A recent article from the JAMA Psychiatry points to unique challenges that mental healthcare treatment providers face when practicing telehealth for alcohol or substance use disorder (AUD/SUD) as a primary diagnosis. Notably, the authors point to the ways in which addiction treatment relies on in-person visits: “Compared with mental health, adoption of telehealth for [AUD/SUD] has been limited because [AUD/SUD] treatment often relies on frequent visits, intense monitoring through urine toxicology, and other practices that pose additional barriers,” (Lin, Fernandez, & Bonar, 2020). In an era defined by physical distancing and virtual everything, we are all specifically interested in ways to maintain health safety without compromising the quality of mental health treatment and care.
Throughout the spring of 2020, we at New Paradigm Recovery implemented telehealth practices that – while compliant with patient privacy standards – were not without inherent complication and challenge to the efficacy of care. On the plus-side, our clients were able to discreetly drop off urinalysis samples with no face-to-face interactions. New clients came in person to our offices in order to complete initial paperwork, then quickly joined the virtual world. Group, family, and individual sessions continued online. We adapted to the challenges as quickly and seamlessly as we could. Our comprehensive and holistic addiction treatment program continued unabated so that we could continue to offer the lifesaving help and resources to clients and families who desperately needed our support.
We did, however, return to in-person meetings, sessions, and groups as soon as public health guidelines allowed. Why would we do so, you may ask? If telehealth was working, why would we jump back to in-person treatment while the pandemic raged on? The answer is not very complex: engagement.
The first part of our decision to return to in-person treatment was practical: New Paradigm Recovery simply has the space to accommodate groups where physical distance and safety are ensured; we can safely seat more than 12 masked-clients with more than 6 feet of personal space in an airy group room, using air purifiers to continually circulate and clean the air. With screening protocols in place (like the ability to check client and staff temperatures and to order COVID-19 tests), distancing protocols honored within our facility, and safety and sanitation measures easily at our disposal, we were able to safely return to in-person treatment. But even if we ‘could’, the question of ‘should’ remains.
Our ‘why’ concerns the quality of care. Quality of clinical care is always the most important factor behind any decision at New Paradigm Recovery. While some research suggests that telehealth can be as effective as in-person health for mental health services, the research is limited and not widely supported. Another recent article in the Journal of Social Work Practice in the Addictions draws attention to some of the concerns:
There are obvious limitations to telemedicine for the treatment of SUD among patients that lack access to the internet or a device that can be used for audio- video conferencing … There may also be patients that have difficulty engaging in telemedicine appointments and may require in-person treatment due to the severity of their SUD and/or severe mental illness. Lastly, although most of a mental status exam can be performed adequately via telehealth, SUD populations often have an increased risk for medical comorbidities that are sometimes better assessed with an in-person physical exam. (Kleykamp, Guille, Barth, & McClure, 2020)
These limitations are inherent threats to the quality of clinical care: telehealth and tele- treatment removes engagement from the continuum of care that is always a necessary component of MH treatment and recovery from alcoholism and addiction. Engagement is not merely about establishing and maintaining connections with those around us; engagement is about establishing and maintaining connections with the people around us who understand how we feel through shared experience, those who understand our struggles, and those who can offer empathy and guidance as we endeavor to find solutions to problems that we cannot resolve on our own.
We now know the existence of isolating with family in a closed environment. While we enjoy love with our family members, we do not always share a common experiential understanding when it comes to struggling with addiction. More often than not family members have their own personal experiences and struggles with a loved one’s addiction which might prevent them from being objective, or as supportive of one another as might be beneficial. In essence: engagement is not about the presence of love. It is about acceptance, the absence of judgment, and the shared goals and experiences that are unique to an underlying series of challenges increasingly pervasive in an isolated environment.
Finally, there simply needs to be more research and more data about outcomes of telehealth in substance use treatment to give both clinicians and patients/clients a more comprehensive understanding of these practices. The current pandemic has offered the world a proving ground for the effects that isolation has on mental health, but it will take years for the consequences to be evaluated and understood.
While proud that our clients were able to continue the treatment process from the safety of their own home during quarantine periods, we are far from ready to declare telehealth for mental health the “new normal”. Telehealth is a remarkable advance; one that promises to remove some barriers to mental health care, promote overall wellness, and bring treatment options to people in otherwise underserved populations. As existing research studies are published and produce meaningful data, we look forward to understanding better the implications of new technologies in the treatment world. Until then, as long as we are able, we will be masked-up, checking temperatures, remaining six feet apart, getting vaccinated, and staying engaged. In person.
Kleykamp, B. A., Guille, C., Barth, K. S., & McClure, E. A. (2020). Substance use disorders and COVID-19: the role of telehealth in treatment and research. Journal of Social Work Practice in the Addictions, 20(3), 248-253. doi:10.1080/1533256X.2020.1793064
Lin, L. (., Fernandez, A. C., & Bonar, E. E. (2020). Telehealth for Substance-Using Populations in the Age of Coronavirus Disease 2019 Recommendations to Enhance Adoption. Journal of the American Medical Association; Psychiatry, 77(12), 1209-1210. doi:10.1001/jamapsychiatry.2020.1698