This study aimed to update GMT (a cognitive remediation program for brain injury) to tailor it to the key cognitive deficits and treatment context of MUD, and to maximise users’ engagement with its contents and delivery. We utilised an evidence- and person-based approach, collaborating with clinical stakeholders, neuropsychology experts, designers in healthcare, and people with MUD to develop the four-week GMT⁺ program. Results from our four-phased approach revealed that GMT⁺ can be feasibly and ecologically applied in addiction treatment settings and has shown initial evidence of consumer engagement. These findings illustrate the benefits of the evidence- and person-based approach and provide confidence to move into the evaluation phase with a protocol that minimises potential risks, for example, barriers to implementation, or a lack of consumer engagement.

The initial focus on four cognitive processes (i.e., attention, impulse control, goal setting, decision-making) was endorsed by experts and consumers. We selected these four components based on emerging research revealing impairments in these specific executive functions, as well as their relationship with key addiction treatment outcomes^{8, 9, 11, 32}. One of the primary goals of addiction treatment is to help individuals to develop self-control strategies to manage cravings and emotionally salient situations, skills that inherently rely on these prioritised cognitive processes.

The updated GMT⁺ program trains these components through enhancing meta-cognition (‘thinking about thinking’), fostering skill practice in everyday situations, and reinforcing a simplified cycle to employ in any given moment [Be Aware (of inattention) →Pause (to prevent acting on autopilot)→Envision Goals (to prevent goal distractions)→ Decide (to consider longer-term outcomes)]. Consumers build on these skills as they progress through the program, providing an opportunity for skill acquisition and mastery through self-initiated practice and active reflection of cognitive processes and situational consequences. Unlike some existing interventions that train specific cognitive processes through repetitive task practice, e.g., computerised working memory or inhibitory control training^{33, 34}, GMT⁺ teaches consumers to group multiple skills together and apply them in ecologically relevant situations (for example, noticing drug-cravings, taking a depth breath, and bringing attention back towards short-term or long-term goals).

Neuropsychology experts highlighted the need to help participants to habitualise strategies to promote their effectiveness in critical real-world situations. We addressed this suggestion with the inclusion of the GMT⁺ mindfulness bracelet to serve as a specific visual cue to promote a stimulus-response association³⁵, for example, noticing the bracelet and applying ‘pause’. As this bracelet is always accessible to consumers, it may enhance the chance of successful habit formation³⁶. We also incorporated activities in the take-home journal to encourage consistency of practice and skill mastery^{36, 37}. For example, a checkbox to note how many times consumers used their bracelet each day, activities to reflect on how different GMT⁺ skills were employed that day, and creative activities that were superficially enjoyable (e.g., dot-to-dot, mindful drawing) but required the use of GMT⁺ skills to complete.

Consumers provided input on their personal goals during recovery and emphasised the need to develop relatable characters and scenarios. We used this feedback to create a range of character profiles and situations where a character may have benefited from applying GMT⁺ strategies. We provided consumers with the opportunity to personalise their group treatment by selecting their preferred GMT⁺ ambassador character to enhance meaning and motivation to engage in group discussions³⁸. Consumers indicated a preference for simplified creative journal activities with a clear purpose. We responded to this feedback by creating enjoyable activities requiring brief instructions and including clear links to everyday challenges for consumers to reflect on. We reason that these activities will be well suited to promote strategy habituation due to anticipated adherence to regular journal completion (skills practice). Consumers also preferenced the word ‘Pause’ over ‘Stop’, which was considered punitive. Amending the language and visual representation of key strategies is critical to fostering program engagement and acceptability of the strategies. An unintended benefit might also be to promote self-compassion during a fragile treatment period where self-criticism may be more likely to lead to earlier program drop-outs and re-engagement in addictive behaviours^{39, 40}.

The final showcase to clinicians identified important unintended effects, for example, GMT⁺ uses multitasking (even if all activities are not completed) and task errors as ways to illustrate challenges for executive function; however, these aspects may trigger procrastination and perceived hopelessness. We addressed this feedback by enhancing the context around these activities (i.e., explaining the aim as ‘making progress towards goals’). Facilitators are also prompted to share personal accounts of everyday ‘slips’ to group members and to normalise mistakes on the tasks as part of the learning process, with the goal of reducing feelings of shame or a tendency to overidentify with making errors.