Welcome to the new column “Industry Trends” for the Counselor Connection newsletter. Each month I will report and discuss on innovations and continuing issues that impact addiction and behavioral health treatment programs in our attempts to improve treatment outcomes and increase the number of recovering individuals. My first column addresses how the Internet might be used to engage more clients in their own treatment and improve low retention rates.
Chronic medical conditions require more than a single treatment. They often require additional treatment and continuing care. Chronic diseases have long-lasting effects and are controlled, but not cured. In many cases this means lifelong monitoring of conditions, aftercare, and lifelong recovery. Conditions such as heart disease, diabetes, bipolar disorder, hypertension, and obesity are all examples of chronic diseases. Chronic disease, according to the Centers for Disease Control (CDC), accounts for 70 percent of all of the deaths in the United States (2013). The opposite of “chronic” is “acute,” which refers to medical conditions that are immediate or severe. It also means that treatment is usually limited to the current need for intervention and often only one treatment.
Addiction is a chronic disease, not an acute disease. Although this statement is obvious it has not always resulted in a lifelong response for continuing care. The exception to this of course is Alcoholics Anonymous (AA). For many alcoholics their sobriety is contingent on their continuing attendance at AA meetings. In other words, lifelong sobriety is the outcome of continuing care of a chronic disease. In fact, one of the definitions of a chronic disease is that it is progressive, a definition that has lasted at least since 1935. Additionally, alcoholics have been encouraged to understand the need for self-management of their disease with the help of others, such as professionals, sponsors or peers.
According to the Center for Managing Chronic Disease (CMCD), this combined approach of individuals relying on themselves and others to control their disease involves (n.d.):
- Self-management by the person
- Family involvement
- Clinical expertise and systems
- Work/school support
- Community awareness and action
- Environmental measures
However, this has not always been the case in treating addiction in the United States. During the past sixty years many organizations, hospitals, and treatment programs have emerged to help addicts recover. Initially, inpatient treatment appeared to be the preferred model of choice, especially a twenty-eight-day residential program. Follow-up was often limited to referral to Twelve Step programs. Although residential treatment was a huge step in the treatment field, it had more of an acute approach rather than a chronic approach. Many people, often including the addict, believed that once she or he completed the residential program that they were “cured.” Continuing care and outpatient care was a long way in the future. Unfortunately, even with the advent of health insurance for addiction treatment, the acute approach was often applied. Addicts were limited to one-time treatment or to a total number of treatment days for their entire lives. This was not a chronic approach to a chronic disease.
However, things began to change in the late 1970s and 1980s as more and more treatment professionals began to realize the importance of aftercare in order to maintain sobriety. This was brought about by a better understanding of the role of relapse in the treatment of the disease and that treatment was not a onetime intervention. Simply, relapse needed to be acknowledged and indicated requiring continuing care.
At this point the emergence of continuing care began to occur; we began to realize that addicts could not and should not do this alone. Treatment professionals needed to stay in contact with their clients. Family members needed to become involved to not only support the sobriety of their family member, but also to address many of their own issues.
The importance of staying in contact with a recovering alcoholic or addict cannot be overestimated. Treatment programs are truly beginning to realize this and going beyond traditional methods of outpatient counseling and follow-up. Foremost among these innovative techniques is the use of online extended care. Online extended care represents innovative methods for staying in touch with clients in order to provide additional care not only for addiction and relapse, but also for associated co-occurring disorders common to addiction. It just makes sense—as stated earlier, the disease of addiction is chronic and treatment needs to be correlated with the type of disease.
Do continuing client contact, monitoring progress, and outpatient programs reduce relapse? Is there a positive connection between maintaining contact with clients after formal treatment and the maintenance of sobriety? Does contact need to be face-to-face to be effective or can other methods of communication prove valuable?
Overall, recent studies indicate that extended contact with alcohol- and drug-abusing clients increases the probability of positive outcomes. This extended contact has ranged from telephone calls to the use of e-mails and the Internet. For example, John McKay, the director of the Center on the Continuum of Care in the Addictions at the University of Pennsylvania, has conducted several studies along with others utilizing telephone-based continuing care for alcohol dependence and cocaine dependence (McKay et al., 2010; McKay, 2005; Mensinger, Lynch, Tenhave, & McKay, 2007). It was found that telephone-based continuing care as an adjunct to outpatient care produced fewer days of alcohol use than outpatient care only. Other studies have indicated that maintaining contact with clients over extended periods of time has better outcomes than traditional only treatment. Specifically, Dr. McKay’s research findings suggest the following:
- Continuing care interventions of a year or longer are more likely to show significant positive effects
- Continuing care treatments that are less burdensome to patients appear to promote higher rates of sustained engagement
- More structured and intensive continuing care may be more effective for patients with severe substance dependence and associated problems and for those who fail to achieve reasonable progress while in the initial phase of treatment
- Use of medications as part of continuing care is increasing (McKay, 2006).
All of these studies and methods of engaging clients raises an interesting question: To what extent can the Internet be used for online extended care? Currently there are several treatment programs are developing and administering such approaches, such as Caron Treatment Centers, Origins Recovery Centers, and the Valley Hope Association. The common key to their endeavors appears to be not only to keep clients engaged, but also for clients to contribute to their own treatment outcomes. In the past fifteen years, this has become common practice in other health maintenance programs. For example, health insurance companies and physicians are encouraging more and more people to become proactive in their own health care. In order to do this many health care providers are frequently and routinely contacting their patients to encourage self-care combined with suggested health practices. Additionally, these providers are developing more and more preventive medicine techniques. Such an approach is beginning to appear in addiction treatment.
In the near future we may see more and more treatment programs begin to utilize the Internet to more effectively engage clients in their own treatment outcomes as well as continue to provide treatment services and continual care. The Internet is currently being used or might be used in the following ways to further this trend, assuming of course that clients give permission to be contacted or provide their e-mail addresses to each other.
The following are several ways that the Internet can benefit aftercare:
Interactive Access to Counselors
This form of engagement would allow clients to contact an on-duty counselor with questions or concerns. It might also provide a mechanism for an interactive conversation between clients and counselors. Although counselors are not sponsors, being able to contact someone in times of crisis might be invaluable.
The importance of sponsors for sobriety cannot be underestimated, and adding an electronic component to this facet of lifelong recovery can only help.
The debate to seek treatment is often decided upon by the support and intervention of others. Treatment programs are in the position to use the Internet to provide needed motivation to enter their programs.
The Internet allows users to remain anonymous, which can be a helpful way to overcome stigma and other barriers to recovery.
Recovery Chat Rooms
The best advertisement for a treatment program is a client’s success story that can be shared through online message boards and chat rooms.
Treatment programs can develop educational and counseling videos that can be viewed anytime online.
This can include available counselors, educational series, and referral resources with or without the family and the addict entering treatment. Especially important would be the development of information and help that would be age-appropriate for children of addicted parents.
Behavioral Health Referral Source
The majority of addicts manifest at least three to five behavioral disorders in addition to their addiction. It is important to maintain a list of referral services for these associated problems and doing so online would make it easy to update and revise as new information arises.
Just because someone says, “Help is everywhere” doesn’t mean people know where to find it. At a minimum the internet can provide places, days, and times for local Twelve Step programs as well as formal treatment programs.
It is hoped that through the use of the Internet more individuals, families, and friends will become engaged in the treatment process. The Internet is a viable method to bring treatment options to the public and has great potential to expand the news that treatment works. It has the potential to improve low retention rates in treatment and outpatient care and it is there for the addict when family and friends turn away. The internet has served to bring the world closer together and it can serve to bring people closer to treatment and to maintain foster and maintain sobriety.
The Center for Managing Chronic Disease. (n.d.) What is chronic disease? Retrieved from http://cmcd.sph.umich.edu/what-is-chronic-disease.html
Centers for Disease Control and Prevention. (2013). Deaths and mortality. Retrieved from http://www.cdc.gov/nchs/fastats/deaths.htm
McKay, J. R. (2005). Is there a case for extended interventions for alcohol and drug use disorders? Addiction, 100(11), 1594–610.
McKay, J. R. (2006). Continuing care in the treatment of addictive disorders. Current Psychiatry Report, 8(5), 355–62.
McKay, J. R., Van Horn, D. H., Oslin, D. W., Lynch, K. G., Ivey, M., Ward, K., . . . Coviello, D. M. (2010). A randomized trial of extended telephone-based continuing care for alcohol dependence: With treatment substance use outcomes. Journal of Consulting and Clinical Psychology, 78(6), 912–23.
Mensinger, J. L., Lynch, K. G., TenHave, T. R., & McKay, J. R. (2007). Mediators of telephone-based continuing care for alcohol and cocaine dependence. Journal of Consulting and Clinical Psychology, 75(5), 775–84.