Web-Based Substance- Abuse Interventions for Rural and Underserved Offenders

Tom Wilson, MA, LCPCTom Wilson Counseling Centers, Inc.

www.TomWilsonCounseling.com

www.nfarattc.org

Agenda

Part 1: Overview of the past and current use of technology-based interventions for substance-use disorders.

Part 2: Description of how computers and web-based interventions have been used to deliver services to rural and underserved offenders—by Tom Wilson Counseling Center, Boise, Idaho.

Why Rural Offenders?

Approximately one quarter of the U.S. population (62 million people) lives in

frontier/rural areas

16–20% of those individuals experience substance dependence, mental illness, or

both conditions(NRHA, 2008)

Individuals residing in remote areas have higher mortality rates, higher suicide rates, and more severe alcohol/drug problems

(Baca et al., 2007; Goldsmith et al., 2002)

People in rural areas use substance-abuse treatment less often than in urban areas

They have more personal, social, and geographic barriers to accessing services.

There may be a stigma associated with treatment.(Finfgeld-Connett & Madsen, 2008; Oser et al., 2012)

3.3%

19.3 million people needed but did not receive treatment for illicit drug or alcohol use

Did not feel they needed

treatment

(NSDUH, 2011)

In 2011, 20.6 million people aged 12 or older met the criteria for substance-use disorders

Felt they needed treatment—Did not

make an effort

Felt they needed treatment—Did make an effort

Barriers to Treatment

Barriers include

• Travel Costs• Transportation access• Time Away From Work • Child Care • Lack of Service Providers

Privacy and Confidentiality

(Moyer & Finney, 2004/2005)

The lowest concentration of mental health professionals was

found in frontier/rural areas(counties with less than 10,000 people)

(Ellis et al., 2009; HRSA, 2011)

How could addiction treatment or other behavioral health providers expand their reach and overcome

barriers to serve these populations?

(Kazdin & Blase, 2011; Perle & Neirenburg, 2013)

One Answer…Telehealth Technologies

Telehealth Definition: The use of telecommunications and information technologies to provide access to health information and services across a geographical distance. Technologies included in telehealth are:• Videoconferencing• Telephones (smart and dumb)• Email and texting• Web-delivered programs• Apps

(Institute of Medicine (IOM), 2012)

1879

TELEHEALTH is not new

(Aronson, 1977; Backhaus et al., 2012; IOM, 2012; Wittson et al., 1961; Wittson & Benschoter, 1972)

Why Use Telehealth Technologies?

Reason #1

Most telehealth research supports that outcomes are as good or better than in-person strategies for behavioral health services (mental health and substance abuse).

(IOM, 2012)

Largest provider of telemental health services using videoconferencing(Godleski et al., 2008; Darkins et al., 2008; IOM, 2012; Deen et al., 2012; Godleski et al., 2012)

VA Services 146 hospitals provided 55,000 community-based

outpatient clinic patients with 140,000 telemental health visits

6,700 patients received home-based telemental health services

25% decrease in hospitalization for receiving telemental health services between 2006-2010

30% reduction in admissions during the first 6 months of care in 2011

(Darkins et al., 2008; IOM, 2012)

Indian Health Services (IHS)

Serves 2 million American Indians and Alaska Natives representing 566 federally recognized tribes

Includes 600 hospitals, clinics, and health stations under tribal governance

Implemented mobile telemedicine services in the 1970s

Alaska Federal Health Care Access Network utilizes telehealth

(IOM, 2012)

University of Virginia’s telehealth program has documented the avoidance of

7.2 million miles of travel(Rheuban, 2012)

Annually, 10 million patients receive

telemedicine services

(IOM, 2012)

Why Use Telehealth Technologies?Reason #2: Access to technology is widespread.

• Access to the Internet has increased dramatically

• 90% of individuals worldwide have access to mobile phone services.

• Smartphone access is expected to triple by 2019

• Internet and mobile access is growing among traditionally underserved populations

Marsch, 2014

87% of Americans use the Internet

(Pew Report, 2012)

85% O

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80% send and receive text messages

(Pew Report, 2012)

Over HALF have gathered health information on their phones

Almost 20% have a health app

(Pew Report, 2012)

Skype and other

videochat platforms are

free or low cost

Videoconferencing Is Mainstream

Why Use Telehealth Technology? Reason #3: High Customer Acceptability

Customers are more likely to use services that are on-demand

and less costly than scarce providers or

services.

Lack of Adoption by Professions

There are few published works on the use of telehealth technologies to provide or enhance substance-abuse services in rural areas.

(Balas & Boren, 2000; Benavides-Vaello et al., 2013; Ryan & Gross, 1943)

The Promise of TechnologySeveral research studies demonstrate that technology-based behavioral health tools:

Can be useful and acceptable to diverse populations

Have an impact on health behavior and outcomes

Can produce outcomes comparable to (and some cases better) than providers.

(Marsch, 2014) Dartmouth Center for Technology and Behavioral Health

The Promise of TechnologyTechnology-based behavioral health tools… Increase quality, reach, and responsivity of care

Can be more cost effective than in person services

Can increase service capacity of organizations

Can be responsive to individual's behavioral need trajectory over time

(Marsch, 2014) Dartmouth Center for Technology and Behavioral Health

Examples of Technology for Substance-Use Disorders

Decision Support Systems- e.g., Let’s Talk About Smoking (Brunette)Assessment- ASI-MV (Butler) - CHAT (Comprehensive Health Assessment

Tool for Teens) (Lord)Brief Intervention- Drinker’s Check-up (Hester)

Examples of Technology for Substance-Use Disorders

• Treatments/PsychoeducationTherapeutic Education System [“TES”] (Marsch, Bickel)Cognitive Behavior Therapy CBT4CBT (Carroll) SHADE (Kay-Lambkin)

• Recovery SupportAddiction–Comprehensive Health Enhancement Support System [“A-CHESS” ] (Gustafson)

Web-Based Screeners

Web-Based Support Groups

Web-Based Support

PsychoeducationalSelf-Help

Mutual Support

Virtual Reality

Use of computers to deliver some aspects of psychotherapy or behavioral treatment

directly to patients through interaction with a computer program (located on a device or

virtual learning environment [the cloud)].

(Carroll & Rounsaville, 2010)

Computer-Based Treatments

Using Web-Based, Substance-Abuse Interventions With Rural

and Underserved Offenders

© 2012 Tom Wilson Counseling Center

Rural Nature of Idaho

Thirty-five of Idaho’s forty-four counties are rural or frontier and many areas have limited access to specialty care.

While rural Idaho continues to face challenges recruiting and retaining medical and behavioral professionals, telehealth and telemedicine are playing an increasingly important role.

(Idaho Telehealth Alliance, 2015)

Objectives of Web-Based Services To expand the reach of substance-use

services to our remote, rural, or challenged clients through technology

To help clients overcome personal, social, and geographical barriers to substance-

use disorder services

To deliver substance-use services guided by evidence-based practices and

principles

The Aim of Prevention

The aim of prevention is to:• Deter the onset of alcohol or other

drug abuse • Provide individuals with the

information and skills necessary to prevent the problem.

Importance of Early Prevention

“…It is easier to build strong children than to repair broken men...”

—Frederick Douglass

Theory of Prevention

Drug abuse can be prevented if: Risk factors in a population are

identified and reduced Protective factors are identified

and strengthened

ABOUT OUR PROGRAM

Tom Wilson Counseling Center specializes in providing alcohol and

drug-abuse prevention education services for

forensic (court–ordered) clients.

Most of our clients are low-risk offenders

charged with substance-abuse-

related offenses and are on diversion or bench probation.

Challenges of In-Person Classes

Traditional in-person classes are difficult for offenders who:

• Travel for work• Have a suspended

license• Live in rural areas• Have child/family

obligations• Experience

communication problems

• Have no local SUD provider

Why Adopt Technology?

Information technology is now an effective way to deliver health

information/content

Cost has dropped significantly due to open source movement, cloud technology, etc.

Access to well-designed applications has increased dramatically

Advantages of Online Learning

Self-paced learning can take place anywhere,

anytime.

Accessible to virtually all learners—regardless of disability, location, or

learning schedule.

Providers can use creative methods and delivery

modalities.

Disadvantages of Online Learning

Requires computer or mobile device and Internet access, and some computer literacy.

Some participants uncomfortable with or distrustful of technology

Does not work well for some learning styles or activities that require group interaction

Program Design

Target Behavior: Harmful

alcohol use

Objective: Change

attitudes toward drinking

Target Population: Underage Drinkers

Delivery Medium:Web-based education

Evidence-Based Components

Motivation- Enhancement Techniques

Stages of

Change Activities

Cognitive Behavioral

Skills

Web-Based Programs Include:

Moti vati onal Enhancement Therapy

Non-confrontational intervention

Begins with self-assessment

Personalized feedback report on pattern of use

Feedback includes normative comparison of results

Stages of Change

Introduce the Stages of Change

Identify stage-specific thoughts and beliefs

Identify activities that help an individual move from one stage to the next

Stages of Change Acti viti es

What stage am I in?

Readiness to change example

Decisional Balance—Benefits vs. costs of change

Sample Lesson Process

Read content and answer

review questions

Receive feedback

If correct, continue or

retry questions

Feedback Example

Your Response:

You told us you drink 8–14 drinks per week on average when you drink.

Based on your response, you drink more than 81% of all males and 94% of all females.

You

Example of Calculation ExerciseYour typical blood alcohol content is the amount of alcohol in your blood on a typical day when you drink.

To calculate your typical BAC (blood alcohol content), use the online BAC calculator provided.

Online BAC Calculator

Feedback for Typical Drinking BACs Your response:You calculated your BACs for a typical drinking occasion as falling between .06 to .10.

At BAC Levels of .06 to .10, you will have impairment of muscle coordination and a slower reaction time, and disregard for personal safety.

Sample Lesson PageBinge Drinking

• Is defined as 5 or more drinks on the same occasion at least once in the past 30 days.

• Health, social, and academic problems occur when men drink 5 or more drinks per occasion, and women drink 4 or more per occasion.

• Binge drinking is the most common pattern among underage drinkers.

• Less than 25% of persons aged 12 or older participated in binge drinking

Click for Review Question

Other Mediums of Delivery

Using Text Messaging as an Intervention

“In a recent study, Text Messaging to Emergency Patients Reduced Their Alcohol Consumption”

12-week trial of receiving automated text messaging asking about drinking

Men who had 5 + drinks and women who had 4+ drinks received text messaging of concern about level of use

Asked if they would cut down. + for yes, ask for reconsider for no

Other Mediums of Delivery2. Online Assessment

and Feedback with “E-checkup to Go” for

university freshmen

3. Online Assessment and Feedback with “Brief Assessment and Intervention for College Students”

Conclusions

The tools of information and computer technology are successfully being implemented to remotely treat and prevent substance abuse.

The tools of technology can increase accessibility of behavioral health services to

rural offenders through web-based delivery.

Technology-assisted services will help offenders improve compliance—reducing the burden on

diversion and community supervision services.

Current Research on Outcomes

Recidivism Rates of Online DUI ClassesConducted at Tom Wilson Counseling for 2010–2013

• Participants—557 (68% male, 32 % female)• Mean age of participants: 35• Completed DUI classes in 2010–2013 (study

4/2015)

• Cognitive-behavioral curriculum like DWC• TWCC Recidivism rate (7.5%)• CDBH 2008 Study of in-person DUI Program

Completers Recidivism rate (7.8%)Preliminary Study Results 4/30/15 (Raissa Miller, Ph.D. Boise State University) (Gender, age, and prior arrests are not predictors of subsequent arrests)

Contact Information

Tom Wilson, LCPC, CPC 514 S. Orchard Street, Suite 101

Boise, ID 83705Office: 208.368.9909

http://www.TomWilsonCounseling.comemail: twilson@tomwilsoncounseling.com