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Web-Based Substance- Abuse Interventions for Rural and Underserved Offenders
Tom Wilson, MA, LCPCTom Wilson Counseling Centers, Inc.
www.TomWilsonCounseling.com
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www.nfarattc.org
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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.
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Why Rural Offenders?
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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)
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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)
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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)
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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
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Barriers to Treatment
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Barriers include
• Travel Costs• Transportation access• Time Away From Work • Child Care • Lack of Service Providers
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Privacy and Confidentiality
(Moyer & Finney, 2004/2005)
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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)
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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)
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One Answer…Telehealth Technologies
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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)
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1879
TELEHEALTH is not new
(Aronson, 1977; Backhaus et al., 2012; IOM, 2012; Wittson et al., 1961; Wittson & Benschoter, 1972)
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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)
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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)
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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)
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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)
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University of Virginia’s telehealth program has documented the avoidance of
7.2 million miles of travel(Rheuban, 2012)
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Annually, 10 million patients receive
telemedicine services
(IOM, 2012)
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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
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87% of Americans use the Internet
(Pew Report, 2012)
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85% O
F AM
ERICAN
ADU
LTS H
AVE M
OBILE
PHO
NES
OR
TABLETS
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80% send and receive text messages
(Pew Report, 2012)
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Over HALF have gathered health information on their phones
Almost 20% have a health app
(Pew Report, 2012)
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Skype and other
videochat platforms are
free or low cost
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Videoconferencing Is Mainstream
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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.
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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)
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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
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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
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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)
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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)
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Web-Based Screeners
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Web-Based Support Groups
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Web-Based Support
PsychoeducationalSelf-Help
Mutual Support
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Virtual Reality
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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
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Using Web-Based, Substance-Abuse Interventions With Rural
and Underserved Offenders
© 2012 Tom Wilson Counseling Center
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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)
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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
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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.
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Importance of Early Prevention
“…It is easier to build strong children than to repair broken men...”
—Frederick Douglass
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Theory of Prevention
Drug abuse can be prevented if: Risk factors in a population are
identified and reduced Protective factors are identified
and strengthened
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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.
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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
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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
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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.
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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
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Program Design
Target Behavior: Harmful
alcohol use
Objective: Change
attitudes toward drinking
Target Population: Underage Drinkers
Delivery Medium:Web-based education
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Evidence-Based Components
Motivation- Enhancement Techniques
Stages of
Change Activities
Cognitive Behavioral
Skills
Web-Based Programs Include:
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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
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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
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Stages of Change Acti viti es
What stage am I in?
Readiness to change example
Decisional Balance—Benefits vs. costs of change
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Sample Lesson Process
Read content and answer
review questions
Receive feedback
If correct, continue or
retry questions
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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
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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
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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.
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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
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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
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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”
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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.
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Current Research on Outcomes
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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)
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Contact Information
Tom Wilson, LCPC, CPC 514 S. Orchard Street, Suite 101
Boise, ID 83705Office: 208.368.9909
http://www.TomWilsonCounseling.comemail: [email protected]