Addiction remains an enormous problem in the United States despite significant advances in the sophistication of our treatment system. The SAMHSA 2002 National Survey on Drug Use and Health reported that 18.6 million Americans needed treatment for a serious alcohol problem, and 7.7 million people needed treatment for a diagnosable drug problem. (1) Fewer than 3 million obtained treatment in 2002. More than 350,000 people wanted to obtain chemical dependency treatment services in 2002 but were unable to do so. Concerns about cost and stigma, as well as unawareness of where to find treatment resources, were some of the reasons cited in this survey as barriers to treatment access. These barriers can be at least partially addressed by services provided over the Internet.
The Internet presents some unique opportunities for appropriate addiction treatment. Services provided over the Internet can be conceptualized as an additional outpatient level of care in which issues of cost, geography/ location, and stigma are minimized as barriers to treatment. After the initial outlay for computer equipment and connection to the Internet, cost to the individual provider for ongoing services is lower if he/she no longer needs office space outside home. The potential cost to agencies is not clear at this time, particularly if expensive audiovisual equipment is being used and maintained, but there is a real potential to reduce patient expenses.
Geography and mobility impairments are not issues either; as long as both the counselor and the client can access a personal computer, counseling can occur no matter where either is located. Also, many articles about online therapy discuss the disinhibiting effect of computer-mediated communication, making stigma much less of an issue. (2)
Online treatment uses three distinct modes: e-mail interaction, real-time chat-room therapy, and Internet delivered audiovisual treatment. E-mail therapy seems to be the most frequently used modality. As technology improves, we can expect more live video treatment over the Internet.
Who Might Benefit From Online Treatment?
Online addiction treatment will be accessed most easily by those who are computer literate. People who can benefit from online treatment include those who are geographically isolated, lack local treatment resources, or refuse to access local addiction treatment resources (for whatever reason). For example, the issues and problems faced by adult children of alcoholics seem ideally suited for treatment on line because of the anonymity afforded by communication conducted over the computer. (3)
To benefit from e-mail or chat services, the client has to be a relatively competent typist (or use voice-to-type software). The client also has to have sufficient written communication skills, as well as an understanding of the abbreviations (e.g., "BRB" means "be right back" and "LOL" means "laughing out loud") and emoticons used in online interactions (e.g., when you tilt your head to the left, a colon, lowercase letter o, and closing parenthesis [:o)] is seen as a smiling face--a good reference site is www.computeruser.com/resources/ dictionary/emoticons.html). The therapist needs to be experienced in face-to-face counseling prior to online work to be able to "read between the lines" to perceive what the client is saying and not saying. Of course, the counselor needs the same skill set as the client as far as adeptness in writing and communicating online.
Who Might Be Inappropriate for Online Treatment?
Clients who are medically compromised and those in need of detoxification services obviously need to be treated in person (and often need an inpatient level of care). Clients who require monitoring also will need to see someone face to face. Clients who are quite resistant to the treatment process might be inappropriate for active treatment online. Clients who are severely mentally disabled in addition to their drug and/or alcohol problems might not be ideal candidates for online addiction treatment, depending upon their level of stability.
Different Levels of Online Engagement
Pretreatment information. Internet users can obtain up-to-date, accurate information about drug and alcohol problems, without revealing their identities and in the privacy of their own homes. The ease with which this information can be obtained is quite a boon for the person willing to look at his/her substance abuse privately. An example of an excellent information site is About.com, which has an entire section devoted to solid information about alcoholism and substance abuse (http://alcoholism.about.com). The number of people who lack basic information or have misinformation about drugs and alcohol is surprising. Of course, the Internet is known to have a lot of misinformation, so when patients come to treatment--online or otherwise--they might bring misconceptions fueled by information on the Web.
Secondary prevention. Some people who have had a substance abuse problem can use the information they find on the Web to make needed changes. They can also talk to an online counselor about their concerns regarding their drug and/or alcohol use and obtain feedback, as well as any recommendations for treatment. Counselors working in either e-mail or chat rooms can use Motivational Interviewing Techniques as described by Miller and Rollnick. (4) These techniques provide clients with an opportunity to explore their substance use and its consequences in a manner that is relatively free from shame.
Assessment and referral. An increasing number of people are seeking psychotherapy online. The presenting problem is most often not substance abuse or dependence, but the online therapist can uncover these issues with certain clients over time. Clients can be directed to Web sites that offer alcohol/drug self-assessment tools, such as www.alcoholscreening.org, which uses a test based upon the Alcohol Use Disorders Identification Test (AUDIT) and provides feedback. This site also has a database of treatment centers searchable by city and state or zip code.
The online therapist can ask text based questions to determine whether a client's drinking is excessive or ask about his/her drug use and what consequences are related to it. Elizabeth Zelvin includes a chat transcript in her article "Treating addictions in cyberspace" that shows how the therapist can help clients explore their drinking issues. (5) As stated earlier, treatment over the Internet can't involve either detoxification or substance monitoring, but referrals for both can be made easily.
Active treatment. For some clients, treatment over the Internet might be what they need to achieve lasting sobriety. A number of private practitioners currently provide online addiction treatment services using either e-mail or chat as the treatment medium. This number can be expected to grow as demand grows for Internet counseling.
The online chemical dependency treatment program eGetgoing (www. egetgoing.com) is accredited by both CARF and JCAHO. It uses audio and video over the Internet to provide group treatment for U.S. clients. Additionally, it has links to inpatient treatment agencies across the country to which clients needing that level of care can be referred.
Relapse prevention. An online provider using either e-mail or chat can easily reinforce the tools for recovery obtained in treatment. Written text provides a permanent copy of concepts and information needed by the addicted person to prevent relapse. This text can be viewed as a personalized handout focusing on the issues and concepts that apply to the particular client. Written text, while at times stark, can be honest and direct, which can be quite helpful for the alcoholic/addict in both active treatment and relapse prevention.
Also, self-help groups like Alcoholics Anonymous have an online presence 24/7 and function quite similarly to face-to-face meetings.
Advanced recovery issues. Online chat seems to be ideal for advanced recovery work. (3) Even though alcoholics/ addicts learn to be more open as a part of their recovery, there are often unresolved family-of-origin issues that are hidden until the client achieves ongoing sobriety. These issues might be best resolved through longer-term, low-cost therapy with an experienced professional online. Irrational ideas clients learned growing up in addicted or dysfunctional families can be challenged starkly in typed text--a powerful tool.
Concerns About Online Treatment There are several legitimate concerns about the provision of services over the Internet:
* Confidentiality and other ethical concerns
* Lack of research
* Client safety issues
* Lack of nonverbal cues
* Concern about the therapist's ability to develop a therapeutic relationship without being able to see the client
* Lack of training for online work
* Lack of supervision
* Concern about patient verification of the therapist's credentials
* Concern that the client is not who he/she claims to be
These and other concerns are being addressed through organizations such as the International Society for Mental Health Online (www.ismho.org). ISMHO has suggested principles for online work, offers the Online Clinical Case Study Group, maintains both public and members-only e-mail discussion groups, and offers monetary awards for student research on online mental health. In addition, colleges and universities are considering development of courses regarding online therapy. Research is being conducted on the many issues related to online therapy or counseling; Professor Azy Barak has developed a list of many studies regarding the use of the Internet in mental health treatment (http: //ismho.org/issues/cswf.htm). Barak also reports that a number of case studies have been presented at conferences reporting on the effectiveness of online treatment. A recent article in the Journal of Clinical Psychology reviews recent research, as well. (2)
Summary
The Internet can be used as a powerful source of healing for at least some who suffer from addiction. There are definitely valid concerns that must be addressed. In the meantime, however, we should not ignore the potential benefits online addiction treatment can offer some patients.
References
(1.) U.S. Substance Abuse and Mental Health Services Administration. 2002 National Survey on Drug Use and Health. Available at: www.samhsa.gov/oas/nhsda/2k2nsduh/ Overview/2k2Overview.htm#toc.
(2.) Rochlen AB, Zack JS, Speyer C. Online therapy: Review of relevant definitions, debates, and current empirical support. J Clin Psychol 20114; 1-15.
(3.) Stofle GS. Choosing an Online Therapist: A Step-by-Step Guide to Finding Professional Help on the Web. Harrisburg, Pa.: White Hat Communications, 2001.
(4.) Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: The Guilford Press, 1991.
(5.) Zelvin E. Treating addictions in cyberspace. Journal of Social Work Practice in the Addictions 2003;3:105-12.
Gary S. Stofle, LISW, CCDCIIIE, is Program Manager for the Recovery Team at Columbus Area, Inc., a community mental health center. He is also the author of Choosing an Online Therapist: A Step-by-Step Guide to Finding Professional Help on the Web (White Hat Communications, 2001). For further information, email stofle@aol.com. For reprints in quantities of 100 or more, call (866) 377-6454.
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