Table 3.

Qualitative Quotes

Subtheme	Quote (Age, Level of Care)
THEME: GAPS IN CURRENT TREATMENT
Substance use not adequately addressed in current treatment	“I go to the groups and stuff but they don’t really talk about substances or anything, so I mean I wouldn’t say it’s something that I get a lot of help with.” (23, inpatient)
	“…there’s lots of other things that are covered, and not everybody struggles with it so, it’s not brought up as often in group or that kind of thing.” (18, residential)
	“I have two therapists that I’ve been seeing, but we discussed [substance use] briefly but that’s not the focus of the treatment. I guess my hope when I came in here is that there would be more options for individual-based like substance abuse treatment.” (25, inpatient)
Lack of integrated treatment	“I would say there isn’t like a huge – I guess there’s not a huge emphasis on [substance use]…I mean obviously we’re here for eating disorders, but, there’s only so many times you can meet with your individual therapists and so much of that is with mood and body image.. so in the groups it’s kind of challenging as well because you talk about it in a more generalized sense…so I would say that that’s kind of something that’s, like a little bit challenging is not being able to talk about [substance use] in direct connection with my feelings and my treatment specifically.” (24, residential)
	“I have to kind of seek help on my own, like, individually…which can be difficult and intimidating, so sometimes I just kind of sit with it… it’s been kind of strange breaking it down, figuring out whether or not, hallucinations are from drug use or mental health issues –it’s kind of, it’s been a process, figuring it out alone.” (18, residential)
THEME: IMPORTANT TOPICS TO ADDRESS
Sociocultural issues	“I feel like, like peer pressure almost, has a lot to do with it. Um, just a lot of stresses that females like, I feel go through that men don’t.” (23, inpatient)
	“Cause a lot of people drink in college. And just like the stereotype around it. I’m young so it’s expected that I’m just going to drink and have a good time, but, when you’re not always in the best mental state, it’s not the best thing to do.” (19, residential)
Age-related reasons for use	“I haven’t even turned 21 yet and so everybody my age drinks. Even my friends that don’t - like some of my friends do struggle with substance abuse, both alcohol and not alcohol - and being around them is really difficult obviously, but then even my friends that don’t have any abuse of substances, it’s still difficult to be around because they still do drink and it is such like a social and cultural thing.” (20, residential)
	“they kept on bringing up the word ‘abstinence’ and it really freaked me out because I’m 24, I want to be able to go out and have a beer with my friends” (24, inpatient)
Gender-related issues	“Specifically for women I think that like, I’m not enough. I have too much to take care of all the time. I have so many roles and responsibilities that I don’t feel like I’m allowed to talk about or, ask for help with, then turning to substance use seems pretty natural.” (19, residential)
	“Hormone fluctuations, that would be a really big one – cause I do notice that I tend to drink more glasses of red wine right before my period.” (25, inpatient)
	“I also think that substance use in women is pathologized in ways it’s not in men…it’s just like men have traditionally been allowed to go after work and let off some steam with the boys and drink and that’s not a problem necessarily unless something serious, like they can no longer support their family, whereas a woman is oftentimes seen as selfish or deemed as like unfit or as having a problem really quickly. Which I don’t think is to say that that person doesn’t have a problem, but it’s just like it’s looked at with this different lens.” (19, residential)
Connection between substance use and co-occurring disorder(s)	“How it’s related to eating disorders –how they coincide, I guess. ..I think they kind of feed off each other, so yeah, it’s important to – cause I feel like when I’m bad with one, it’s probably, it like makes me bad with the other one as well, so I think I need for both to just stop for it to be better for me.” (25, residential)
	“I was reading an article about how it’s just extra difficult if you have mental illness and addiction or like trauma and addiction, it’s harder to deal with, so I think maybe in some ways yeah I would kind of like to see a connection and see why – and maybe realize like why that led to that.” (24, inpatient)
THEME: TECHNOLOGY SOLUTIONS
Coping skills	“…grounding skills or anything like that – those are really helpful in the apps.” (23, inpatient)
	“one other thought I had –what about, um, the importance of having information or skills, particularly focused on the interaction of substance use and depression or anxiety and how those co-occur and affect each other?” (25, inpatient)
	“I know some apps have like breathing techniques or like grounding techniques – so maybe like incorporating that would be useful, like if somebody was having really high urges and couldn’t ground themselves, like to use, having something that would help you go through that process of grounding, may be really helpful.” (20, residential)
Tracking substance use and mental health symptoms	“Maybe have something in terms of like a way to track or follow goals…for instance if you want to start by cutting back and, you know, set a goal in tracking things and maybe tracking other aspects of health to see how they maybe, possibly correlated with substance abuse.” (25, inpatient)
	“…we have this thing called a diary card –you probably know the concept –and, having an online or I don’t even know tech – pixelated diary card…I don’t think I would feel more inclined to use it than my paper one, but you could have more options, you know, it could be logged in, like there could be a bigger archive and you could draw more generalized conclusions about patterns of behavior if they were all on the same server.” (19, residential)
	“I think maybe a way to track both time of day and how I’m feeling and just like how distressed I am and why I think I need to use [substances]. And see patterns. Cause I’m a pretty logical person –if I could see it all laid out like ‘oh every time I like come home from school or something I need to smoke.’” (24, inpatient)
Support/peer component	“I think this information is pretty easily accessible online, but maybe to have some sort of location services that can help you locate nearby, like AA or SMART Recovery – or different treatment options if you want to, you know, go to somewhere in person. To have something kind of all in one place so that you know, you don’t have to go to like five different websites, and, can just kind of have one-stop-shop kind of-kind of a thing.” (25, inpatient)
	“Maybe having it somehow be able to reach out for support in your area especially, like meetings in your area or treatment programs or a health professional you can contact or something like that, I think would be super helpful.” (24, residential)
	“I think maybe getting some education behind the different types of meetings -- or like a list of meetings that you can maybe look up on an app, would be helpful.” (20, residential)
Reminder of goals	“Maybe some kind of technology that offers alternatives, that you know, assessing, ‘oh I’m doing this, you know, what is it that I really want here?’ Cause say, if I’m going out at night and I think, ‘oh yeah I just want to do all this drinking’ and I need to think like, you know ‘what do I really want?’ I want to be able to socially connect with people and make sure that I have a lot of fun and I have to think back on all the other times I’ve tried doing this and it’s like, ‘oh, you know every time you do this you make yourself miserable, it turns out horribly.’” (22, residential)
	“I think, especially with people who have substance abuse, you can tend to dip in and out of responsibilities, so I think having a reminder or a notification pop up would be probably crucial.” (20, residential)
THEME: TECHNOLOGY PREFERENCES
Mobile phone accessible	“I had an app where it’s kind of like everything was in one place, I would – I would definitely use it.” (19, residential)
	“…not necessarily an app – but more like, like mobile-friendly would probably be helpful…I’m not necessarily in front of my computer all the time but I always have my phone.” (22, residential)
Engagement with technology	“I think it’d actually be very helpful because sometimes if, you know, in certain situations you can’t make it to a group, or you can’t make it to therapy, or doctor’s appointment, you’ll have something you use every day, constantly.” (23, inpatient)
	“I don’t envision it as something that I open up the app and then sit there for an hour on it at a time, I would’ve envision it as more of something that, you know, you can open up and use for a couple minutes throughout the day, as you want, maybe more than a couple minutes, but, yeah something that’s that easy to access on my phone.” (25, inpatient)
Visual appearance	“I actually enjoy reading. So, I don’t mind either one. I don’t want to sit there for hours watching a video that I could have read in like 2 minutes, you know? So I personally would prefer more text.” (23, inpatient)
	“I kind of like when there’s a video and then it’s like a recap in the text.” (25, inpatient)
	“I personally am really visual learner and it is much more helpful for me to hear things, but I’m also dyslexic so it’s hard for me to read. But I think probably having a balance of both would be important. Especially for distress tolerance skills, like if somebody is having urges and that’s what they’re using it for, I think it would probably be important for it to be maybe mainly visual cause I know a lot of people have a hard time reading stuff when they’re not completely grounded.” (20, residential)
	“I think it’s important that it is up-to-date looking.” (24, inpatient)
Interactivity	“I think the interaction like would be fairly important because, I mean it’s hard, it’s like speaking to someone, like having feedback and input definitely is helpful – so something that could emulate that interaction a little bit.” (18, residential)
	“if you could customize– like our distress tolerance, our skill cards are like a whole thing, but if you could narrow it down to these help me in this situation, like put that in a folder or something that would be helpful, which obviously you need to be able to customize.” (19, residential)