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| Web-based Aftercare: The New Choice |
| Columns - On the Web | ||||||||
| Friday, 31 January 2003 | ||||||||
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Imagine a patient with diabetes. Let's imagine that the patient was diagnosed about ten years ago and has been less than compliant with nearly all treatment issues. He doesn't check his glucose levels very often, eats whatever he wants, and often misses his follow-up appointments. As we might expect, he frequently ends up in the hospital with complications. Newly admitted to the hospital with a blood sugar six times the usual level, we fix him up and get him ready for discharge. Instead of sending him home, we decide to send him halfway across the country on a commercial airline, alone, to a rehabilitation facility where he will receive an intensive course of treatment designed to alter his outlook. On the airliner, he receives a small bag of "lunch" that includes cookies. With that plus the frequently delivered soda and juice, he ends up arriving at the facility in dire need of medical attention. I've described a medical illness complicated by psychological factors. The entire story is identical to that seen in charts of patients with substance use disorders, except that the alcoholic replaces the cookies and soda with the easily obtained spirits. And while we wouldn't think of placing a diabetic directly into the commercial airline situation following an acute hospitalization, we do this all the time with alcoholics. A distant rehab is often a useful approach given that patients are removed entirely from their environment, which we know to be a significant contributor to the psychological aspects of their disease. The problem, of course, is that at the end of rehabilitation, the patient often has little choice but to return home. Suddenly, all the connections that have been established dissipate and the patient has only inner strength and the potential of local 12-step meetings to help guide him in the future.The advantages of an online facility Some organizations have attempted to address this by establishing local groups within significant population centers. This at least means that the newcomer will have an additional item in common with the fellow program graduates. All the faces will still be new, however, and the newcomer may have quite a way to travel to reach the available groups. An alternative is a web-based follow-up program using some of the same staff members as were present at the live program. Such a program could ensure that each patient participates in a program with not only staff they know, but other patients they know as well. The advantage of setting up this type of online facility is that it could be used as an initial point of contact for patients unable to travel, or who find attendance at such a facility unaffordable, or whose insurance finds it medically unnecessary. I recently attended a meeting for one company that has built the necessary underpinnings for online group therapy. eGetgoing supplies each participant with a headset and microphone, for now only PC-compatible, then provides a complete schedule of groups with a specific counselor. The participant is able to see and hear the counselor and to hear all the group participants. Each participant therefore remains anonymous. The groups are focused around the 12-step process and allow for the individual to participate independent of location. While the idea isn't a new one, eGetgoing is the first, and as far as I know so far, the only company to have an online treatment program accredited by both the Commission for the Accreditation of Rehabilitation Facilities (CARF) and the Joint Commission (JCAHO) as well. The company has taken the necessary responsibility to ascertain that privacy issues, ethical issues, and state licensure issues are each addressed. While this has unfortunately left them unable to use state-licensed specialists within their online programming, this is an area we can all start to advocate for now that the technology is available to reach groups of patients in a manner unencumbered by location. Differing standards of anonymity Why do we have differing standards of anonymity for online groups than we do in real life? If a patient goes to an AA meeting, he sees each person, hears each person, and knows each participant's first name. If one of those people happens to be a famous baseball player or musical personality, so be it. In that room, each individual has only a first name and an illness to cope with - and their batting average is irrelevant. So why, in an online group, must we have no face and a screen name that typically hides the first name? Why must privacy in an online group be more powerful than privacy in a live group? The potential for harm seems higher online, leading us to protect our credit cards with passwords and encryption-capable web browsers when we're online, while we're happy to hand them to anybody in a live situation. Somehow, walking into an AA meeting in person seems more secure to many than clicking into one online. Is the feeling of security misguided? People not attending the live AA meeting can see you walking into the building. That's not the case online. I believe we have a misplaced fear, but that being said, it is often worth protecting the unknown to a higher standard than the known. Since the vast majority of participants are unfamiliar with online security methods, they can't know whether hackers are tracking their every move and tracing them back to their IP address, ready to submit their findings to one of those weekly grocery store newspapers. What do you think of online groups for addiction treatment? Are they the wave of the future, or are there significant problems that remain unresolved? Stuart Gitlow, MD, MPH, is the author of Substance Use Disorder: A Practical Guide, from Lippincott Williams & Wilkins. He is Vice-Chair of the American Medical Association's eMedicine Advisory Committee. He writes and speaks frequently on both topics.
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