For some people, evidence-based treatments just don’t click. Fortunately, modern technology has provided many new options for treatment.
Decades of research has shown that evidence-based behavioral treatments for addiction disorders are effective—much the same way that pharmacological treatments are—including cognitive behavioral therapy (CBT), contingency management (CM), community reinforcement approach (CRA), and motivational enhancement therapy (MET). However, many people, for various reasons, can’t take advantage of them. According to Dr. Lisa Marsch, the director of the Center for Technology and Behavioral Health at Dartmouth University and developer of one of the few web-based behavioral tools that are actually being used to treat patients, over 90% of illicit drug or alcohol users in the US do not get treatment.
“The reason I got interested in leveraging technology is to promote more widespread access to evidence-based therapies,” Marsch says. Internet and mobile access is high and growing, even within the most underserved and vulnerable populations. Everyone has access to the Internet, it seems, making computer-assisted dissemination of these tried and true behavioral therapies a reality.
Increasing access to behavioral therapies is one key advantage to using technology-based solutions. It’s also cheaper, more systematic, highly personalized, engaging, and importantly, allows clinicians to treat more patients. Figuring out how and when a behavioral treatment works can lead to more effective treatments for more people—and that’s where computer-assisted therapy hopes to have a lasting impact.
Computer-assisted therapies can come in a variety of delivery formats—computer, cellphone, iPad—intervention types—brief interventions, behavioral therapy, relapse prevention/aftercare—and have been used across many substances of abuse, including opioids, cocaine, alcohol, and cannabis.
Some of the tools that are currently being used follow.
In general, telemedicine—telepsychiatry is a subset of telemedicine—essentially replaces the in-person counselor with a virtual version through cellphone, video, or web-based applications. Emergency telepsychiatry services are already offered in hospital emergency departments, jails, community mental health centers, substance abuse treatment facilities, and schools. One advantage to telepsychiatry is that it requires less staff—which can ease the common staff shortage seen in the mental health treatment industry. It helps lower costs and increases access to professional care, thereby increasing emergency care outcomes.
One form of online psychology that has been proven to be efficacious is preventive feedback. A counselor gives a patient a survey to determine if she drinks more than the average person, with the goal of “normalizing” her drinking or other substance use. Lots of surveys like this exist, and while they still can be delivered in person or by snail mail, most are offered via the Internet. One site developed by Dr. John Cunningham,checkyourdrinking.net, helps drinkers evaluate how much they’re drinking and if it’s a problem. Cunningham is the deputy director of the National Institute for Mental Health Research at the Australian National University.
There is much evidence supporting the effectiveness of personalized feedback interventions for hazardous alcohol use, and one of Cunningham’s recent studies backs up this body of work. In a randomized, controlled clinical trial, Cunningham gave 741 hazardous drinkers personalized feedback, and he found that it helped reduce number of drinks in a week but not the highest number of drinks on one occasion.
“There is clear evidence that this type of intervention can still have an impact when the person accesses the intervention over the Internet, without anyone else present,” Cunningham says. “This is important, as most people with hazardous alcohol consumption will never access any type of face-to-face treatment for their alcohol concerns.”
At Yale University, Dr. Kathleen Carroll’s research group developed computer-based training for cognitive behavioral therapy, or CBT4CBT, which uses a multimedia format to deliver cognitive behavioral concepts and coping skills. Across several studies looking at the program’s efficacy since the late 2000s, Carroll has continuously shown that treating patients with cognitive behavioral therapy that is not delivered in the traditional counselor-facing-patient format works. And works well.
In a 2008 study, she showed that in a randomized clinical trial of 77 substance using outpatients, those who were assigned treatment as usual plus the CBT4CBT training showed more urine samples that were negative for any type of drug and “tended to have longer continuous periods of abstinence during treatment.”
In a follow-up trial, of the 82% of the original group who were then interviewed one, three, and six months after the study ended, “those assigned to [treatment as usual] increased their drug use across time while those assigned to CBT4CBT tended to improve slightly.”
Finally, a more definitive randomized controlled trial of 101 cocaine-dependent patients maintained on methadone were assigned either standard methadone maintenance or methadone maintenance with weekly access to CBT4CBT over the course of eight weeks. She found that “participants assigned to the CBT4CBT condition were significantly more likely to attain three or more consecutive weeks of abstinence from cocaine (36% compared with 17%).”
Created by Dartmouth’s Marsch, TES, or Therapeutic Education System, is “an interactive, web-based, self-directed tool composed of 65 modules addressing a broad array of skills and behavior designed to help substance-abusing individuals successfully stop their substance use, gain life skills, and establish new behavioral repertoires that do not involve substance abuse and can be clinically meaningful.” The program’s core modules focus on cognitive behavioral and relapse prevention skills while optional modules address a broad array of skills and behaviors related to employment, family/social relationships, financial management, communication skills, decision-making skills, management of negative moods and depression, time management skills, and recreational activities. TES also includes a contingency management program whereby patients can earn monetary vouchers or prizes in exchange for staying sober.
“We developed it because there are many treatments that work…that don’t actually get used in the real world,” Marsch says. “[TES] is intended to be a self-directed behavioral intervention for SUDs.”
And, it’s been proven to be effective in several clinical trials. In an initial 2008 randomized, controlled trial evaluating its efficacy, 135 volunteers who met DSM-IV criteria for opioid dependence and who were being maintained on buprenorphine were randomly assigned to receive community reinforcement approach (CRA) therapy from a therapist, CRA from TES, or standard treatment. Marsch found that both types of CRA promoted comparable levels of continuous opioid and cocaine abstinence and greater weeks of abstinence than the standard treatment.
In 2014, she conducted the first randomized, controlled trial evaluating the efficacy of the web-based behavioral intervention where it partially substituted for standard counseling. Among opioid-dependent intakes on methadone maintenance treatment who were randomly assigned standard treatment or reduced treatment with TES over a 12-month period, those receiving TES had “significantly greater rates of objectively measured opioid abstinence (48% versus 37%).
“What we find is that it has a big impact on the outcomes in addiction treatment if we add it on to existing,” Marsch says. When they offer it instead of standard treatment as usual, “we often get at least as good as and sometimes better outcomes,” as is demonstrated by the 2014 trial.
She credits the high level of interaction as a major selling point. “If you’re sitting in a group session, it’s often a passive experience,” she says. Some of the key advantages of using TES over traditional behavioral counseling include that it’s more engaging because it’s one-on-one, patients have to demonstrate a mastery of one skill-set before moving onto the next module; they can move at their own pace; they can focus on topics relevant to their individualized experiences and they get to go over topics that might not be covered in traditional counseling. People might feel safer, or more relaxed, using an application like this. At the end of the day, this might actually be a good thing when it comes to learning a new set of coping skills—difficult at best for many recovering addicts and alcoholics.
Web-based interventions have the chance to not only improve evidence-based behavioral care by making it cheaper and more accessible, but they also free up clinicians who are overworked or clinics that are short-staffed. There are over 19 current projects for substance use disorders being developed at the Dartmouth center. Read more “the fix”…