Development and initial testing of mindful journey: a digital mindfulness-based intervention for promoting recovery from Substance use disorder

Figures & data

Figure 1. Example animations in the video clips of Mindful Journey.

Figure 2. Example visuals of the screens on the app.

Table 1. Key Elements Informing intervention development.

Element	Details
In-person mindfulness treatments for SUD	Several existing in-person mindfulness treatments for SUD have demonstrated efficacy, and therefore can inform content development of the app These include Mindfulness-Based Relapse Prevention (MBRP) [23], Acceptance and Commitment Therapy (ACT) [25,53], Mindfulness-Oriented Recovery Enhancement (MORE) [24], Regulation of Craving Training (ROC-T) [57] and Dialectical Behavior Therapy (DBT) [56] When developing the content for the app we drew upon these treatments Key features drawn from MBRP included formal meditation practice, inquiry after meditations, using an acronym to promote mindfulness in daily life, applying mindfulness to craving, difficult emotions, thoughts, and sensations, being curious and present in daily life, self-compassion, exploring needs underlying urges to use substances, and self-care (i.e. lessons 1 to 10) Key features drawn from ACT include acceptance of craving (lessons 3 and 4), seeing thoughts as thoughts (lesson 6), and values clarification (lesson 14) Key features drawn from MORE include savoring of pleasant experiences and positive emotion regulation (lessons 10–13) Key features drawn from DBT include using multiple methods to teach mindfulness (e.g. acronyms, brief exercises, catchphrases, and modeling) (integrated throughout all the lessons)
Clinical experience	Clinical experience offering mindfulness treatment to individuals with SUD can be very valuable in informing ongoing refinement of treatment Our team drew upon our extensive clinical experience delivering MBTs for SUD For example, many of the authors have had clinical experiences in which they recognized that patients were satisfied with acronyms for learning tools and frequently used acronyms to apply skills. Importantly, research data also indicates that participants with SUD who have received MBT frequently use acronym-based tools [56,59]. Therefore, we included acronyms in the app Additionally, many of the authors have had clinical experiences in which the inquiry process following meditation practice (i.e. reflecting on and talking about experiences one noticed during a meditation) was a valuable process to pique participant’s curiosity in their own experiences and the process of relating mindfully to these experiences. Therefore, we included inquiry-based questions (e.g. what did you notice?) after every meditation practice, and we included therapist-client videos involving inquiry-based discussion.
Predictors of relapse	Research shows that negative affect, difficulties regulating negative affect, substance craving, and anhedonia predict relapse The app includes content focused on these core processes (e.g. directly explaining to the user how these processes predict relapse)
Mechanisms of recovery	Research suggests that improvements in mindfulness, reductions in craving, improvements in negative emotion regulation, and increases in savoring may be mechanisms underlying the effect of mindfulness-based treatments on recovery outcomes Table 3 provides details on key content in the app that is intended to mobilize each of these mechanisms. The app also directly explains to users that mindfulness, reductions in craving, improvements in emotion regulation, and savoring are key factors that promote recovery
Multi-dimensional recovery	Recovery has been defined as a multi-dimensional, dynamic process of change involving remission from SUD, reduction in substance use, and improvements in functioning and quality of life We included content in the app designed to target each of these dimensions of recovery (e.g. discuss mindfulness as a general skill used in range of life situations, not just those related to substance use) The app also defines multi-dimensional recovery to users and directly explains to users that the app is designed to promote multi-dimensional recovery
Digital interventions for SUD	Developing Mindful Journey was informed by existing digital interventions for SUD, particularly Computer-Based Training in Cognitive Behavioral Therapy (CBT4CBT) [60] For example, our team chose to develop multiple digital lessons that are 30- to 45-minutes in length (described further below) because prior research testing digital intervention like CBT4CBT have shown that digital interventions in the format of multiple 30- to 45-minutes lessons are acceptable, feasible, and efficacious among individuals with SUD [49]. Additionally, consistent with CBT4CBT, we chose to: (a) deliver the content primarily via video clips and audio-guided exercises, rather than text-based information, (b) have all language in program be at a 6^th grade reading level or lower, (c) include narrators who guide participants through the program, and (d) include example clients who share their experiences and model skills Key features drawn from ROC-T include combining distal substance cues (e.g. cash) with mindfulness instruction (lesson 3)
Digital mindfulness treatments	Developing Mindful Journey was also informed by existing digital mindfulness treatments This includes iCanQuit a smartphone app-based on acceptance and commitment therapy [53] that aims to promote cessation from tobacco use. Similar to iCanQuit we included example clients, animations, and broke down lessons into smaller segments. Moreover, similar to iCanQuit, Mindful Journey has a targeted focus on acceptance of craving This also includes web-based mindfulness-based cognitive therapy (MBCT) for depression [51]. For example, similar to MBCT we include sequential series of lessons that are approximately 45-minutes long, and we include inquiry-based reflection questions after each meditation practice Similar to other mindfulness apps, such as Headspace [58], we used animations to teach mindfulness concepts and skills
Brand identity	Brand identity is the unique ‘personality’ of the app and how the app is designed to make people feel. The brand identity is ideally suitable for the target audience, which is individuals in early recovery from SUD. A cohesive and suitable brand identity will increase engagement in the app The key personality descriptors of the app are calming, encouraging, playful, scientific, professional. The app is designed to make users feel at ease, welcomed, supported, hopeful, curious, and trusting of the content The brand identity can be expressed through multiple elements, including the name of the app, color schemes, logo, other visual content, and the tone and language used in the meditations and in the videos with narrators/therapists and the example clients The color scheme is three shades of blue to connote calmness and ease. The logo is a blue wave that connects with the metaphor of craving as a temporary wave that one can ride out. This logo is intended to provide encouragement that craving and other challenges are not insurmountable, but instead one can ride out or surf the wave and continue moving in the direction of recovery. The font used for the word mark (i.e. the word Mindful Journey next to the logo image) and the font used in the videos is a style that balances professionalism and playfulness The app tries to avoid taking a too serious and formal tone that may come across as cold or stale. Instead, the app strives to sometimes exude an attitude of playfulness, lightness, and curiosity. For example, the BOAT and the SOAK are somewhat playful acronyms. The catchphrase ‘Use the BOAT to stay afloat’ is somewhat silly. The inclusion of animations, instead of video clips of real people, is intended to deliver the content in a lighter and more playful way The visual content of the videos (e.g. illustration, moving animations) are modern, simple, and professional looking, and include charts and images of a brain to connote scientific credibility. The app is scientific by clearly explaining—in simple language—how mindfulness is theorized to improve recovery. The narrators/therapists talk in a gentle and supportive tone while also being professional and direct. The example clients express hope and encouragement of how mindfulness can improve their recovery
Simple layout and navigation	Simple and noncomplicated layout and navigation will enhance engagement The sequence of 15 lessons involves very simple linear navigation. All users have to do is press continue again and again to navigate to the next section within a lesson and to advance to the next lesson after finishing a lesson A bottom navigation bar that stays on the screen is commonly used in apps so users can easily access core sections of the app. We included a bottom navigation bar with 4 icons so users can easily access the core sections
Diversity and inclusivity	We designed the app to include individuals with a diverse array of identity dimensions and individual differences (e.g. gender, race, age, occupation, type of SUD) so that individuals using the app feel welcomed, valued, and respected For example, we chose to have two narrators varying in gender and race. And we chose to have example clients that varied in gender, race, age, socioeconomic status and occupation, as well as the primary substances they were using
Low-cost app development resources	Our team strived to leverage low-cost resources for building the digital intervention. This was driven in part by a limited budget and a desire to create a digital tool that can be sustainable over time and does not require exorbitant costs to maintain it Details on the resources we used are provided in Supplementary Table 1
Evidence-based educational principles	Our development approach was informed by several evidence-based educational principles, which are explained below
Active learning	Active learning is learning by doing and reflecting on what one experienced The app includes meditation exercises in every lesson and reflection question after each exercise (e.g. What did you notice?) The app aims to facilitate ongoing active application of mindfulness in daily life and prompts users to reflect on what they experience when applying mindfulness
Spaced learning	Spaced learning is repeatedly engaging in similar learning activities with intervals of time in between each session The app includes numerous lessons (e.g. 15) that individuals complete over time (e.g. 8 weeks) and the app can recommend spaced practice (e.g. 2–3 lessons per week)
Mnemonics	Mnemonics are techniques to improve memory such as metaphors, imagery, acronyms, and rhymes The app includes two key acronym: the BOAT the SOAK The app has a coherent theme with nautical imagery and language, including the BOAT, recovery as a journey or voyage, craving as a wave and riding out the wave with the BOAT, changing weather patterns, and soaking in the sun as savoring Thre app includes ‘Use the BOAT to stay AFLOAT’ as a catchy rhyme. The app includes other metaphors such as emotions as guests or visitors, and mindfulness as a muscle that can get stronger
Vicarious learning	Vicarious learning is the process of learning by observing other people’s experiences and behaviors Participants learn about the experiences of two core characters (Maria and Jamal) and two side characters (Jen and Steven) who re-occur throughout the lessons The app includes several types of videos with the characters that are intended to provide an array of vicarious learning opportunities For example, the characters provide testimonials (i.e. share past or recent experiences, such as challenges and successes during recovery, and application of mindfulness skills) The app includes ‘Inside the Mind’ videos in which participants get an inside look at characters’ internal thought processes while applying mindfulness in various situations The app includes individual- and group-based therapy videos with discussions between therapists and the characters. These include inquiry-based discussions about momentary experiences after meditations, as well as discussions about the process of recovery and relapse and key concepts and application of mindfulness skills
The multimedia principle	The multi-media principle posits that learning with visuals and words is more effective than words alone. We designed the program to be primarily video-based, instead of audio only Carefully designing videos with moving animations, still graphics, and text-based animations that complement the words spoken by the narrator/therapists or characters
Minimizing cognitive load	Minimizing cognitive load is the process of offering learning content in a manner that does not overload working memory capacity The lessons broken into numerous ‘bite-size’ segments The app introduces new content at a relatively slow pace and includes lots of repetition and review The app includes a simple, linear process of navigating through lessons The app includes many semi open-ended questions (‘What did you notice?’) with examples of potential answers (warmth, tingling, pressure), instead of fully open-ended questions
Positive reinforcement	At the end of lessons, a funny congratulatory GIF is presented The narrators provide ongoing warm and genuine verbal praise as users advance through the content

Table 2. Target mechanisms and content intended to mobilize these mechanisms.

Target mechanisms	Key content
Mindfulness: paying attention to present moment experience with openness, curiosity, and nonjudgmental acceptance	One or two audio-guided mindfulness meditations for each lesson, typically around 5- to 10-minutes each Reflection questions immediately after mindfulness meditations to facilitate nonjudgmental describing of subjective experiences (e.g. thoughts, emotions, sensations) with words Brief (about 3 min) audio-guided exercises of the BOAT (Breathe, Observe, Accept, Take a Moment) and SOAK (Stop, Observe, Appreciate, Keep Curious) tools to facilitate mindfulness in daily life Didactic narrator-led video clips explaining mindfulness, key related concepts (the nature of thoughts, emotions, and sensations) and the application of mindfulness in daily life Video clips with characters providing testimonials or characters having a discussion during an individual or group-based therapy session to model key processes, such as nonjudgmental describing of present moment experience with words, as well as the application of mindfulness in daily life A variety of additional questions prompts related to mindfulness and its applications, including quiz questions, as well as both open-ended and mixed open-/closed-ended questions eliciting personal perspectives and understandings on the material and plans for applying skills in daily life
Substance Craving: the subjective desire to use substances	Audio-guided mindfulness exercises combining imaginal exposure to a situation eliciting substance craving with mindfulness instruction Exercises combining presentation of images to elicit craving (food and distal substance cues such as cash) and audio-guided mindfulness instruction A variety of question prompts related to craving and coping with craving, such as quiz questions, question to identify triggers of craving, creating a plan for coping with triggers and craving Audio-guided exercises, video clips, and question prompts focused on key themes, such as: (a) using the BOAT to cope with craving, (b) exploring personal needs underlying craving for substances, and (c) the role of self-compassion in recovery
Negative emotion dysregulation: difficulty managing the experience of negative emotions and how one responds to these emotions	Audio-guided mindfulness exercises combining imaginal exposure to a situation eliciting negative emotions with mindfulness instruction Reading of the ‘Guest House’ poem [23] by Rumi to facilitate reflection of negative emotions as temporary guests or visitors Audio-guided exercises, video clips, and question prompts focused on key themes, such as (a) using the BOAT to cope with negative emotions, (b) the nature of emotions, (c) the role of thoughts in challenging situations, (d) mindfulness of thoughts, (e) the role of the body in managing emotions, and (f) mindfulness practice as self-care in daily life
Savoring: the ability to appreciate pleasurable features of daily experiences and positive emotions that arise from these experiences	Audio-guided mindfulness exercises combining imaginal exposure to pleasant situations with mindfulness instruction Exercises combining presentation of images to elicit positive emotions and audio-guided mindfulness instruction Audio-guided exercises, video clips, and question prompts focused on key themes, such as (a) using the SOAK during daily activities, (b) the role of curiosity in savoring, (c) appreciating the full range of positive emotional experiences (including contentment, calm, meaning, connection, and love), (d) clarifying personal values and meaning-making, and (e) appreciating positive emotions while also allowing them to come and go instead of ‘chasing’ them or ‘clinging’ onto them

Figure 3. Visual schematic of the steps in our app development process.

Table 3. Overview of the 15 core lessons in Mindful Journey.

Lesson number and name	Core learning objectives	Audio-guided mindfulness meditation practices
Getting Started	Define mindfulness Identify ways in which mindfulness in plays a role in recovery Practice guided mindfulness exercises Explain the steps of the BOAT (Breathe, Observe, Accept, Take a Moment) Describe how to use the Mindful Journey app	Body and breath practice BOAT practice
Responding with Awareness	Define automatic pilot Describe the role of automatic pilot in substance use Identify and define the three components of the triangle of awareness (thoughts, emotions, sensations) Practice mindfulness after thinking about challenging personal situation Explain how to use the BOAT in daily life	Brief BOAT BOAT with imaginal exposure to challenging situation
Coping with Cravings	Define craving Practice mindfulness while viewing images that may elicit craving Describe the similarity of cravings with ocean waves Explain how mindfulness can be applied to a situation that elicits craving	BOAT Exercise – Food Cravings (with visual display of food images) BOAT Exercise – Substance Cravings (with visual display of distal cue images)
Riding the Wave	Define a trigger and describe the roles of triggers in substance use Identify personal triggers Practice mindfulness after thinking about a situation that triggers craving for substances Create a plan for coping with triggers	BOAT with imaginal exposure to substance craving
Emotions as Visitors	Identify types of difficult emotions and describe how they play a role in substance use Practice mindfulness of one’s current emotions before and after listening to a poem about emotions as guests Explain how difficult emotions are similar to guests or visitors Describe the role of mindfulness, particularly the component of acceptance, in the process of coping with difficult emotions	Mindfulness of emotions with reading of the Guest House [23]
Seeing Thoughts as Thoughts	Define thoughts Differentiate thoughts from body sensations and emotions Describe the role of thoughts in the relapse cycle [23] Practice mindfulness of thoughts after hearing about an imaginary ambiguous situation Practice mindfulness of current thoughts while using the breath as an anchor for attention to return to	Walking Down the Street Exercise [23] Mindfulness of Thoughts
Practicing Self-Compassion	Describe the role of self-criticism in the relapse cycle Practice mindfulness while offering compassionate words to other people and oneself Explain how self-compassion can facilitate recovery Create a brief self-compassion reminder statement Practice mindfulness while mentally reciting one’s self-compassion reminder	Compassion Practice Self-Compassion reminder exercise
Exploring Your Needs	Describe types of needs that human beings have in life Explain how substance use is related to trying to meet one’s needs Practice mindfully reflecting on one’s own personal needs that may underlie craving and substance use Explain how the BOAT can be used as a tool to check-in with one’s needs in the moment	Exploring Your Needs Practice Brief BOAT
Taking Care of Your Body	Explain the importance of self-care in recovery, including taking care of one’s body Practice mindfulness while engaging in gentle movements and stretches, as well as while intentionally resting one’s body	Mindful Movement Mindful Rest
Being Curious	Explain the steps of the SOAK (Stop, Observe, Appreciate, Keep Curious) Describe the role of the SOAK in recovery. Define curiosity	SOAK practice Brief SOAK exercise with visual display of vivid photos.
Savoring Positive Experiences	Explain how the SOAK can be used in daily life Practice mindfulness after thinking about a pleasant situation Describe how the BOAT and the SOAK are both mindfulness tools one can use in different situations Creating a specific plan for engaging in a pleasurable activity over the next week and planning to practice the SOAK in this situation	Brief SOAK practice SOAK practice with imaginal exposure to pleasant situation
A Healthy Relationship with Positive Emotions	Explain how a relentless pursuit of positive emotions can be problematic and trigger substance use Describe the difference between letting positive emotions come and go versus chasing them or clinging to them Practice mindfulness after thinking about a situation that triggers intense desire for more positive emotions Explain how not allowing oneself to feel positive emotions can also be problematic Practice mindfully reflecting on ways of welcoming positive emotions and recognizing one is deserving of them	Letting Positive Emotions Come and Go (with imaginal exposure to situation triggering intense desire for more positive emotions) Welcoming positive emotions
Exploring New Positive Emotions	Identify other types of positive emotion words besides happy, such as love, interest, calm, amusement, confidence, or meaning Write about a specific activity that might bring about a one of these other types of positive emotions Practice mindfulness after writing and thinking about this specific activity Explain how connecting with a variety of positive emotions is important during recovery Explain how positive emotions and negative emotions can be felt at the same time	Brief SOAK Getting to Know Positive Emotions (includes SOAK)
Connecting with Your Values	Define values and describe their role in the recovery process Practice mindfully reflecting on personal values in key domains of life Explain the connection between mindfulness and making choices guided by our values Practice mindfully reflecting on values after thinking about a situation that triggers craving	Values Practice Brief BOAT with imaginal exposure to situation eliciting craving to use substances.
The Journey Ahead	Mindfully reflect on one’s recovery journey so far and the journey ahead Describe the impact of mindfulness practice on the brain Explain the importance of a regular mindfulness practice routine Describe how the BOAT and the SOAK are both mindfulness tools one can use in different situations Practice mindfulness after listening to the Serenity Prayer	Reflecting on Your Journey Serenity Prayer Exercise

Table 4. Demographic data for participants (n = 5) in Phase 1.

Measure
Age, mean (SD)	52 (10.95)
Gender, N (%)
Women	4 (80%)
Men	1 (20%)
Race, N (%)
African American	2 (40%)
Asian	0 (0%)
Multiracial	0 (0%)
Native American	0 (0%)
Pacific Islander	0 (0%)
White	3 (60%)
Other	0 (0%)
Ethnicity, N (%)
Hispanic/Latino	0 (0%)
Education, N (%)
Less than high school	0 (0%)
High school or GED	2 (40%)
Some college or  Associate degree	2 (40%)
Bachelor’s degree  or higher	1 (20%)
Employment, N (%)
Working	3 (60%)
Not Working	1 (20%)
Unable to Work	1 (20%)

Note. SD: standard deviation.

Table 5. Qualitative feedback from Phase 1 single lesson testing.

Qualitative Queries	Themes
What did you learn?	Steps of the BOAT and BOAT as a recovery tool (5)
	Awareness of feelings and not reacting (3)
	Focusing on one’s breathing (3)
	Slowing down, being present, and focused (2)
	Accepting things as they are (2)
	Staying sober is just as important as getting sober (1)
What was most helpful?	BOAT was catchy and useful (4)
	Program was easy to follow and easy to navigate (4)
	Breaking down mindfulness into detailed steps (2)
	Observing clips of therapy sessions (1)
	Quiz questions helped for memorization (1)
	Brief length of each lesson component helped with engagement (1)
	Open-ended questions gave chance to reflect and relate to material (1)
	Liked how characters were moving and not just still images (1)
	Voices in meditations were soothing (1)
What was least helpful or difficult?/Feedback for improvement	Lesson was somewhat too long (2)
	Hard to concentrate during meditations (1)
	Practical challenges of meditating (1)
	Confused about whether to close eyes or not during meditations (1)
	Volume could be louder (1)
	Too much typing. Prefer to click answers (1)
	Hairstyles of characters out of date (1)

Note. The number in parentheses next to each theme indicates how many participants (out of 5) reported on a given theme in their qualitative feedback.

Table 6. Acceptability ratings for the phase 1 single lesson.

	Mean (SD)
Usability	4.20 (0.48)
I am satisfied with the program.	4.20 (0.44)
The program did a good job at keeping me engaged.	4.60 (0.54)
I thought the visual content of the program was appealing and high quality.	4.20 (0.83)
The material covered in the online program was clear and understandable.	4.75 (0.50)
I would want to continue using the program.	4.20 (1.30)
I think ‘Mindful Journey’ is a good name for the program.	4.00 (0.71)
I think the program would be helpful for me and my recovery.	4.60 (0.55)
The BOAT was a helpful tool for learning mindfulness.	4.6 (0.89)
The program was too long.	1.40 (0.55)
The pace of the program was too slow.	1.80 (1.30)
The pace of the program was too fast.	1.80 (0.45)

Note. Usability was assessed with the SUS, which included 10 items each rated 1= strongly disagree to 5 = strongly agree. The SUS score in the table is the average score per item. All other items were also rated from 1= strongly disagree to 5 = strongly agree.

Table 7. Demographic and clinical data for participants (n = 5) in Phase 2.

Measure
Age, mean (SD)	36 (5.98)
Gender, N (%)
Women	3 (60%)
Men	2 (40%)
Race, N (%)
African American	3 (60%)
Asian	0 (0%)
Multiracial	0 (0%)
Native American	0 (0%)
Pacific Islander	0 (0%)
White	2 (40%)
Other	0 (0%)
Ethnicity, N (%)
Hispanic/Latino	0 (0%)
Education, N (%)
Less than high school	0 (0%)
High school or GED	3 (60%)
Some college or Associate degree	1 (20%)
Bachelor’s degree or higher	1 (20%)
Employment, N (%)
Working	1 (20%)
Not Working	3 (80%)
Unable to Work	0 (0%)
On public assistance	3 (60%)
Referred by criminal justice system	5 (100%)
Type of Substance Use Disorder
Alcohol Use Disorder	2 (40%)
Cocaine Use Disorder	2 (40%)
Opioid Use Disorder	1 (20%)
Hallucinogen Drug Use Disorder	1 (20%)
Marijuana Use Disorder	2 (40%)
Sedative Use Disorder	1 (20%)
Two or more SUD diagnoses	3 (60%)
Primary Substance Used
Alcohol	2 (40%)
Cocaine	1 (20%)
Heroin	1 (20%)
Phencyclidine (PCP)	1 (20%)
Lifetime number of inpatient treatment episodes for SUD	3 (3.93)
Lifetime number of outpatient treatment episodes for SUD	3.4 (2.61)
DSM-5 SUD Symptom Count (out of 11 criteria)	10.6 (0.54)

Note. SD: standard deviation.

Table 8. Acceptability ratings for the phase 2 full program with all 15 lessons.

	Both Wave 1 and 2 (n = 4)	Wave 1 Only (n = 3)	Wave 2 Only (n = 1)
	Mean (SD)	Mean (SD)	Mean (SD)
I thought the app was easy to use.	4.5 (0.57)	4.67 (0.57)	4 (N/A)
The material covered in the program was clear and understandable.	4.25 (0.50)	4.33 (0.57)	4 (N/A)
The program did a good job at keeping me engaged.	4.5 (0.57)	4.67 (0.57)	4 (N/A)
I thought the visual content of the program was appealing and high quality.	4.25 (0.96)	4.33 (1.15)	4 (N/A)
I found the program helpful for me and my recovery.	4.25 (0.50)	4.33 (0.57)	4 (N/A)
I learned valuable skills after participating in the program.	4.25 (0.50)	4.33 (0.57)	4 (N/A)
I am confident in my ability to apply these skills in my daily life.	4.50 (0.57)	4.67 (0.57)	4 (N/A)
The phone coaching calls were helpful	4.00 (0.82)	4.00 (1.00)	4 (N/A)
The phone coaching calls motivated to use the app	4.00 (0.82)	4.00 (1.00)	4 (N/A)
My phone coach was supportive and encouraging	4.25 (0.50)	4.33 (0.57)	4 (N/A)

Note. For wave 2, one participant dropped out of the study (started an inpatient treatment program) and did not complete the post-testing survey. All items were rated from 1= strongly disagree to 5 = strongly agree.

Table 9. Qualitative feedback from full program testing in Phase 2.

Qualitative Queries	Themes and example participant quotes (italicized)
What did you learn?	Awareness and not reacting automatically^c (5)
	Accepting difficult emotions and craving^c (4)
	Noticing thoughts as thoughts^c (4)
	Being kind and compassionate towards oneself^c (3)
	Being curious and appreciating the little things^c (3)
	Importance of regular mindfulness practice^c (3)
	Reflecting on needs underlying desire for substances^c (2)
	Importance of self-care^c (2)
	Values-based action^c (2)
What was most helpful?	BOAT and how it breaks it down into steps is helpful^c (4)
	Easy to use the program^c (4)
	Engaging^c (3)
	Accessibility of the program^c (2)
	Good amount of variety in the content^c (2)
	How it was mostly videos/audio and not too much text^c (2)
	All the videos helped for staying engaged^c (2)
	Use the BOAT to stay afloat is a catchy phrase^a (1)
	SOAK as a new and different way to practice mindfulness^b (1)
	Mindful movement as a new way to practice mindfulness^a (1)
	Repetition/reminders of concepts and skills were helpful^a (1)
What was least helpful or difficult?/Feedback for improvement	Wanted more characters^a (2)
	Some of the videos with Maria were boring or unrelatable^a (1)
	Some videos with narrators are very short and could just be text^a (1)
	First lesson is too long^a (1)
	Want more movement with the animations^b (1)
	Concern about lack of motivation^b (1)
	Wanted more techniques and less BOAT^a (1)
	Content was repetitive towards the end^a (1)

Note. *Indicates that the theme was derived from data in wave 1 only, not wave 2. ^bIndicates that the theme was derived from data in wave 2 only, not wave 1. ^cIndicates that the theme was derived from both wave 1 and 2 data. The number in parentheses next to each theme indicates how many participants (out of 5) reported on a given theme in their qualitative feedback.

Bowen S, Chawla N, Grow J, et al. Mindfulness-based relapse prevention for. In: Addictive behaviors. Guilford Publications; 2021.

 Google Scholar

Hayes SC, Luoma JB, Bond FW, et al. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44(1):1–25. doi:10.1016/j.brat.2005.06.006.

 PubMed Web of Science ®Google Scholar

Bricker JB, Watson NL, Mull KE, et al. Efficacy of smartphone applications for smoking cessation: a randomized clinical trial. JAMA Intern Med. 2020;180(11):1472–1480. doi:10.1001/jamainternmed.2020.4055.

 PubMed Web of Science ®Google Scholar

Garland EL, Baker AK, Riquino MR, et al. Mindfulness-oriented recovery enhancement: a review of its theoretical underpinnings, clinical application, and biobehavioral mechanisms. In: Handbook of mindfulness-based programmes. New York (NY): Routledge; 2019. p. 327–340.

 Google Scholar

Roos CR, Harp NR, Vafaie N, et al. Randomized trial of mindfulness-and reappraisal-based regulation of craving training among daily cigarette smokers. Psychol Addict Behav. 2023;37(7):829–840. doi:10.1037/adb0000940.

 PubMed Web of Science ®Google Scholar

Linehan MM. DBT skills training manual. 2nd ed. New York, NY: Guilford Press; 2015.

 Google Scholar

Witkiewitz K, Bowen S, Harrop EN, et al. Mindfulness-based treatment to prevent addictive behavior relapse: theoretical models and hypothesized mechanisms of change. Subst Use Misuse. 2014;49(5):513–524. doi:10.3109/10826084.2014.891845.

 PubMed Web of Science ®Google Scholar

Carroll KM, Ball SA, Martino S, et al. Computer-assisted delivery of cognitive-behavioral therapy for addiction: a randomized trial of CBT4CBT. Am J Psychiatry. 2008;165(7):881–888. doi:10.1176/appi.ajp.2008.07111835.

 PubMed Web of Science ®Google Scholar

Carroll KM, Kiluk BD. Cognitive behavioral interventions for alcohol and drug use disorders: through the stage model and back again. Psychol Addict Behav. 2017;31(8):847–861. doi:10.1037/adb0000311.

 PubMed Web of Science ®Google Scholar

Segal ZV, Dimidjian S, Beck A, et al. Outcomes of online mindfulness-based cognitive therapy for patients with residual depressive symptoms: a randomized clinical trial. JAMA Psychiatry. 2020;77(6):563–573. doi:10.1001/jamapsychiatry.2019.4693.

 PubMed Web of Science ®Google Scholar

O’Daffer A, Colt SF, Wasil AR, et al. Efficacy and conflicts of interest in randomized controlled trials evaluating headspace and calm apps: systematic review. JMIR Ment Health. 2022;9(9):e40924. doi:10.2196/40924.

 PubMed Web of Science ®Google Scholar

Data availability statement

Data from this study are available by request from this first author CRR.