Valley Hope Association Accessible Care Effective Support Services AC/ESS Programming

1. Valley Hope AssociationAccessible Care Effective Support Services AC/ESS Programming Holly Krebsbach, MS, LPC, LISAC Corporate Clinical Supervisor Outpatient Services

2. Objectives • 1. Definition of internet therapy • 2. Guidelines for internet therapy • 3. Resistance in the counseling field • 4. Multi-Modality approach • 5. Valley Hope Accessible Effective Support Services (AC/ESS)

3. What is Online Therapy • Online or Internet therapy or counseling, Is referred to as ongoing, interactive, text-based, electronic communication between a client and a mental health professional aimed at behavioral or mental health improvement. • Telehealthcan be defined as the use of telecommunications and information technologies to provide access to health information, assessment, diagnosis, intervention, consultation, supervision, education, and follow-up programs across geographical distance (Glueckauf, Pickett, Ketterson, Loomis, & Rozensky, 2003; Glueckauf, Whitton, & Nickelson, 2002; Liss, Glueckauf, & Ecklund-Johnson, 2002; Nickelson, 1998). • E-therapyis defined as “…a new modality of helping people resolve life and relationship issues. It utilizes the power and convenience of the Internet to allow simultaneous (synchronous) and time-delayed (asynchronous) communication between an individual and a professional”Grohol (1999). • Common terms: E-therapy, online counseling, cyber therapy, web counseling, and computer-mediated psychotherapy.

4. Online Therapy • Synchronous Environment • Provide a real-time link between users computers • Shared Hypermedia – Instant messaging • Asynchronous Environment • Occurs when communication is not simultaneous or in live time • Similar to message boards

5. Guidelines for Online Therapy • ACA, AMA, APA, and AMHCA have all published specific internet guidelines or advisory statements for their members and many others have embedded guidelines for e-therapy in their code of ethics. • Informed Consent –MD – explanation of treatment services, counselor scope of practice, risks, alternatives for care, expectations. • Clinical practice-operating procedures • Emergencies – patients at risk, exploitation, neglect • State Guidelines vary from one state to another • Informed Consent, Mandatory disclosure, minimum requirements for computer program, emergency plan for patients in crisis, emergency plan for technical problems, record of closest mental health agency, explanation of risks, grievance process.

6. Reasons for Resistance • Expressed opinions about whether professional therapy can be done without face-to-face interaction • Ethical issues involving client protection • Unclear legal jurisdiction • Regulatory and licensure issues • Confidentiality of computer-based messages is compromised without encryption and user passwords

7. Reasons for Resistance • Verification of the age, gender, and honesty of consumer disclosures is complicated • Need for careful self-assessment of areas of professional competence and computer skills prior to the initiation of any online clinical service.

8. Reasons for Resistance • Obstacles to getting help to e-clients in crisis or at risk for harming others is also a serious ethical issue for e-therapists who may be thousands of miles (and several time zones) away from the client. • Possibility of technological failure always exists

9. Research • A majority of e-therapy web sites have been developed by people identifying themselves as mental health professionals, though they are not. High level of non-compliance with informed consent and all other APA guidelines. • Studies comparing e-therapy with traditional psychotherapy, suggest that some people find it easier to self-disclose on the computer than in face-to-face situations. • Therapeutic alliances in e-therapy are similar to the alliances formed in face-to-face treatment . • Studies comparing traditional therapy with e-therapy found that e-therapy outcomes generally parallel traditional service. • Some consumers seem to find the convenience, economy, and relative anonymity of e-therapy attractive. • Heinlen, K., Welfel, E., Richmond, E., & O'Donnell, M. (2003). The nature, scope, and ethics of psychologists' e-therapy Web sites: What consumers find when surfing the Web. Psychotherapy: Theory, Research, Practice, Training, 40(1), 112-124.

10. HIPPA Requirements • Electronic Means of Communication • HIPPA required confidentiality • Patients are protected as cited by federal laws: • (See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR, Part 2 for Federal Regulations). • Releases of information disclosure only unless there is a threat to self or others

11. Valley Hope’s Compliance • Patient signs a consent for treatment • Detailed outline of treatment services, electronic means info, grievance, cost of treatment, limitations and risks-outline expectations. • Mandatory Disclosures • Confidentiality • Website is secure • Access to the website done by authorization only • Encrypted website • Three levels of security • Time out for patients inactive in the system • All inclusive website: Electronic documents, private messages, group discussion and individual assignments are transmitted within this website only.

12. AC/ESS Programming • Intention of developing program is to reach populations that are underserved • Rural areas • Physical disabilities or ailments that prohibit attendance of traditional outpatient programming • Driving restrictions • Work schedule that prevents patients from consistently attending traditional programming • Unique circumstance where outpatient would not be feasible • Removes Barriers to Treatment for patients /family

13. AC/ESS Programming • AC/ESS programming is a multi-modality program. • Includes in person clinical assessment, treatment planning, additional assessment for appropriateness for the AC/ESS program and individual sessions. • Phone therapy when sessions are not able to be done in person • Online therapy room with group members • 18 modules includes individual lectures and assignments • Individualized treatment

14. AC/ESS IOP • Intensive Outpatient Programming (IOP) • 9 hours per week of therapy • Individual, marital and family sessions as it pertains to the addiction • Chaplain sessions offered • Family program attached to the IOP program

15. Additional Features • Offline attendance – counselors can input time spent with the patient in treatment planning, individual sessions, family sessions, and chaplain. This adds to cumulative total for an accurate account of time per week spent in IOP. • Survey results – IOP and CC patients are asked to take a Please Help US survey at specific times in their treatment episode. This helps Valley Hope to gather recovery data and patient satisfaction data. This can be submitted anonymously. • IOP the survey is given at admission, 3 weeks and 6 weeks into treatment. • CC the survey is given at 3, 6,9, and 12 months. • Supervisors have access to staff attendance and staff private messages. Supervisors can also view journals.

16. AC/ESS Family IOP • Created for family members to be involved in a primary level of care. • Length of program is 3 weeks • 9 hours per week • 1 individual face to face session or phone session per week • Chaplain availability • Family sessions available • Daily discussion topic in therapy room • 11 Educational modules in online therapy room with lectures and assignments that must be completed each week. • Group therapy in the online therapy room • Private message communication in online therapy room

17. AC/ESS Continuing Care • 1 hour per week of online therapy • Individualized treatment for level one programming • Phone or in person therapy offered

18. AC/ESS Concurrent Programming • Patients attend on ground group therapy once per week and online one hour per week. • Two hours of group therapy per week for one year. • Accountability increased • Accessibility to counselors and group increased. • Flexibility to both options is attractive to patients.

19. Data for AC/ESS • After two years of programming data was gathered • Compared four data sets of 50 patients in each set • The data set was on ground IOP, on ground continuing care, AC/ESS IOP and AC/ESS continuing care.

20. Demo Room for IOP

21. Demo Room for IOP

22. Demo room for IOP

23. Data for Length of Stay • Compared length of stay for continuing care • Average length of stay (ALOS) for patients discharged from AC/ESS continuing care was 28.8 weeks in treatment compared to 19.01 weeks in treatment for patients discharged from on-ground continuing care.

24. Length of Stay for IOP • AC/ESS comparative to on ground Services • At 5.54 average weeks in treatment AC/ESS patients length of stay is greater than the 4.24 weeks in treatment reported for on-ground patients.

25. Sobriety Data • 74 percent of AC/ESS CC (continuing care) patients remained sober through the entire treatment episode compared to 62 percent of the on-ground patients. • Similarly, 80 percent of AC/ESS IOP patients remained sober through the entire treatment episode compared to 58 percent for on-ground patients. The results were similar for the other sobriety measures.

26. Sobriety Data • AC/ESS patients were less likely to relapse than on-ground patients and the rate of sober discharge was higher for AC/ESS patients than for on-ground patients.

27. Family Participation • In the AC/ESS IOP family program, family member data showed the following: • 45 out of the 50 AC/ESS IOP patients episodes included family participation. For on-ground patients 29 out of 50 episodes included family participation. • This may be due to flexibility of program. • Could eliminate the shame or fears of expressing feelings around addiction for family. • Removal of barriers

28. New Statistics for AC/ESS • Time between online logins • 1.48 Days • Average Minutes Per Session • 25.41 Minutes • Average Sessions Per Week • 4.73 Per week • Average Minutes Per week • 120.2 Per week

29. New Statistics for AC/ESS • Data shows that patients log on frequently • Average is 25 minutes per log in • Patients average 2 hours per week online • Data are from the sample of actual AC/ESS continuing care patients that were active on 8/16/2010 after removing 3 percent of the largest outliers and 3 percent of the smallest outliers as measured by days in treatment since admission, count of sessions logged, and total login time. The result was n=311. The 18 outlier records were removed from the sample to ensure data showed typical program results.

30. Summation of Data • Valley Hope has delivered care via the AC/ESS option for more than four years and the outcome data clearly suggest that AC/ESS produces treatment outcomes on the various measures included in this report that are equal to or more effective than the outcomes produced by on-ground treatment programs.

31. DUI Programming • DUI Screening • Must be conducted in person • DUI Education • 16 hours of group and individualized programming • DUI Treatment • 32 hours or more of DUI treatment • First online DUI program in the State of Arizona

32. Questions? • For further questions on this program please email Holly Krebsbach at hollyk@valleyhope.org. • Visit our website at www.valleyhope.org