Theoretical and empirical references were adopted based on an extensive literature review on stigma. Four axes were selected to guide the protocol development process and the definition of the active components, specifically in the context of SUDs and stigmatization process. The axes are sets of strategies established in the literature of stigma and which have already demonstrated prior evidence of effectiveness: 1) Key Ingredients of Anti-Stigma Programs for Health Care Providers (Knaak et al., 2014); 2) Strategies to Change Public Stigma (Corrigan, Schomerus, Shuman, et al., 2017); 3) Primer: Reducing stigma among drug users - Guide for professionals and managers (Ronzani et al., 2014); 4) Acceptance and Commitment Therapy & Training (ACT) (Hayes et al., 2004; Varra et al., 2008) (Figure 1).

To contemplate and reach the active components (Phase 1), we proposed activities structured in a protocol and applied to pilot groups. We chose to report the intervention using the Template for Intervention Description and Replication (TIDieR), to ensure that the relevant data to characterize the intervention were adequately described with potential to be replicated (Hoffmann et al., 2014). The intervention mediating researchers took courses with Brazilian therapists specialized in the ACT. For contextual adaptation concerning language, understanding, and feasibility, pilot groups were made up predominantly of psychologists and students, accompanied by local researchers’ presence for adjustments.

We also carried out a first step of the content validation (Polit, 2015), through the consecrated method of qualitative evaluation carried out by expert judges (Souza et al., 2017). Three ACT experts with experience in the clinical, supervisory, research, and training context were invited as independent judges (Polit, 2015). The evaluation process was carried out online using an electronic form developed in the Qualtrics software. In this form, general information about the study, the context that justifies its realization, the guiding axes, the active components, and other resources used in Phases 1 and 2 were entirely presented. Regarding the evaluation, general and specific instructions were provided to detail the tasks to be performed. For each of the activities/exercises described, the judges were asked to assess whether and which active components were covered, how accurate they were, and how appropriate they were to healthcare professionals’ target audience. Blank spaces for suggestions and comments were also made available.

Figure 2 shows the ten active components proposed, which will be defined in sequence together with the desired objectives in the context of the stigma of health service professionals and related to SUDs.

Committed Action (1): is the behavior consistent with the individual’s values. Grounded on the understanding that it is important to regulate behavior based on these values, the committed action is the path to be taken. Therefore, it shows behavioral patterns that allow living the responsibility for actions daily, through objective and concrete goals in the short, medium, and long term. In this process, consistency between behavioral patterns and values must be assessed on an ongoing basis. Professionals who have the value of providing adequate care need to persist in acting committed to it. Working on this process can operate as a facilitating mechanism for the professional to remain, review or start to take an action committed to the value, even though she or he may encounter unpleasant public and hidden events in their professional contact with people with SUDs. Even though difficult thoughts and feelings appear in this contact, the behaviors when coherent with the values and not with these unpleasant events, tend to achieve a quality care (Hayes et al., 2016; Westrup & Wright, 2017).

Acceptance (2): is to receive situations as they arise and with the thoughts and emotions they produce. It is an active disposition to perceive and allow psychological responses without trying to suppress or avoid them. Acceptance is the voluntary adoption of an intentional, receptive, flexible, and non-judgmental opening attitude in the experience of each moment. Part of the process includes understanding that it is more viable to consider the emotions and thoughts labeled “negative” as “natural”. However, it is an unconventional approach, insofar as our culture and some aspects of mental health action suggest that people can control thoughts and emotions, although most of the time, the evidence does not demonstrate this practical ability. In contact with people with SUDs, various emotions often arise, often being judged as negative and subject to suppression attempts. Anxiety, euphoria, anger, frustration, and pity come to the fore, guiding the care offered by professionals, sometimes discriminatory, authoritarian, condescending, and/or superficial. Working on acceptance with professionals can favor the gradual abandonment of unnecessary struggle to control these emotions and thoughts, aggravating even more emotional and cognitive discomfort (Hayes et al., 2016; Masuda et al., 2012).

Contact Present Moment (3): is to be as fully aware as possible of the events that are happening at the moment, realizing the circumstances to enable more effective behaviors. It is to identify the experience of being here and now, acknowledging that the behavior occurs only in the present moment, not in the past or the future. For health professionals, getting in touch with the present moment can help them to connect with the experience of being present for someone who is in the service searching for welcoming and care. It can promote greater resilience in difficult situations and crises with people with SUDs, in which difficult thoughts and emotions appear, but can be perceived and observed without compromising the flow of committed actions. In addition to these benefits, working with the present moment can reduce anxiety, tension, and fatigue symptoms, and enhance interpersonal relationships (Hayes et al., 2016).

Contact, Awareness, and Empathy (4): contact with another person (face to face, video, report) can challenge and contest previous judgments, assumptions, and generalizations disseminated by other people or by our own experiences. Specifically in the context of people with SUDs, when this contact is positive and sensitizing, it can reduce the desire for social distance and facilitate a genuine approach. Especially for health professionals who are faced with situations of intense vulnerability and severe consequences of use, working on contact, awareness, and empathy are essential parts of the assistance. It creates greater opportunity to openly know the stories of the people who are there, sharing many of the most challenging moments and emotions of their lives, such as dependence, pain, guilt, misery, hunger, abuse, and violence suffered and practiced. It allows professionals to see individuals with difficulties and qualities beyond SUDs and understand the relationship between the barriers they must deal with these people at work and similar barriers in their personal lives (Corrigan, Schomerus, Shuman, et al., 2017); Knaak et al., 2014; Westrup & Wright, 2017).

Defusion (5): is the process of distancing between the experience and the report about it (spoken words or words like thoughts). It is the transformation of the literal function that we establish in our life history based on some events and the language we use to describe them. It is seeking to describe more and evaluate less. In other words, through defusion, there is an attempt to reduce the control of these internal events over behavior, which maximizes contact with the present experience as it presents itself. Several stigmatizing stereotypes are widespread through the undervalued labeling and categorization of people with SUDs, such as dangerous, violent, unreliable, underhanded, criminals, without character. Working the defusion with professionals allows them to recognize that they do have negative thoughts and emotions toward these people, and they often guide their professional practice literally from these internal events. They are invited to understand that context and current experience with the people they assist are often ignored and thoughts and feelings, forcefully merged with previous negative experiences and negative evaluations disseminated in the culture, become the primary source of behavior regulation (Hayes et al., 2004; Hayes et al., 2016; Masuda et al., 2012).

Education (6): has as one of its purposes to replace the myths propagated about health conditions through more precise conceptions. The accumulation of systematic scientific knowledge over decades, added to the current evidence on various health conditions, supports the dissemination of adequate information, which may include symptoms, etiology, risk factors, social determinants, prognosis, and types of treatment. However, some health conditions are strongly stigmatized as SUDs. The dissemination of false information contributes to aggravate stigma, which has not manifested itself differently among health service professionals. Although they have training in other areas, they often lack education and experiences in the area of SUDs. Therefore, working on education is essential so that professionals feel technically more prepared to provide care to people with SUDs, can base their actions on data consistent with reality and on the most significant evidence, and to encourage using more appropriate and less stigmatized language. Besides, knowledge allows them to act as propagators of accurate information to the population, also promoting the use of health services to treat problems arising from SUDs (Corrigan, Schomerus, Shuman, et al., 2017; Ronzani et al., 2014).

Engaged and careful management of the mediator (7): to ensure that the content, messages, and themes are addressed and reach the target audience appropriately, it is important that the mediating professional uses strategies and skills that bring him or her closer to that audience, like engaged and careful management. In the context of SUDs stigma, this management can be characterized by the enthusiasm and involvement of the mediator who uses a person-centered and first-person approach, as opposed to a perspective centered only on the pathology or stigmatized condition. Besides, engaged and careful management can be identified by creating a safe and non-hierarchical space, where feelings and thoughts can arise and be shared, welcomed, understood, accepted, and discussed without harsh judgments. When supported, professionals may be better able to reveal their reactions and negative experiences in contact with people with SUDs and more willing to work on them. Mainly because the mediators themselves, through modeling and shaping resources, will also share their own experiences and difficulties, approve initiatives by professionals to open up similarly, and reinforce the key messages that favor the minimization of stigma (Hayes et al., 2004; Knaak et al., 2014; Westrup & Wright, 2017).

Harm Reduction (8): concerns a set of actions strongly supported by public health and human rights, aiming to reduce the negative consequences of using legal or illegal drugs of people who are unable or unwilling to interrupt this use. The focus then becomes prevention or harm reduction rather than the prevention of drug use. Contrary to myths that are widespread and rooted among many health service professionals, harm reduction complements other strategies that can decrease use, is not incompatible with abstinence (although recognizes that it is difficult to achieve) and seeks to protect people who use drugs from irreparable harm. It emphasizes that there is a possibility of recovery for people who use drugs and that can be more effective if the strategies consider the context, desire, and readiness to reduce the use, pattern, problematic consequences, and the role that this use has in each person’s life. It allows professionals to rethink rigid and stigmatizing conceptions that abstinence is the only form of recovery, that its non-compliance is linked to lack of commitment, how much these repeated frustrations have affected the care provided, and how fundamental for adherence to treatment this care is (Hawk et al., 2017).

Self as context (9): is the process of developing another notion of identity, more fluid, continuous in time, and observant of the experience itself. It occurs by moving away from concepts that end up being part of our lives, are linked to valuative adjectives, and are very rigid. The self as context or the observing self can also be understood as a self-conscious perspective over time, especially in the present moment. Working on this notion with health service professionals who deal directly and indirectly with people with SUDs is important so that when they develop a conscious “me-here-now” experience, they become more flexible in dealing with the different situations that arise and expand their performance repertoire. In this sense, the self as a context starts to present itself to these professionals as a place from which they will observe the experiences more openly, exercising empathy and communication (Hayes et al., 2016).

Values (10): are desired consequences in the lives of people constructed verbally and they establish the context to define what are the essential elements behind the objectives. They differ from the objectives as far as they are not an outstanding achievement, they need to be experienced every moment. In other words, values are the course, and the objectives are the ports. Changing to questions, a person’s values answer to: what do you want your life to be? What do you want your life to represent? How would you like to be remembered? For health professionals working with people with SUDs, elucidating core values is important to determine a point of orientation, through which they can always be guided to assess whether they should persist in their actions or change them toward the chosen direction. Working with values allows professionals to be open to the challenge of accepting difficult emotions and thoughts that may arise about themselves and about people with SUDs, such as disability, frustration, limitation, contempt, sadness, and anger. Clarifying these life directions allows professionals to identify whether their actions are committed to these directions (Hayes et al., 2004; Hayes et al., 2016).

Variations of more extensive versions of the protocol in duration and number of activities were tested in pilot groups, having been reduced according to feasibility concerning the time, performance, involvement, and availability of the participants. Table 1 presents the characteristics of the main elements that compose the preliminary version in a workshop format application, based on the TIDieR guide (Hoffmann et al., 2014).

From the preliminary version of the intervention protocol, the ACT expert judges assessed the coverage, accuracy, and suitability of the intervention to the target audience for each of the 27 activities proposed. All the 10 active components described above were covered by the activities. For added rigor, we specifically considered the data corresponding to the “highly” category for accuracy and suitability, in each of the components. This choice was justified by the intention to rethink the use of activities that were identified as capable of covering the component but did not do so in a highly accurate and suitable way to the target population by consensus among all three judges. Table 2 shows the results of this evaluation.

The results were promising and pointed out that all three judges agreed that the active components were covered through the proposed activities. In terms achieving high accuracy of the activities to the components, there was consensus among the three judges for all components except “Acceptance”, “Engaged and careful management of the mediator” and “Self as a Context” although these components still obtained a high accuracy evaluation for at least one activity by two judges. In terms of achieving an assessment of high suitability of activities to components for the target audience, there was consensus among the three judges for all components except “Committed Action”, “Self as Context”, and “Values”, although these components still obtained a high accuracy evaluation for at least one activity by two judges. These points signal the need to review what is proposed through these activities, and perhaps identify more suitable activities for this target population.