Will My Insurance Pay for Rehab?
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Online Addiction Therapy Can Go Viral
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We are about to witness an almost unimaginable jump in the rates of substance use and other addiction diagnoses and treatment. Released last month, the DSM-5 acknowledges, for the first time, the reality of a non-substance-related addiction: gambling. It is almost certain that this broadening view of addiction will (sooner rather than later) include addiction to sex, love, shopping and other activities in which people can engage compulsively and destructively. Meanwhile, addiction to food is one of the hottest topics in American public health news.
But even limiting ourselves to drugs and alcohol, addiction diagnoses jumped by 70 percent in the first decade of the century. As a result of the passage of the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA), it is projected that nearly 100 million more Americans will receive expanded addiction treatment coverage, or coverage for the first time, many through government programs, especially Medicaid. (Such high estimates won’t necessarily translate into reality, given the cost-cutting instincts of private insurers.)
How will we deal with this explosion? My own answer is, addressing addiction online. To that end, I have worked with Internet experts to create an online version of the Life Process Program (LPP), which I created in 1991 with Archie Brodsky and Mary Arnold. After a year in development we recently activated the program.
The Life Process Program, which has been CARF-accredited as a residential program, is cognitive-behavioral therapy (CBT) for alcohol, drug and gambling addictions; it also focuses on an individual’s values and goals. The program combines my books (7 Tools to Beat Addiction, The Truth About Addiction and Recovery), exercises based on the readings and clients’ experiences, and an ongoing self-narrative in which clients explore their past decisions and alternative scenarios. The goal is to incorporate clients’ sense of purpose and their decision-making to empower them to reject addictive activities in favor of productive ones that lead to eliminating or curtailing substance use.
Online, clients have the option of face-to-face sessions, delivered via Skype, with the same coach who reviews their written materials. This can translate LPP virtually intact to the Internet environment. The program has eight modules, which comprise eight weeks of residential treatment. Online LPP is more flexible in letting respondents work at their own pace to fit with their schedules and inclinations.
Online addiction treatment is not the only possible way for us to cope with the coming onslaught of clients, but as a technological advance, it will likely attract more and more healthcare providers. Therefore, certain serious questions merit debate.
1. Can online addiction assistance be effective (enough)?
There is reason for confidence that online works. For one, instant access—which is offered online—has generally been shown to be crucial in avoiding relapse.
For another, brief interventions work. Of all forms of alcoholism treatment, the greatest number of studies finding benefits involve brief interventions. A brief intervention originally referred to an initial contact with a healthcare provider who advises the client to reduce or cease drinking. But no formal program is provided, and clients are left to determine how they will quit or cut back. Important to the effectiveness of such interventions is a predictable follow-up point, when the drinker knows his or her progress will be assessed.
Another effective form of alcoholism treatment, according to a meta-analysis of 22 studies, is bibliotherapy, where the provider gives the client a book or manual to follow.
My colleagues and I built LPP on evidence-based treatments, and our residential program carefully tracked outcomes. Our results showed distinct improvements—often meaning abstinence—for more than two-thirds of our total enrollees (including those who failed to complete their stay).
In the case of depression, not only is telephone treatment effective, but it draws in many people who would otherwise remain untreated.
2. Can quality of care and access be guaranteed?
One of the main benefits of the Internet is that it offers easier access and greater flexibility. Scheduling and traveling present far fewer constraints. These are practical advantages, but they can be critical to client participation.
Quality control issues such as recruitment, training and supervision may be even more important for online addiction coaching than for more technologically conventional kinds. An online program is able to call on a pool of non-staff private counselors compatible with the program’s approach and to allow supervisors to monitor sessions between clients and helpers, including by video.
For online LPP I had access to a number of counselors trained and supervised in our residential treatment program. Todd McCoy, a counselor who managed the male residence on our campus, now coordinates coaching for the online LPP. Comparing the two methods, McCoy says, “The biggest surprise to me was how little difference there was. Skype was successful for connecting with clients, as good as being in the same room in terms of seeing a client's body language.”
In addition to administering the program with our own staff, we license the LPP to outside therapists and programs worldwide, offering a readily available way to implement a proven, non-12-step program. Outside therapists can use LPP offline or online, a combination of both, or as homework between sessions.
We have tested this hybrid model with the Muscala Chemical Health Clinic, in Edina, Minn. Bob Muscala and I have worked together for more than 30 years, so he is intimately familiar with our approach. “Although I regularly meet with clients in the facility, I also utilize online options like Skype for individual contact and Google+ video conferencing for group sessions," he says. "These options in combination with the online LPP are essential for clients who can’t get to me, either because they have lost their driver’s licenses or have other problems, or because they live far away or where nighttime travel may be difficult or dangerous.”
3. Will addicted individuals commit to an online program?
Research has shown that, in the case of depression, not only is telephone treatment effective, but it draws in many people who would otherwise remain untreated.
“People suffering major depression are more likely to get psychotherapy if it's offered by phone,” WebMD reported based on a Northwestern University study. “Psychotherapy is an effective treatment for depression. Patient surveys show most would prefer psychotherapy to antidepressant drugs. Yet only a small fraction of patients referred to psychotherapy actually show up for sessions.”
In addition to the superior accessibility of the treatment, researchers found that “after 18 weeks of treatment, the depression declines were equivalent in the two groups" (i.e., phone vs. face-to-face).
“The biggest difference from a residential program is the same as it would be with any outpatient program—you have no way of compelling participation,” McCoy says. “People might get halfway through the program and say they’re done. In the residential program, they’re not (usually) going home. Online, they can disappear without even informing you. On the other hand, this same freedom of self-determination is one of the biggest benefits of online LPP—if people are there, it’s because they want to be there.”
Indeed, outpatient settings like LPP have the advantage of allowing people to follow through in their “real” lives by practicing the addiction-fighting techniques they are learning. Muscala says, “Clients vary in their ability to utilize a self-regulated program like the online LPP, which I factor into assigning them to LPP or to other treatment options. Most clients, however, find the online approach to be ‘sexier’ than printed materials.”
4. Is an online program able to provide safeguards against client harm comparable to in-person treatment?
Providers face liability issues whenever they try to care for severely addicted individuals on an outpatient basis. Unlike in a residential program, online LPP does not enable us to control the environment and supervise addicts’ lives full-time.
But because of the need for readily accessed help, online may be a big boon for those with the worst addiction problems, many of whom are poor and will be eligible for Medicaid-funded treatment. Harm-reduction programs such as needle exchanges and safe injection sites (like Insite, in Vancouver) focus almost exclusively on this population, who are the most underserved and most at risk for serious misfortune—and for whom instant, on-the-spot help can be lifesaving. Research has consistently shown that simply by bringing injecting addicts into contact with a health (or help) provider makes it more likely that they will begin to address their overall health and safety needs.
5. Does participating in an online program prevent people who need more intensive help from seeking it?
Severely addicted clients—ones who might become involved in accidents or develop afflictions—are not suitable for online treatment. Unfortunately, the choice for them is often not between a less intensive and more secure treatment, but whether they develop any therapeutic connection at all. On the other hand, as has been shown with needle exchanges and treatment for depression, giving people access to nonintensive counseling is a definite help and can sometimes serve as a path to more intensive treatment as clients become accustomed to receiving care.
Let me end with another question. There has been considerable criticism that the DSM-5 will result in a massive rise in rates of substance use disorder diagnoses and that this, in turn, will drastically extend the treatment net to people who don’t need it. Those who would otherwise resolve these problems more or less readily on their own will get earlier (meaning cheaper) help, while those who present more severe and complicated (meaning costlier) problems will continue to be short-changed.
I sympathize with these fears. We will undoubtedly push more people with milder problems into treatment. But I believe that this result may yield many benefits, at least in the long term. While I am a great believer in self-cure for addictions, I have also spent my career offering help to addicted individuals through writing, counseling and treatment programs. My feeling is that people will tend to seek out the level of help they need—and they should be given a range of choices to permit them to do this. The online Life Process Program will, I believe, provide empowering assistance for certain people to do what they must ultimately do for themselves—come to grips with their addictions.
Stanton Peele, PhD, JD, is the author of nine books, including Love and Addiction (1975), The Meaning of Addiction (1985/1998), Diseasing of America (1989), The Truth about Addiction and Recovery (with Archie Brodsky and Mary Arnold, 1991), Resisting 12-Step Coercion (with Charles Bufe and Archie Brodsky, 2001), 7 Tools to Beat Addiction (2004) and Addiction-Proof Your Child (2007), as well as 200 professional publications.
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- non-substance-related addiction
- Affordable Care Act
- Mental Health Parity and Addiction Equity Act. MHPAEA
- Life Process Program
- Archie Brodsky
- Mary Arnold
- brief intervention
- Todd McCoy
- Muscala Chemical Health Clinic
- Bob Muscala
- Northwestern University
- needle exchange
- safe injection sites
- Stanton Peele