and statisticalinformation. Although the workbook contents were carefully developed to increase
clarity and comprehensibility, further considerations are necessary, given the relatively
low educational backgrounds of people with SUD. Some examples include the additionof colloquial street names of substances, adding explanatory pictures, and presenting
heavier knowledge with simpler and easy-to-understand texts. Further, the participants
felt frustrated when having technical issues related to unstable internet connections or
smartphone devices. This is another obstacle to the widespread implementation oftelemedicine. Nevertheless, it is hoped that this infrastructural obstacle can be gradually
overcome following the rapidly expanding use of the internet in Indonesia, where
smartphone use itself is estimated to increase from 74% in 2019 to as high as 89% by2025 (The Mobile Economy 2020). The COVID-19 pandemic has turned telemedicine
from an alternative feature to a core necessity, and thus opening novel ways to do online
group communication (via software, application, and social networks) and also pushing
the local policymakers to put more investment in infrastructure relating to Internet
access.
Altogether, our pilot result gave an encouraging look into how peer counsellors
can be involved within a formal psychotherapeutic session for clients with SUD. While
we measured the duration of abstinence as the primary outcome, it is emphasised in the
Indo-DARPP sessions themselves that participation is welcomed, regardless of one's
own status of substance use. Summarily, we put the following points as the purpose of
Indo-DARPP:
1. Instil internal motivation instead of forced, external pressure
2. Implement community-based approach or outpatient, not prison-like inpatient
institution
3. Value autonomy of clients: to achieve abstinence or not, at what pace, with what
method.
4. Create a safe place for clients to discuss freely and honestly, together with peers
who also have substance-related issues
Nonetheless, the results should be interpreted with caution. This pilot study isof exploratory and preliminary nature with a very limited sample size without any
statistical tests—being the first to try out the newly developed psychotherapy inIndonesia—and was not meant to determine clinical effectiveness akin to those ininterventional studies employing more rigorous design such as randomised controlled
trial with a large enough sample size predetermined by a sample size calculation.

2727

3-3-3. Designing evaluation study of Indo-DARPP
Although the pilot study showed well acceptability and usability of the IndoDARPP program, the fact remains that there is a scarcity of evidence in terms of peer
involvement in formal psychotherapy for SUD, not only in Indonesia but also inSoutheast Asia in general. Thus, we are running a large-scale, multicenter randomised
controlled trial recruiting people with SUD across Indonesia, done in multiple settings
including in referral hospitals, Puskesmas, as well as private peer-run rehabilitation
NGOs, with several combination duets of peer counsellor and HCW as the session
providers. The detailed protocol has been peer-reviewed and published (Yamada et al.
2021).
Features of the study design can be described in terms of the pragmaticexplanatory multidimensional continuum. Here, pragmatic trials mainly aim toinvestigate the effects of an intervention under the usual circumstances where it will beapplied. Meanwhile, explanatory trials mainly aim to determine the effects of anintervention under ideal conditions (Thornicroft and Patel 2014; Schwartz and Lellouch1967). When designing a clinical trial, researchers need to make a wide range ofdecisions, each of which would determine the degree of how pragmatic (or explanatory)
the corresponding dimension of the trial will be. Those dimensions include, for example,
the eligibility criteria for trial participants, the flexibility with which the experimental
intervention is applied, and the degree of practitioner expertise in applying andmonitoring the experimental intervention. Therefore, each trial usually has both
pragmatic and explanatory aspects to an extent, and can be described in a
multidimensional continuum instead of a binary categorisation.
Figure 5 depicts the features of the Indo-DARPP evaluation trial using thepragmatic–explanatory continuum indicator summary (PRECIS) wheel (Thorpe et al.
2009). Within the 10-dimensions of the PRECIS wheel, the outer markers denote more
pragmatic elements, while inner markers of the blue line denote more explanatory
elements.

Figure 5. Features of the Indo-DARPP clinical trial, as described using the pragmatic–explanatory
continuum indicator summary (PRECIS) wheel.

28

28

In the case of the Indo-DARPP evaluation trial, we generally designed the study
to be closer to the pragmatic poles, as we would like to see whether the intervention
may work in the local everyday reality, rather than in highly controlled conditions. As
can be seen in the blue line within the PRECIS wheel, we took a pragmatic outlook interms of, for example, the flexibility of comparison intervention and the practitioner
expertise of comparison group, i.e., control conditions were set as treatment as usual,
which greatly varies and were provided in the usual care without any additional training
for this research purpose. Another is in participant compliance, where the program isdesigned as community-based, as opposed to institution-based, with emphasis on theautonomy of clients. The eligibility criteria for participants were also set to be rather
pragmatic; one of the inclusion criteria was 'drug use for at least once in the past year',even though other similar studies employ more strict criteria (e.g., frequent drug use in
the past month). One of the reasons is that, based on our experience at collaborating
clinical sites, patients under treatment include people who are abstinent for more thana month but still experience cravings, and they indeed show interest in receiving relapse
prevention psychotherapy. We thus preferred such broader criteria, which more closely
represent a population seen in a real world clinical practice in the Indonesian context.
Meanwhile, in some of the dimensions, we designed the trial as relatively explanatory.
For instance, we measure various outcomes, including those not necessarily assessed inusual clinical practices, thus pushing the outcome dimension toward the explanatorypole.
4. Conclusion
As observed in psychotherapy sessions, experience-based knowledge isimportant to maintain a horizontally close relationship between providers and clients.
As discussed in this paper, people with SUD have not only been frequently targeted by
the criminal justice system, but also deprived of their autonomy in healthcare settings.
Here, peer counsellors with experience-based knowledge have the potential to enact
critical roles, to bring about transformation in the current healthcare practices andsystems. The existence of professional peer counsellors naturally elevates the status ofpeople who use drugs in the eyes of society, while at the same time elevating theautonomy of actual clients seeking healthcare.
Through observation, we can infer many dynamics existing in psychotherapy
provision between different combinations of providers. It is hoped that after the current
trial is complete, we can obtain more data to clearly elucidate the roles of peer
counsellors within a psychotherapy co-provision with HCWs and effects on autonomy
and clinical outcomes of people with SUD. In the future, if psychotherapy co-provisionsuch as that found in Indo-DARPP is to be implemented widely, a broader scope ofunderstanding regarding the positionality of peer counsellors is necessary.
Acknowledgement
The research for this article received funding from the Japan-ASEAN Platformfor Transdisciplinary Studies project of the Center for Southeast Asian Studies of Kyoto
University. Other funding sources were the Japan Society for the Promotion of Science(JSPS) Grants-in-Aid for Scientific Research (KAKENHI) (Grant number
JP19K24256) and the Research Unit for Development of Global Sustainability of Kyoto
University.
2929

Some parts of this article are reports of the Indo-DARPP study which we areconducting in collaboration with Universitas Indonesia, and in partnership with
Karisma Foundation, Kapeta Foundation, Duren Sawit Special Regional Hospital, Aceh
Mental Hospital, Puskesmas Jatinegara, Puskesmas Gambir, and HIV/AIDS ResearchCenter of Atma Jaya Catholic University in Indonesia, as well as Tokyo University of
Science and the National Center of Neurology and Psychiatry in Japan. The authors are
immensely grateful to the collaborators, partners, and participants of the Indo-DARPP
study. For this article, we especially acknowledge Mr. Rahadianto Purnomo for sharing
his indispensable insights with the authors. We would like to thank the Japan-ASEAN
Platform for Transdisciplinary Studies project team for all the supports they provided.
Special thanks go to Dr. Ryota Sakamoto and Dr. Mario Ivan Lopez for their valuablecomments on the study and this manuscript. We also wish to thank the members of theField Medicine Seminar of Kyoto University for giving us important inputs for the
study. The contents within are solely the responsibility of the authors and should not be
attributed to any other agency or individuals.

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Supplementary file
Table S1. Comparison of changes in outcomes between Indo-DARPP + TAU and TAU only
Indo-DARPP + TAU

TAU only

n=4

n=3

Mean

(SD)

Mean

(SD)

30.0

(0.0)

30.0

(0.0)

Post

17.0

(15.4)

20.0(17.3)

Post-Pre-13.0(15.4)-10.0(17.3)

Pre

0.5

(0.3)

0.1

(0.2)

Post

0.2

(0.3)

0.3

(0.4)

Post-Pre

-0.3

(0.3)

0.1

(0.5)

Pre

0.4

(0.5)

0.7

(0.4)

Post

0.6

(0.5)

0.6

(0.4)

Post-Pre

0.2

(0.5)

-0.1

(0.2)

Pre

0.1

(0.1)

0.2

(0.3)

Post

0.0

(0.0)

0.2

(0.3)

Post-Pre

-0.1

(0.1)

0.0

(0.1)

Pre

0.3

(0.1)

0.3

(0.1)

Post

0.1

(0.0)

0.1

(0.2)

Post-Pre

-0.2

(0.1)

-0.1

(0.1)

Pre

0.0

(0.0)

0.0

(0.0)

Post

0.1

(0.2)

0.2

(0.2)

Post-Pre

0.1

(0.2)

0.2

(0.2)

Pre

0.1

(0.1)

0.2

(0.2)

Post

0.1

(0.1)

0.1

(0.1)

Post-Pre

0.0

(0.1)

-0.1

(0.1)

Pre

0.6

(0.2)

0.5

(0.0)

Post

0.4

(0.2)

0.3

(0.2)

Post-Pre

-0.1

(0.2)

-0.2

(0.2)

Pre

44.8

(12.6)

48.7

(9.1)

Post

52.8

(20.3)

52.7(23.1)

Post-Pre

8.0(13.0)

4.0(15.7)

Pre

48.3(10.0)

49.7(14.4)

Number of days using primary drug
Pre

ASI
Medical

Employment

Alcohol use

Drug use

Legal

Family/ social

Psychiatric status

WHOQOL-BREF
Physical health

Psychological health3535

Social relationships

Environment

Post

60.5

(18.0)

40.3(13.4)

Post-Pre

12.3

(9.5)

-9.3

(2.3)

Pre

48.0

(14.4)

33.3(33.5)

Post

60.5(26.6)

30.7(19.6)

Post-Pre

12.5(14.2)-2.7(19.3)

Pre

52.5(13.2)

52.3(14.4)

Post

47.8

(7.5)

44.0

(0.0)

Post-Pre-4.8(11.6)-8.3(14.4)

Pre

30.0

(4.2)

35.7

(4.5)

Post

32.3

(1.5)

34.0

(4.6)

Post-Pre

2.3

(5.7)

-1.7

(5.5)

Pre

5.8

(2.1)

6.3

(1.5)

Post

5.0

(2.6)

6.3

(0.6)

Post-Pre

-0.8

(1.5)

0.0

(2.0)

Pre

1.8

(1.0)

1.3

(1.2)

Post

1.3

(1.0)

1.7

(0.6)

Post-Pre

-0.5

(0.6)

0.3

(0.6)

Pre

1.3

(1.3)

1.0

(1.0)

Post

1.3

(0.5)

1.3

(0.6)

Post-Pre

0.0

(0.8)

0.3

(0.6)

Pre

2.0

(1.2)

2.0

(1.0)

Post

1.5

(1.3)

1.7

(0.6)

Post-Pre

-0.5

(0.6)

-0.3

(1.2)

Pre

1.3

(1.3)

2.0

(1.0)

Post

1.0

(0.8)

2.3

(0.6)

Post-Pre

-0.3

(0.5)

0.3

(0.6)

Pre

1.5

(1.3)

1.7

(0.6)

Post

1.8

(1.0)

2.3

(1.2)

Post-Pre

0.3

(0.5)

0.7

(0.6)

Pre

1.8

(1.0)

1.3

(1.2)

Post

1.5

(1.3)

1.7

(1.5)

URICA
ActionBrief-COPE
Substance use coping

SCL-90-R
GSI

Somatisation

Obsessive-Compulsion

Interpersonal sensitivity

Depression

Anxiety36

36

Hostility

Phobic anxiety

Paranoid ideation

Psychoticism

Post-Pre

-0.3

(0.5)

0.3

(0.6)

Pre

0.8

(0.5)

1.7

(1.5)

Post

0.5

(0.6)

1.7

(0.6)

Post-Pre

-0.3

(0.5)

0.0

(1.0)

Pre

0.5

(1.0)

1.0

(1.0)

Post

1.0

(0.8)

1.0

(1.0)

Post-Pre

0.5

(0.6)

0.0

(0.0)

Pre

0.8

(1.0)

1.3

(1.2)

Post

1.0

(0.8)

1.7

(0.6)

Post-Pre

0.3

(0.5)

0.3

(0.6)

Pre

1.3

(0.5)

1.7

(1.5)

Post

1.3

(1.0)

1.7

(0.6)

Post-Pre

0.0

(0.8)

0.0

(1.0)

Pre

4.8

(0.5)

6.7

(0.6)

Post

5.8

(2.2)

8.7

(3.2)

Post-Pre

1.0

(2.2)

2.0

(2.6)

Pre

10.5

(0.6)

8.3

(0.6)

Post

13.5

(3.8)

15.0

(1.0)

Post-Pre

3.0

(4.2)

6.7

(0.6)

Pre

10.8

(2.9)

9.7

(2.5)

Post

7.8

(4.6)

8.3

(2.1)

Post-Pre

-3.0

(5.0)

-1.3

(4.5)

Pre

2.6

(0.4)

2.6

(0.2)

Post

2.2

(0.7)

2.6

(0.5)

Post-Pre

-0.4

(1.0)

0.0

(0.3)

Pre

2.8

(0.6)

2.7

(0.3)

Post

2.4

(1.0)

2.8

(0.2)

Post-Pre

-0.4

(1.0)

0.1

(0.2)

Pre

2.8

(0.2)

2.4

(1.0)

Post

2.4

(1.0)

2.8

(0.2)

Post-Pre

-0.6

(1.1)

0.0

(0.6)

Pre

2.5

(0.5)

3.1

(0.8)

Post

2.2

(0.8)

2.6

(0.9)

-0.35

(1.0)

-0.5

(0.5)

RAVLT
Trial 1

Trial 2

Recall

ISMI
Total

Alienation

Stereotype endorsement

Discrimination experience

Post-Pre

3737

Social withdrawal

Stigma resistance

Pre

2.5

(0.6)

2.3

(0.3)

Post

2.2

(0.7)

2.6

(0.6)

Post-Pre

-0.3

(1.0)

0.3

(0.7)

Pre

3.0

(0.3)

3.1

(0.2)

Post

2.7

(0.8)

3.0

(0.2)

Post-Pre

-0.3

(1.1)

-0.1

(0.1)

ASI, Addiction Severity Index; WHOQOL-BREF, World Health Organization Quality of Life
Brief Version; URICA, University of Rhode Island Change Assessment; Brief COPE, BriefCoping Orientation to Problems Experienced; SCL-90-R, Symptom Checklist-90 Revised; GSI,
Global Severity Index; RAVLT, Rey Auditory Verbal Learning Test; ISMI, Internalized Stigma of
Mental Illness.

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