Course on Electronic Commerce & Online Market for Health Services

Therapeutic Emails

By Farrokh Alemi, Ph.D., Mary Haack, Ph.D., Elias Vasquez, Ph.D., Susanne Nemes, Ph.D., Renita Aughburns, Duncan Neuhauser, Ph.D, Shirley Moore, Ph.D.

 Draft of Thursday, November 28, 2002. 

For final version see http://www.substanceabusepolicy.com/content/pdf/1747-597x-2-7.pdf

This research was supported by a grant from Robert Wood Johnson Foundation.

Abstract

Surveys show that overwhelming numbers of patients’ wish to contact their clinicians by email.  Despite the patient wishes, very few providers maintain email contact with their patients.  Providers’ resistance to use of email may be due to lack of training, to the need to modify processes of care or to misperceptions about adequacy of emails in maintaining a therapeutic relationship.  We have managed nearly 300 patients online for recovery from substance abuse.  In this paper, we describe how we use emails for online management of substance abusers.  We propose the anatomy and components of emails that clinicians should send substance abusers.  We also describe the content of emails that clinicians should send substance abusers depending on their recovery stage.  The paper ends with the case of an actual patient under care of one of our counselors.   We discuss how communications between the provider and the patient in this case fits with our proposed model and how could these conversation be improved.

Introduction

A number of investigators have examined the impact of online interventions on behavior change.[1]^-[2]^,[3]^,[4]^, [5]^, [6]^, [7]^-[8] Interventions that include role-playing,[9] electronic social support, [10]^,[11] and tailored educational messages[12]^, [13]^, [14]^, [15] lower cost of care and improve health of clients. For example, a study at University of Wisconsin provided 200 HIV clients with computer services, including an electronic support group -- where clients could post written messages for each other.  Clients were randomly assigned to control and experimental groups.  Only the experimental group had access to the computer services. Investigators found that the experimental clients were more likely to report higher quality of life in several dimensions including social support and cognitive functioning.  They also had fewer office visit (dentists, primary provider and alternative care providers), shorter primary care visits, fewer hospital admissions and shorter hospital stays.  In summary, experimental clients had better mental health and lower total health care cost than the control patients.[16] The study by Gustafson and colleagues, and other studies mentioned earlier, has established the efficacy of online services in bringing about behavior change.

If online services are effective in bringing about behavior change, it is natural to extend these services to treating patients online.  Few investigators have used computers for treatment.  Recently, two groups of investigators in the United States and England have focused on eliminating the need for a clinician and having the computer treat patients. Osgood-Hynes and colleagues have shown that patients can use a computer to effectively treat their own mild depression.[17]  Griest and colleagues have shown that computers can treat obsessive-compulsive disorders.[18]  In these two studies, computers organized the care, interacted with patients and monitored their progress.  Most providers do not want computers to replace them but to assist them in interacting with their patients.  This paper focuses on how email contacts can enhance the bond between the clinician and the patient.  In the proposed intervention, the computer is not the treatment but the medium through which treatment is delivered.  The clinician's interaction with the patient remains the core activity. 

Computer facilitated counseling has been tried in the past. Friedman and colleagues showed that computer facilitated counseling can help hypertensive patients reduce their blood pressure.[19]  But it has not been tried in substance abuse; with one exception.  In the last decade, we have conducted a number of linked studies on the potential impact of various components of online treatment on recovering patients.  We describe this research below.

Our Experience

In the early 1990s, we conducted a number of experiments on efficacy of online services.  We found that repeated use of online services was positively correlated with retention in substance abuse treatment.[20]  In this study, 82 cocaine-using pregnant patients had access to online services through their telephone line.  Of those who had access to online services, 35% used the system more than 3 times a week.  Eighty two percent of patients who used the systems more than 3 times a week participated in treatment in contrast to 55% of the patients who used the system less than 3 times a week or not at all.  More frequent users were 1.5 times more likely to be in community-based treatment.  Similarly, patients who used online services 3 times a week were 1.7 times more likely to participate in self-care, such as narcotic anonymous.  Thus, more online use was associated with more treatment and more self-care, two factors that predict long term effective substance abuse treatment.

In a second study, [21] the impact of electronic self-help groups on 53 recovering pregnant women was examined.  Subjects were recruited from previously randomly assigned groups.  One group had access to online services and was provided with online support group.  The other group was provided with only in-person support group.    Biweekly participation rates for the online support group over four months ranged from 54% to 79%; in contrast the participation rate in the face-to-face group ranged from 0% to 20%.  Clearly, though not surprising, patients found the online participation to be easier and more convenient.  What surprised us were the patients' comments online and the impact of these activities on cost of care.  We analyzed the comments patients made online.  Among the comments, 67.3% were intended to provide emotional support to other patients.  The remaining comments were task oriented (e.g. announcing a community program).  None of the comments involved flaming or overt disagreements.  The more patients used online services the more they felt a sense of solidarity with each other, as measured by standardized measures of social norms.   In other words, online support groups created the same types of emotional engagements that one expects in face-to-face meetings.  Online groups behaved as if they were face-to-face.  A further surprise came from the impact of these online groups on recovery and cost of care. There was no statistically significant difference in recovery rates but there was a significant drop in utilization of health services.  The control group had 42% to 164% more visits than the control group across office and clinic visits for mental and physical health.

These studies raised the expectation that online services could complement substance abuse treatment.  We were asked to provide supplemental online services to Target City patients in Cleveland. Patients seeking treatment were assigned to different outpatient treatment programs through the Cleveland Target City central intake unit.  At the time of assignment to an outpatient setting, these patients were also invited to participate in online services.  Surprisingly 87% of patients participated regularly in online services.  But only 30% of the same patients showed for their first outpatient appointment.  Clearly 50% of the patients received only online treatment.  Although we were tasked to enhance treatment, for at least 50% of the subjects we were the only care they received.[22]  Therefore, we quickly had to develop and put in use content that covered the entire treatment and therefore could replace as opposed to augment treatment.  As a consequence, we gained experience with counseling 300 patients on substance abuse, an experience that is the basis of the current paper.

            When we changed from a clinical study to delivery of services, we also noticed, despite our success, providers could not obtain the same results.  We began to see the need for more documentation of what we were doing online so that others could replicate our model.  In addition, over the years, we have come to see the fallacy of evaluating the impact of online services: It is not the availability of the online service that creates the impact; it is the content of what is said and done online that is important.   In this regard we had written:

"Judgment as to the effectiveness of the computer services should be postponed until we have more information regarding the role of message content and presentation...  In essence, the appropriate question to ask is not whether these computer services can make a difference in the patients’ lives but what message content could bring about such changes.  In the final analysis, computer services are just a medium and what should be of utmost importance is the content transferred through this medium and not the availability of the medium."[23]

Because of concern with content, scientists who have tried to replicate or improve upon our studies have repeatedly asked us for a blueprint.  This paper provides a detailed description of how emails can be used in treatment of substance abuse. 

Overview of Online Treatment

            Our ideas for online services have been influenced by the Continuous Self-Improvement theory[24] and recent work on situational determinants of relapse.[25]-[26][27][28][29][30][31][32][33][34]      These studies emphasize that habits emerge from and can be challenged by altering the environment.   Like these studies our counselors focus on the relationship between daily routines and relapse to drug use.  Lasting change occurs when the individual modifies daily routines and not just his/her own behavior.  The counselors’ role is to shift attention from client’s personal effort to environmental changes that involve a number of people and that have more lasting impact on the behavior of the client.    To this end, the online counselor helps the client organize face-to-face recovery teams that work with the client to change the environment. 

            Our approach to online counseling also relies on Cognitive behavior Therapy[35] in the sense that we emphasize a functional analysis of substance abuse, individualized training in situational determinants of relapse, and activities in between sessions.

            Our work has also been influenced by the work of Miller and Rollnick.[36]  These authors have laid out how "motivational" interviews help change addictive behavior.  The two key components of these types of interviews are:

(1)   Getting the client to think through the consequences of his/her actions.

(2)   Helping the client articulate why she or he is ambivalent about stopping substance abuse.

Motivational Interviewing is especially well suited for online delivery because it relies on dialogue between counselor and the patient.  Through these dialogues, counselors could be further reassured that their comments and questions are understood by the patients.  At the same time, it is our experience that patients prefer to talk to rather than listen to the counselor.  Because Miller and Rollnick's work emphasize directed questioning of clients, their work is especially suitable for online delivery.

            Online counseling involves the maintenance of a longitudinal therapeutic relationship for 4 to 6 months.   Both clinicians and clients must be aware that the focus of the activity is on long term change and that the impact cannot be observed for several months. During this period, the patient is expected to be in near daily email contact with the clinician.  Online treatment is more than frequent emails.  In order to put the role of emails in online treatment in perspective, it is necessary to understand the various services available to the patients online.  These services are as follows:

(1)   Written contract for change.  The contract lays out the specific plan for change.  It also provides consent to steps that the clinician can take in case of client's relapse.  These activities include (1) increasing online contact, (2) asking a significant other to talk with the client, (3) a telephone call from the clinician, (4) a clinic visit or other interventions as agreed upon.   A sample of written contract for change is available through first author.

(2)   Electronic support groups.  Clients use the electronic support groups to discuss recovery issues with each other.  Client’s comments are not censured, except when they involve illegal activities.  All discussion groups have a sponsor that monitors the comments made on the discussion.  For patients who share a specific characteristic or who have attained a specific level of progress, separate discussions are organized. 

(3)   Online motivational interviews.  Motivational interviews are carried out through daily email contact with patients.  Details of these emails are presented in a later section.

(4)   Relapse prevention assignments.  On a weekly basis, clients receive a survey of their environment.  Clients’ responses provide them and their counselor with insights into risks for relapse.  If client is at increased risk, the counselor may take a number of steps including, (1) increased online contact, (2) asking a friend or a family member to spend time with the client, (3) arranging for face to face visit or (4) other agreed upon steps.

(5)   Diary.  On a daily basis clients are asked to report their drug use.  When an occasional lapse occurs, clients are asked to specify the circumstances around it – with the hope that such introspection will help client gain insight into how their environment can be modified to avoid future relapse.  When the relapse is significant and suggests a return to drug use, the computer alerts the counselor who takes additional actions to help the client return to sobriety.

(6)   Recovery teams.  Members of the household, friends and others who share daily living routines with the clients meet once a week to discuss how these routines may be contributing to drug use.  The members of the team flow chart the events that proceed relapse and identify daily activities that hinder drug use or maintain sobriety.  The counselor has weekly contact with recovery team and helps set the agenda for these problem solving meetings.  More details on the organization of recovery team are provided elsewhere.[37]

In addition to these online components, there are two other elements important to delivery of online services.  First, clients have access to face-to-face counselors if they wish to come in or if the counselor believes a visit is necessary.  Second, clients are subject to random testing for substance abuse to verify their claims of no use.

Anatomy of an Email

Every email has distinct components.  Some components (e.g. email address) are necessary to the function of an email; other components are unique to the type of emails we send to our patients and thus can be thought of as a necessary component of the therapy.  The components of emails we use are the following:

1. The clients alias (de-identified for the protection of the clients)
2. The counselor’s name and title
3. The counselor’s work email. 
4. Date email sent and date email opened
5. Time it takes for the addressee to open emails (this information is calculated by the computer, displayed at time of drafting the email and is important as it establishes whether emails remain a viable method of communication).
6. Greetings, including salutation.  Typically the email should start with “Dear Alias”, followed by “How are you?  I hope all is well?” 
7. Statement of the issue.  This is the core message of the email.  We encourage counselors to send only one message per email. 
8. Optional example so that the issue is well understood.  The counselor may give an example from his/her own life or other clients’ experiences with the issue.
9. Leading question.   All emails need to end with a leading question that verifies understanding of the issues raised by email and propels clients to respond.
10. Signature and title of counselor
11. Statement of confidentiality of email communications

Most of the elements mentioned above are present in email programs.  The key exception is ending of emails in leading questions.  This is a key aspect of all Motivational Interviews.  It is an important strategy for bringing the client to self insight.

Content of Emails

The nature of the interaction between the clinician and the patient depends on the recovery process of the patient and cannot be specified a priory.  But there are distinct stages that patients go through and at least in the early phases of these stages the content of the communication are relatively standardized.  This section provides the ten stages in recovery and the content of emails in these stages.

1.      Patient is accessible

In this stage, patient and the clinician introduce themselves and verify that they can receive or send emails.  An example email might be:

"Hello I am (short description of the clinician’s background).  I want you to know that our discussions are confidential and will not be reported elsewhere without your permission.  Some exceptions to this are if a court orders us to share our records or if our discussion reveals an activity that by law I am required to report.  Keep in mind that emails can be read on route to me by others.  To keep your privacy, please do not put your name or phone number in emails.  I have your name and phone number and you do not need to send it to me.  Before we get started I wanted to know more about you.   Could you tell me how old are you, who you are, what you do, and any thing else that you think will help me understand where you come from.  Would you introduce yourself?"

2.      Ambivalence about change

The clinician asks why the client is seeking online counseling in order to help the client articulate in his/her own words their drug dependence.  Often clients are referred to online counseling after a specific intake interview.  The clinician could refer to these intake interviews and ask:

"This is xxx.  I want to start by asking you why are you here.  I have seen your responses to the intake interview.  But I want to hear from you and in your own words.  For example, some people come online because they have to; others come to talk to me because they want to accomplish a change in their life.  Can you tell me why you are here?"

The aim of these early conversations is to make the client and not the clinician use words such as “alcohol or drug use.”   Then the clinician follows by asking about the positive feelings the client gets from his/her drug use:

"This is xxx.  I want to ask you about some of the good things that you think you get from your drug or alcohol use.  What do you get from it?  In the past when I have asked this question from other clients they have told me what they enjoy when they use.  Some have said they enjoy being trouble free, others have said they enjoy their friends.  What is it that you enjoy when you use?  What do you get out of it?"

Then the clinician summarizes the response:

"This is xxx.  You are saying that the good things for you are ….Is there anything else?"

3.      Consequences of use

The clinician starts without focusing on the drug or alcohol use.

"This is xxx.  I want you to tell me some of the things that might be a problem or concern for you now.  If you ask me this question, I would list money and relationships top in my concerns.  But I want you take an inventory of your life and tell me what is not going well.  Could you list the issues that are of most concern to you recently?"

If the client is not sure what is meant, examples are given:

"This is xxx.  It was good to see your last email.  You were not sure what I was asking about earlier.  Maybe an example can help.  Some people are concerned about their health, relationships or finances.  Do you have any concerns such as these?"

When broad concerns are raised, the clinician asks for more specific examples:

"This is xxx.  You said you were concerned about ….Can you give me a specific example, a case where this caused you problems or difficulty?"

The clinician provides confirmation, brings forward statements made about how drug use is enjoyed and seeks explanations for why certain events have occurred:

"This is xxx.  Earlier you had said that you enjoy your habit because …..  Now you are saying that you are concerned about … Lets continue with this line of thinking.  I want to get to understand your concerns more fully.  What has contributed to these problems?  If you ask me about my life and what has led to my current problems, I can list for you a number of people who have failed to help me.  But in the end, I have to admit that there are a number of things that I have done that have made my life much harder.  What have you done that has contributed to your problems?"

The clinician does not explicitly point to the relationship between the drug use and the concerns raised by the client, but if the client mentions such relationships, then they are reinforced by the clinician.  If by now concerns are not linked to the drug use, the conversation is changed to a future focus.

"This is xxx.  We discussed some of your present concerns or problems.  Let me ask you about the future.  If you were to continue your current lifestyle, what concerns might you have about the future?"

When drug use is acknowledge, the clinician spends more time on the link between drug use and life problems.

“You say that drug use has contributed to your problems.  I want you to send to me an email about things that happen to you that you did not like when you used drugs.  In a month or so from now, when you are doing better, I will send the message back to you so that you can see where you came from.  As we go through recovery, sometimes we forget why we wanted to stop using drugs and hearing yourself again is a good reminder.  So please reply to this message and tell me in as much detail as possible how your drug use creates problems for you.  Could you give me the story of the worst experience you have had because of drug use?”

In the end the clinician summarizes the concerns with a message such as:

"This is xxx with a summary of what we discussed so far and a request.  Let me see if I can pull together our discussion to date.  You have several concerns.  On the one hand, you are concerned about (give the details of a specific event that raised the concern). As far as the future goes, you are worried that some of these things may get worse….  On the other hand, you enjoy your habit.  You mentioned that you like … I can see from your responses that you have thought these issues.  But most important, you mentioned that your habit contributes to your problem.  In your words “…”.  It is great finding a person who can think through both the positive and the negative parts of your habit.   Most people muddle through unaware of their lives.  You are different. I am glad that you are aware of these and how they affect your life….  We have passed an important milestone in your treatment.  Are you ready to proceed to the next stage?  "

4.      Agreement on need and individual action

The clinician summarizes the discussion to date and initiates a plan for recovery.

"Hi this is xxx  again.  In the past weeks, we have been talking about the consequences of your drug and/or alcohol use.  On the one hand you feel that there are some things that you get out of using drugs, things that work for you.  But there are also many negative consequences and you are concerned.  Let’s move on and see if we can come up with a specific plan that can help you change your drug use.  I have mailed to your home address a brochure that I need you to sign and return.  It is called "contract for change" and it highlights the activities that we would do together to change your drug use. I should tell you that we can succeed if that is what you want to do.  In the end, it all depends on what you want to accomplish.  I cannot decide for you.  I only can act as a coach and cheer you on when you succeed and show you other ways when you fail.  Would you let me know when you have received the brochure?"

At a later point, the counselor asks for how the client plans to quit drug use:

"Hi this is xxx  again.  You sound like you are ready to stop using.  When people want to change their behavior, they need to set a date, engage in numerous preparation activities, have public rituals marking the change and create ways of keeping up with their resolutions.  I need to hear from you regarding what are your plans.  When do you want to stop or if you have stopped already when you plan to do so that you can keep your resolution?”

This step also marks the beginning of the individual's attempt to stop his/her drug and/or alcohol use.

"Hi again.  This is xxx.  I wonder how you are doing and if you have been successful in changing your drug use.  Tell me how you have been trying to change, where has there been set backs and what you intend to do."

Often clients’ plans are not concrete.  Clinicians emails should solicit specifics from the client regarding who, what where and when they will take action.  It also helps to ask for the actions the client might take immediately, in an hour and in a few days.

"This is xxx.  I can see you have thought through the actions you want to take.  Can you help me by telling me what you will do immediately after this email, what will you do in an hour or so, what will you do tomorrow and what will you do this weekend so that you will stop drug use  Be specific.  Tell me how you have been trying to change, where has there been set backs and what you intend to do at specific times this week."

5        Self disclosure and request for help

The clinician would send the following message:

Hello, this is xxx.  I was wondering how you are and also wanted to remind you what we agreed upon earlier in the Contract for Change.  You agreed that you will admit to your friends and family members that you are powerless over your drug addiction and that it has become unmanageable.  Have you done so?  Who have you talked to about your situation?"

In response to the message, the clinician will address the concerns raised and then also end with the following message:

"This is xxx again with an idea.  Why don't you tell the people online about your intention to change your drug use?  Select the discussion group.  When you go there tell them your first name and admit to them that your drug use has become unmanageable.  You will find them that they also need your help."

Later, the clinician will ask for a summary of reactions the client has received from others:

"This is xxx.  I hope that by now you have admitted to people you know and the people online that you need their help.  If you have done so, I like to hear from you what reactions were and how you felt."

The clinician helps the client to engage others in the change he/she is contemplating:

"This is xxx. You are not alone in this.  There are many people who can help you.  Some are online and some are right there with you.  You can get help from clinicians.  But the most important people that can help you are family and friends who care for you and want you to stop using drugs.  You need to sit down with them and get their help.  Your recovery needs to be a team effort.  There are a lot of things in your environment that need to be changed for you to succeed.  You have been making a great personal effort to succeed but now it is time to engage others so that you can modify your environment and succeed even when your resolve fails.  If you ask me who should be part of your team, I suggest those who are most affected by your drug use and with whom you share daily living activities.  A brochure describing how they can help you is available through us.  Could you put together the list of people who share daily living activities with you and who might participate in the recovery team?  Who do you suggest should be on your team?"

The clinician follows up a few days later:

"This is xxx.  I had asked you to put together a team that can help you change.  You may wonder what this team should do. Let me summarize some key points of what will be expected from your team.  The team's goal is to adjust daily routine activities so that is no longer possible or desirable to continue using drugs.  For example, if I was trying to lose weight, an adjustment that I could come up would be to shop for healthier food or food that is less fattening.  There are several ground rules for how the team members should interact.  First, there should be regular meetings.  Second, no one is to be blamed.  If people fail to carry out the task ask yourself how could we reorganize activities so the people involved can keep up with their resolutions.  Third, the team should look for solutions that involve all or most team members and not actions that can be carried out by single individuals.  As I mentioned earlier, I can send you a brief guide to how you can work together.  If you have succeeded in getting people to help, let me know how many people are involved so I can mail you the guide.  If you are concerned about how the recovery team can be organized, what the team will do and who should be on it, email me your questions

A detailed guide to organization of recovery teams is available through the first author.[38] 

6        Review of friends and relations

The clinician leaves the following message:

"This is xxx again.  One of the secrets for not using drugs is staying away from people who use drugs.  You should think about all the people you have contact with and ask yourself which of them use drugs.  Then you should make plans to see friends and family members who do not use drugs and avoid contact with those who do.  Are you willing to work with me on this?  If yes, please reply by making two lists of first names.  In the first list record the first name of all the people you enjoy being with who don't use drugs.  In the second list, record the name of the people who use drugs. 

Conversation continues until the client arrives at specific plans for how to increase contact with some friends and avoid others.  Here is a prompt that can direct the conversation to role playing how to refuse drugs.

"This is xxx.  I am going to tell you the beginning of a story and I want you to complete the story.  Suppose you are out having fun with your friends.  They begin to use drugs and offer you some.  You say "No."  But there you are sitting and watching them have fun.   Your mind tells you must leave but you know that you are going to feel miserable without your friends.  Complete this story for me.  Tell me what happens next and how you feel about it."

Next the client is probed for what they might do to feel good about refusing drugs.

"This is xxx.  Saying "No" is an art.  It is more than just saying you don't want something. In a moment I want you to practice by saying "No" to me.  When you do I want you to keep in mind the following components of saying "No."  When refusing drugs, the first thing you say is the word "No."  Then you should follow this with instructions to the person not to ask you now or in the future again.  Don't make statements like "maybe later."  Make sure that your expression and tone are clear.  Then offer something positive that is incompatible with drug use.  Make sure that you end your comments with a question that focuses your friend attention on a different topic of conversation or activity.  Let’s see if you can do this.  Suppose I am your friend and I am offering you drugs.  Practice with me how you would say no.  Say no to me and I will tell you if you followed my instructions about how to say no." 

The client and the clinician may also switch roles with the patient offering drugs and the clinician saying "No."  If during the intake or other conversations it is clear that the person is living with a person who uses drugs or alcohol, the following message is sent:

"This is xxx.  If you are living with someone who uses drugs or alcohol, there are several things you can try.  You can ask them to change, help them get professional help, and refer them to treatment.  You can sometimes ask them to move out if they do not change.  It is hard, but you can also move out yourself.  But if neither strategy is possible, consider how you can separate as much of your life from them as possible.  Think about eating, sleeping, watching television, or socializing and think how you can do these things separately without the involvement of this person.  This is a hard issue but sooner or later you have to face it.  Let's do it now together.  Please tell me what you are planning to do to reduce contact with people who still use drugs." 

Four weeks later the clinician sends the following message:

"This is xxx.  You had wanted to increase your contact with xxx.  Have you succeeded?  What do you think can help you get there faster?"

7         Group action to adjust daily routines

The clinician needs to think through the need to directly engage in conversation with the entire group that is helping the client or on restricting his/her contacts to the client.  We do not know which approach is best and need to gather more data about this issue.  The following assumes that the contact is through the client.  The clinician helps the client to go beyond immediate commitment to stopping the drug use and see what other steps should be taken to create a positive environment for success.  The clinician sends the following message:

"This is xxx.  It takes more than willpower and discipline to stop using drugs.  You need to create an environment that helps you succeed.  How can you and the people who are helping you adjust daily living activities, like when you eat, when do you sleep, etc. so that you are less likely to relapse?" 

If the client keeps staying with personal motivation, the clinician continues:

"I believe in you and know you can succeed.  But I need your help in understanding your drug use.  Think about the time, money, motivation, and means that go into your drug use.  Then think about how you can plan your days so that there is no time for it, or that you don't have the means for it, or that you are motivated to do something else.  I need you to think of some actions that you and people helping you can take that will  change the environment." 

If an action is suggested, then the clinician explores whether there is a consensus from others about this course of action.

"This is xxx.   You suggested … who else this would affect?  Do you have their agreement? Have you discussed it with them?  Given how much work needs to be done, you need to ask for their help.  You would be more successful to define the problem with them in a way that highlights how it affects them and to search for a solution jointly and not individually.  Take these steps, work on changing the environment together and in a few days I will ask about your progress." 

After a few days:

"This is xxx again.  What have you come up with?  I had asked you to think of specific actions that would remove the motivation and means for your drug use.  Can you tell me what you have come up with? 

The clinician can also explore whether the client has carefully examined his/her routines and how they may interfere with the proposed activity.

"This is xxx.  To accomplish what you want to do several other activities should be done first.  For example, if I was trying to stop alcohol use, I would examine when I drink and see how it is related to various daily routines.  If you are trying to… what other steps should you and others who are helping you take to increase the chances of success." 

The messages are continued until a detailed plan that is small in scale is organized. 

"This is xxx.  We have been thinking together about how to change the environment.  Are you willing to give it a try?  Now that you have found several things that you can adjust in your daily routines, why don't we set a start date?" 

A week later:

"This is xxx.  I was wondering how you are doing.  Did you succeed in accomplishing your plans?  What changes in routine activities did you make and what others you plan to make?"

8        Group action to create a sense of spirituality & community

The following message is sent by the clinician to the clients:

"This is xxx.  Many of us believe that a power greater than us can restore us to sanity.  Some of us have decided to turn our will and life over to god, as we understand god.  It is helpful sometimes to talk about these issues.  Can I ask you what you believe in?  Do you believe in a higher power and how is this higher power helping you cope?" 

The clinician will query more about client's sense of community and belongingness:

"This is xxx.  Can you describe to me the community of people you identify with?   Are they the people you meet at church or organized religious activity?  Do you feel a sense of belonging to a group?" 

The clinician continues the conversation to explore the client’s need for and ability to arrange for a community of like-minded people.  If during these conversations it is clear that the client believes in a god or is positively oriented towards spirituality, the clinician also makes the following offer:

"I know your life is busy.  I wonder if you would like to receive messages of prayer and spirituality on the system?  If you do, send me a message back."

9        Group action to find substitute routines

The clinician sends the following message:

"This is xxx.  Stopping drug use is easier when it is replaced with a fun and healthy social routine.  Some examples are walking in the morning, attending recovery events and meetings, such as NA or AA, helping others in the neighborhood.   I know that there are many things that you are interested in.  I want to spend the next few weeks thinking through what you like to do and how you can make that happen regularly.  Lets start by deciding what is it that you could do that could replace your drug use.  Think about when you typically crave drugs.  Think about a social fun activity that you can do at those times.  Please think about your interests and strengths and tell me what is it that you really would like to do."  

If the interest is reasonable, the clinician follows with:

"This is xxx again.  Yes that sounds like fun.  How would you get started?  Let’s spend some time together thinking through how you can plan this so it will happen.  What steps will you take now, tomorrow and this weekend so that you can succeed at your plans?  

Clients typically plan by committing themselves to actions.  The clinician works with the client to make sure that a system-wide action is contemplated.  The clinician can also explore whether the client has carefully examined his/her routines and how they may interfere with the proposed activity.

"This is xxx.  To accomplish what you want to do several other activities should be done first.  For example, if I was trying to lose weight, I should shop for healthier and less fattening food.  If you are trying to do… what other steps should you and others who are helping you take to make sure that the means and the environment for success is at hand."  

The relationship among the various habits of the clients is further explored.

"This is xxx.  I want you and others who are helping you to think through how daily routines affect what you are planning to do.  By daily routines I mean anything that repeats on a regular basis.  For example, waking up, washing, going to work, preparing food, socializing, exercising, watching TV, visiting friends, etc.  I want all of you to discuss this and then reply to me about how routine activities may prevent you from accomplishing what you want to do. I also want you and others who are helping you to think aloud about how daily routines can be adjusted to promote what you want to do.  Is there a small specific change in daily routines that will lead to the activity you are planning?  The idea is to change routines so that your planned activity would happen without much more additional thought or effort.  In short, to make the new activity happen automatically and as a consequence of other routines – without having to think about it.  What do you think should be done?"  

The messages are continued until a detailed plan that is small in scale is organized. 

"Are you willing to give it a try?  Now that you have found several things that you can adjust in your daily routines so that you can achieve your plans, let’s set a start date.   

A few days before the planned activity the clinician sends the following message:

"This is xxx again.  I know that your big day is coming up.  I want to tell you something that I have learned time after time.  One must work hard at having fun.  Think about it.  You can devote as much time and money to this new fun activity as you used to your drug use.  You can read books about it, purchase equipment for it, dress up for it and do what you need to make it a success.  I am sitting here thinking of you and wishing you much fun."  

A week later:

"This is xxx, wondering how you are doing.  Did you succeed in accomplishing your plans?  What changes in routine activities would make you succeed even more next time?"

10   - Sharing Data

The clinician starts the conversation with the following message: 

"This is xxx.  Every day counts.  Like cancer patients, there is no permanent cure for your disease.  Each day that you are free from drug use is a gift and each time you participate in treatment is an action preventing relapse.  I want you to start counting the days free of drugs and telling your friends and family members how many days has it been.  One way that is often useful is to display in a prominent place, for example on the refrigerator, a calendar in which you could mark the days free of drugs.  For my records, "Are you counting?" "How many days has it been?"  "Have you displaying the number of days you have been drug-free?"  

The client is also encouraged to share their data on use with the group that is helping him/her.  Sometimes, with the client's permission, the clinician can take the role of informing the group through online methods.  If there has been more than 30 days, the clinician sends the following message:

"That is good news.  You have made it this far.  I have an idea.  Why don't you go to the discussion group and tell them of your success?  People who are just beginning are struggling with their drug use.  It will help them if they hear from you that you have made it this far."  

 A week later the following message is sent:

"This is xxx.  I know you have made a great deal of progress by getting this far.  If you ever relapse, don't let yourself go all the way.  As quickly as possible start again on the right track.  Let me or xxx ( a name obtained earlier through the contract) know.  We can help. "

11   Reacting to cycles of relapse

The clinician asks for reports of relapse and asks the client to articulate what can be learned from this.

"Hi this is xxx.  When you are trying to change, from time to time, you lapse.  The key is to bounce back and not to become disappointed.  Each lapse is an opportunity for new set of actions, which would lead to a longer period of being free from your drug use.  Your recent email said that you lapsed.  It is difficult to think through the sequence of events leading to drug use.  But lets start by you telling me when did the drug use happen, who were you with, where were you at, how were you feeling and why you think it occurred."

Once the circumstances around relapse have been explored, then environmental changes are solicited:

“This is xxx.  I can see what happened.  What can you do so the lapse into drug use will not happen again.  Obviously you can exert more effort and remain more committed.  But this is not what I am asking for.  I need you to think about your environment and tell me what in your environment can be changed so you will not lapse again."  

If the client responds with the importance of remaining committed, the clinician tries to help the client to devise strategies to prevent similar situation.

"This is xxx.  You said that you have learned to be more committed and I believe you.  But this is not what I was looking for.  You said … Ok what else could you do?  I mean, is there an adjustment to your daily living activities that will reduce the likelihood of these types of relapses?  

The messages continue until the client arrives at a specific adjustment to daily living activities that can help reduce the likelihood of relapse.

12    Helping others

The clinician sends the following message:

"This is xxx. You know that you have a drug addiction which is a disease.  Having this disease is not an excuse for anything -- not for missing work, messing up family, stealing or breaking people's faith and trust.  I think you have come to a point that you can come clean with the people that have been affected by your drug use.  Are you ready to make a list of persons who have been harmed by your drug use and willingly make amends to them?  Think about it, while it seems you are doing it for them you are really do it for yourself.  Is there someone that you want to approach and tell them that you are sorry for what has happened?  

The conversation is continued until the client selects a person, role-plays what the client will say, and plans a specific activity.  After 90 days of sobriety, the clinician will ask the client to help others with the following message:

"This is xxx.  You have come a long way.  Having had your success and spiritual awakening, it is time that you carry the message to others. If you come to contact with a person who uses drugs, I want you to ask them if s/he is willing to help you by listening to your story.  Then him/her what happened to you.  How you were when you were using drugs and how you stopped..  If after listening to you, s/he agrees to seek help, ask them to send us an email.  Help them send the email if he or she is afraid to do it alone."  

A week later the following message is sent:

"This is xxx.  Are you still free from drugs?  If so, I want you to go to the discussion section and under the topic of stories type your success story.  I want you to tell your story; from the beginning to the end.  Keep in mind that your identity is protected and that you should not use your name or phone number in any communications.  Record your alias, tell how did you start using, what did you feel while using, and how did you succeed in stopping?  When you are done, you should post your message so that others on the system can learn from you.  I am really proud of your success to date." 

Progression of emails

No one form of treatment is good for everyone.  All individuals are distinctly different and the course of the counseling is uniquely different for each person involved.    But over time and across a large number of people, we have noticed a progression in treatment.  

1.      Patient is accessible.  Client has agreed to and does participate online.  Client receives messages and within a short interval (24 to 48 hours) responds to the messages.

2.      Patient has contemplated change.  The client has explored the consequences of the drug use and why he/she is ambivalent about change.

3.      Patient has resolved to change and take individual action.  The client has initiated change and has plans for how to succeed.

4.      Patient has requested for help from others and reviewed current friends.  The client has disclosed to others that he/she needs help. The client has taken steps to stay away from people who continue the drug use.

5.      Patient has organization a recovery group.  The client has succeeded in obtaining commitment from family members and friends to help.  Regular meetings have begun.

6.      Group has decided on environmental changes.  A number of steps has been taken by the group to improve the environment, including:

·        Adjustment of routines.  The client, friends and family members have adjusted daily routines to make it unlikely for the client to continue with the drug use. 

·        Substitute activities.  The group has created new activities that occur at the same interval as the drug use, that are fun, and that do not have the consequences of the drug use.

·        Spirituality and community.  The client regularly participates in religious or spiritual activities and feels a sense of belonging to a community.

7.      Group has shared data regarding the patient’s progress.  The client has publicly displayed data about success and actively engaged friends and family members to evaluate his/her progress.

8.      Patient and the group have learned from cycles of lapse.  The client and the friends and family members, who are helping, have examined failures and arrived at additional adjustments to their daily living activities.  These new activities are expected to increase the intervals between relapses.

9.      Patient has helped others.  The client has worked with others who use drugs to help them stop.

These steps (also shown in Figure 1) describe progression from thinking about change to succeeding at it; a progression from individual to group action.  While some clients may not go through all of these steps, it is our experience that many do.  Furthermore, when each one of these steps is tied to specific rewards and sanctions, clients are more likely to progress through them. 

Case of Toucan

Toucan is the alias of a 47 years old White female that identifies herself as catholic.  She completed 16 years of education and has a business degree; the longest full time job she had was for 5 years.  Toucan works full time as a waitress.  She is not taking medication at this time, has not been in a controlled environment the past 30 days and was hospitalized for physical problems 14 years ago.  One other person depends on her for the majority of her food, shelter etc.   

Toucan has been treated for alcohol abuse 6 times (4 were for detoxification).  She has no history of criminal behavior and an unremarkable family history of alcohol, drug and/or psychiatric problems.  Last year, Toucan married.  She is satisfied with her marriage.  Her husband is also alcoholic.  In the past 3 years, she has been living with her son.  She spends most of her time with her family.  She has two close friends.  She has had close, long lasting personal relationships with mother, brother/sisters, children and friends but not with her father.  She notes that individuals from this group did abuse her emotionally and physically, but not sexually.  She has no history of psychiatric problems.

Stage one:  Patient is accessible

             During the first 2 weeks after Toucan had agreed to participate in this project, her home computer had been installed and communication between Toucan and her substance abuse counselor was evolving.  The process took about 2 weeks as both individuals worked out the problems that are inherent to technology.  Below is examples of emails sent back and forth between them in this phase: 

From: Toucan, To:  Nita   Date: 3/13/2002 3:18:23 PM    Subject: Reply to the phone call Hi, I am responding to your phone call. I really have no idea, what I am doing. I might be in need of your help. I tried to log on chat line a few times, but it was nobody there to chat with. Thanks for your help Toucan  

A key problem in starting a chat room is that early clients find it empty and few actively participate in it. 

From: Toucan, To:  Nita   Date: 3/29/2002 8:49:59 AM    Subject: testing

Hi, I am trying to send a message. I do not know if it will go through. Toucan

 From: Toucan, To:  Nita   Date: 3/29/2002 6:13:42 PM    Subject: testing

Hi, I am trying again to get through. Toucan

From: Nita, To:  Toucan   Date: 4/1/2002 10:40:28 AM    Subject: I wasn't your fault

Hi Toucan, This is Nita (your counselor), after speaking with you on the phone, we investigated the situation. There was something wrong with the system and the emails were not reaching my mail box. So you can contact me now. It is important that we maintain good communication. If for some reason you need to reach me here is my number (973) 951-7897.

We find it helpful to provide the counselor’s phone number to patients in case they need to contact the counselor and cannot do so by email.

From: Nita, To:  Toucan   Date: 4/4/2002 7:24:46 AM    Subject: Consistent contact

Hi Toucan, This is Nita. I emailed you on Monday to let you know that the system is now ready for you to use. To date you have not responded to my email. It is important that we maintain consistent communication so that this process works.

The above emails show a common problem of missed communications.  The client started on the system and expected quick responses.  An error in the data entry was sending client’s emails to a different clinician who was not assigned to Toucan.  By the time the problem was identified and the counselor attempted to send a response, the client had abandon effort.  Eventually, however, through a few more emails and phone calls the client and the counselor were able to connect.   Sometimes missing communications are indicative of relapse, as in the following cases where long periods of time passed without contact:

From: Nita, To: Toucan   Date: 4/14/2002 6:57:52 AM    Subject: No contact

Hi Toucan, This is Nita. When you and I spoke you informed me that you were comfortable with using the system and had sent me a few emails. That was about three or four weeks ago. Since that time I have not received any emails from you. If you are having problems with your system please call me at this number 973-951-7897. There is really no excuse for not keeping in contact with your counselor. The purpose of installing the computer in your home was to make is simple for you to reach your counselor.

From: Nita, To:  Toucan   Date: 4/17/2002 8:31:53 AM   Subject: What going on?

Hi Toucan, This is Nita. I have not heard from you in at least one month. I have attempted to contact you by email and by phone but have received no responses from you. Is there a problem? I spoke with a gentleman on the phone the Tuesday 4/16, who informed that you were not available. Here is my number again, 973-951-7897

 From time to time, problems of missed emails keep coming back when one party, for various reasons, is not available:

From: Toucan, To:  Nita   Date: 6/4/2002 10:51:43 AM    Subject: Are you on vacation?

Hi Nita, I don't know if you received my message or you are on vacation. My husband told me you called last night and asked about me. I didn't receive any email from you for about a week. Let me know what is going on. Love Toucan PS: If you are on vacation, enjoy! You can also drop by to visit me.

Stage two:  Patient has contemplated change 

The following emails show a number of interactions in which the counselor helps the patient explore why she may be ambivalent about change and what are the possible consequences of not changing:

From: Nita, To:  Toucan   Date: 4/26/2002 12:35:21 PM    Subject: Why do you use?

Hey Toucan, This is Nita. You seem to recognize a lot of things. And you also seem to have a lot of answers. Now let's start to address what's going on. I need you to continue to be open and honest. I want to ask you what you would consider are some of the good things about using? I mean what do you get from it? Would you reply and make a list of how and when you feel good about using.? I will let you know what day I am available next week so that we can meet. In the mean time let's keep moving forward.

From: Toucan, To:  Nita  Date: 4/26/2002 8:36:56 PM    Subject: Reply to: Why do you use?

Hi Nita, I'm shy by nature. Alcohol makes me more open and free. I drink sometimes when I'm depressed even though I know, alcohol is depressant and I'll be more depressed later. Sometimes it's just for fun. But it is no fun anymore. I guess I was still in denial. I was reading Twenty-Four Hours a Day book today April 26, and my answer is right there. I must go and never stop going to AA. Stop submitting myself to liquor, instead submit myself to a Power greater which I call God. I believe I've done that this time. I'm hurting so bad inside, for what I've done, for my relapse. And I know it has happened only because I'm stubborn, too self-confident, I wanted to stay sober without AA. I thought, I could do it without a help of others. Love Toucan

From: Toucan, To: Nita   Date: 4/27/2002 5:24:14 PM    Subject: Anxiety

Hi Nita, I have so much anxiety, it's driving me crazy. I do not know how to deal with it. Can you help? I can't sleep, I can't eat I can't stay still. Love Toucan

The above email seems to have been missed by the counselor.  There is no sign of further exploration of the sources of anxiety.  The counselor, however, returns quickly to the exploration of clients’ ambivalence about alcohol use.

From: Nita, To: Toucan   Date: 4/29/2002 10:05:18 AM    Subject: I want to be sure I understand

Hi Well first I have to apologize for not responding immediately. I was very sick this weekend, this is the first day that I have been able to get up. This is Nita. You are saying that the good things for you are that alcohol makes you feel free, maybe less inhibited. And then sometimes you drink because you are depressed. Is there anything else? As far as the relapse is concerned, it's important that you move on. Don't beat yourself in the head about it, realize and acknowledge the circumstances that put you in that mode and work at not allowing it to happen again. One important thing you seem to acknowledge is that you can't do it alone. Do you have a sponsor at AA, are you attending regular

meetings, are there friends or meeting members that you can socialize and communicate with? Some of the anxiety could be because you are not using your time wisely. An idol mind is dangerous. You said that you are not working any more, so what do you do during the day? Tell me about you. Education, professional skills, family and hobbies. I look forward to hearing from you. Read this email carefully and don't continue to hold one woman committee meeting in your head.

From: Toucan, To:  Nita   Date: 4/29/2002 8:21:44 PM    Subject: Reply to: I want to be sure I understand

Hi Nita, yes, I started to go to AA again. And I do not have sponsor yet, even though I know I should by now. During the first few days after I came from detox I cleaned my apartment, and did a lot of laundry. I did not do anything during my binge. So this place looked like pigs did lived here. Also I was afraid to go outside. Panic attacks and anxiety just took over me. I spend most of my time on phone if I needed to talk to somebody. Now I'm looking for some job. I have a lot of debt which I have to pay off, otherwise I will have to call for bankruptcy, which I don't want to do. Those feelings I did have when I drunk that is hopefully in the past. But I need some therapy and time to heal. Yes, sometime I feel as to have a drink, to calm me down, but I know I can't, I know my problems will be worst. Love Toucan 

From: Toucan, To: Nita Date: 4/30/2002 8:08:18 PM    Subject: Reply to: Consequences of use

Hi Nita, I know, I caused all my problems, and the anxiety is a result of them. I had to take care of important things, like charity care. I was in a few hospitals during my binge and have no medical insurance. I have no means to pay for hospital by myself. I check the papers for ads, call, and go for interviews. I was in a few places to apply. We go to the AA at night. And I talk to people before and after the meetings. I was told long time ago, when I first joined AA, not to ask people for job, it should be recovery only. It would be different if I new somebody well. I told to a few friends I still have that I'm looking for job, and they are trying to help as well. Situation is not very good with jobs now. Everybody is downsizing. I'm dealing with my anxiety as good as I can. Don't be concerned. I will not drink over it. I'll call you before I pick up. Besides my memory of drinking is to fresh and too pain full for me to pick a drink know. Sorry for my English, I'm a foreigner Love Toucan. 

From: Toucan, To:  Nita   Date: 5/22/2002 8:51:39 AM    Subject: Reply to: Consequences of use

Hi Nita, even though I'm working all this hours, I'm barely able to pay my bills. So money is my big concern. Than my son lives with my sister and I want him back. I know she takes good care of him but I know he needs me, and want's to be with us as well. I know I can't do anything about it and it's killing me. He is a victim of my drinking, he suffers, and I don't know how to ease his pain. It's going to take a time to put my life back to normal, but how do you explain that to a child? He sees his mother sober, and doesn't understand why he cannot come home. 

From: Toucan, To:  Nita   Date: 5/22/2002 10:33:54 PM Subject: Reply to: I see how this concerns you

Hi Nita, If a friend would be telling me about the same problems I have my advise would be to take it easy. You can't fix everything overnight. Do what ever you can, have faith, things will get better in time. Nita, I know it will take time, but my son doesn't. He is still a kid who wants to be with his mommy. I live my life today on daily basis. I don't even think about tomorrow. I would get crazy if I did. And yes I have faith. I don't think God saved me, to let me down now. Love Toucan 

From: Toucan, To:  Nita   Date: 5/24/2002 8:28:13 AM    Subject: Reply to: Future focus

Hi Nita, I spend as much time with my son as I can, I'm trying to make the best of the situation. He did have a counseling in the past so I really don’t know what more I can do for him. I do not have concerns about the future. I don't think that far. I believe, in time I'll be O.K. My life will be better. I'm very stubborn by nature, and I get what I want if I put my mind into it. Besides nothing can be worst than drinking your life away! And I can see it in AA. Everybody got better, why shouldn't I? Love Toucan  

From: Nita, To: Toucan Date: 5/28/2002 9:34:28 AM    Subject: Let's be sure Hey Toucan, It's Nita. This is a summary of what we have discussed so far. Let me see if I have a clear understanding of our discussion so far. You have several concerns. On one hand you are concerned about getting out of debt and getting your son back as well as staying sober. As far as the future goes, you feel that you don't even think in the future you are trying to live in the day and that by doing all of the things that keep you sober you will have your son with you again. Now, I have request. I want you to write out a message for me about all the things that happens to you that you do not like when you continue to drink. In a month or so from now, I will send the message back to you so that you can see the progress that you are making. As you go through recovery it is important that you remember the reasons you have decided to make changes. So why don't you reply to this message and tell me in as much detail as possible how drinking creates problems for you.          

From: Toucan, To:  Nita   Date: 5/28/2002 1:33:57 PM    Subject: Reply to: Let's be sure

Hi Nita, I responded to your request in previous letter, but I can do it again. When I drink, I hate myself, because I don't only create problems for myself, but for people I love. I loose jobs, financial security, I'm depressed, I don't clean, cook I simply don't care. And that's not me. When I'm sober I'm completely different person. Caring and loving. I know If I continue drinking I will loose even that little I have left. Maybe even my life. I know one thing for sure, I do not want to go back to that pain, loneliness and misery ever again. I deserve better and so do my love ones. Love Toucan  

Stage three:  Patient has resolved to change and take individual action. 

From: Nita, To: Toucan   Date: 6/5/2002 9:59:05 AM    Subject: Agreement on need and Individual action

Hi Toucan, This is Nita. In the past weeks, we have been talking about the consequences of your using. You have identified some of the negative consequences that you are concerned about. Lets move on and see if we can come up with a specific plan that can help you change behavior. I have mailed to your home address a brochure that I need you to sign and return. It is called "contract for change" and it highlights the activities that you should complete to help change your behavior. I should tell you that you can succeed if that is what you want to do. In the end, it all depends on what you want to accomplish. I cannot decide for you. I can only act as a coach and cheer you on when you succeed and continue to provide you with information that can help to prevent relapse. I will be back in touch shortly. 

There is no sign of progression from a resolve to change to actual detailed steps for change.  The counselor can in follow up messages explore how the client plans to change. 

Stage four:  Patient has requested for help and reviewed current friends 

            To date, there is no sign of careful exploration of friends and their contribution to Toucan’s drinking habit.  But as the emails have shown, her husband is alcoholic and she is increasingly aware of how the two of them need help.  Toucan’s care is continuing and the counselor is planning to discuss this issue.

Stage five, six and seven:  Organization of and action by recovery group 

            Toucan’s care is continuing and the counselor has not yet decided to organize a recovery team, even though she has forwarded to her a “Contract for Change” which is the first step in organizing recovery teams.

Stage eight:  Patient and the group have learned from cycles of lapse

            During the time when Toucan was in online counseling there was one major relapse.  For approximately one month Toucan did not reply to her emails.  When Toucan responds, she explains why the lack of communication had occurred, the experience and reactions to her relapse. 

From: Nita, To: Toucan   Date: 4/17/2002 8:31:53 AM    Subject: What going on?

Hi Toucan, This is Nita. I have not heard from you in at least one month. I have attempted to contact you by email and by phone but have received no responses from you. Is there a problem? I spoke with a gentleman on the phone the Tuesday 4/16, who informed that you were not available. Here is my number again, 973-951-7897

 From: Toucan, To:  Nita   Date: 4/23/2002 8:02:50 AM Subject: Reply to: I wasn't your fault

Hi Nita, as you know by now I did have a relapse. I would like to meet you in person, I really do not now what is wrong with me. I need help. I thought I knew everything and I ended up harming so many people including myself. I hope to hear from you soon love toucan 

From: Nita, To:  Toucan   Date: 4/24/2002 10:46:45 AM    Subject: Our discussions  

Hello Toucan, First I am so glad to hear from you, let me give you a big HUG!!!! Yes, I remember us talking about your relapse. Now, let's get to dealing with what is going on in your life so that another relapse may be prevented. You can do this. Don't quit now. Let's figure out together what is going on. As soon as I can arrange we will have a face to face, but in the mean time I want us to get busy dealing with all that needs to be addressed. I need for you to tell me about the relapse. Tell me what was going on prior to it during and after. Don't be afraid to be blunt, it's important that we understand the entire process in order to attempt to avoid another relapse. And just as a reminder, our discussions are confidential (between me and you) and will not be reported else where without your permission. Come on, Toucan you can do this. I am here for you. 

From: Toucan, To:  Nita   Date: 4/24/2002 8:59:49 PM    Subject: Reply to: Our discussions

Dear Nita, what happened was that not only I fired my sponsor but I stopped to go to meeting completely. Not long after, I thought I could do it by myself. I was doing fine, I did not have any urge to drink I was so self confident. One day, at the beginning of April, me and my husband went to a bakery, it was hot, and I said out of the blue "nice cold beer would be good". A bar was just across the street. We did have two at that bar. It was beginning which ended with both of us drunk at the same night. Binge lasted for 16 days. Took me to 5 hospitals and one detox. My husband is alcoholic as well. He is fine know. He went to same detox after I came back. Love Toucan  

From: Nita, To:  Toucan   Date: 4/25/2002 2:24:45 PM    Subject: Our discussions

Hi Toucan, This is Nita. Thanks for responding. I wonder if you learned anything. If so what? You seem to be on the right track, seeking help is important. Now I need you to address the following: I want to start by asking you why you are here? People have many reasons for seeking treatment. Some feel forced by others or circumstances to do it even

though they think that alcohol is not a real problem for them. Others seek it because they are tired of what alcohol has done to their lives. You obviously made a choice to go through the intake interview. But I would like to hear from you and in your words why you are here. Finally give me an idea of what your schedule is like so that we can schedule a face to face. 

Even though the counselor has responded in a positive constructive way, we would have preferred a more detailed understanding of the sequence of events leading to relapse and why it continued for 16 days.  Without such exploration, the client may not be able to prevent the relapse next time.  

Stage nine:  Patient has helped others.  

This stage is too early as client is still in the process of recovery.

Frequency of emails

             Our expectations were that clients and clinicians will have near daily communications.  At a minimum, there should be an email from the client every other day.  Data in Figure 2 describes the frequency of emails sent by Toucan.

In Figure 2, the X-axis shows days since start of online counseling.  The Y-axis shows periods when Toucan did not use the system.  In the first 2 months, there are few contacts.  There are numerous technical difficulties and reports from others that the client is using alcohol.  With the start of second month, Toucan is regularly using the system and the regular use continues for nearly three months.  A relapse occurs at the end, when the client is not available online for an extended period of time.  The last data point shows the client’s return to the system.  In general, use of the system is lower than our expectation of one email every other day.  Given that there were frequent telephone contacts, this use pattern may be reasonable.

Discussion

            This paper has presented one approach to online counseling.  We have also given a case example.  The case highlights a number of issues in online counseling.  In particular, it highlights the use of leading questions in getting clients to arrive to self-insight.  It shows how patients come back after relapse to continue with their care.  But the case also shows a number of problems.  First, it shows that the counselor may have not actively addressed client’s anxiety – though it is not clear from these transcripts if the issue was addressed in phone conversations.  It also highlights a series of technical problems in getting the client and the counselor to communicate with each other.  But taken as a whole, the case shows the start of a therapeutic relationship.  It shows how the patient was engaged and how she progressed through a number of recovery stages, including recovery from a 16 day alcohol binge.

            We have described the details of our online interventions in the hope that researchers can test and improve these interventions. Our approach, as well as all thoughtful treatment programs, is constantly in revision.  We are learning from the counselors who are actively interacting with clients.  One purpose of putting our method of online counseling on paper is to enable others to build on our experience and to change it for the better.

References

This page was created by Farrokh Alemi, Ph.D.  Last revised on 02/19/2007.  This page is part of the course on Electronic Commerce and Online Market for Health Services.  This is the session on Online Clinical Services.