Recovery in a Digital World — Evaluating the Options
Isolation, stigma, and disconnection from traditional in-person models can challenge addiction recovery. Online platforms and applications offer alternatives, but must still bridge the economic divide.
Today, everything is online, even complex mental health care and recovery. Consumer demand for health-related applications has extended the reach of in-person visits, reduced costs, broadened geographical access, and reduced stigma. Not surprisingly, the digital world is now intersecting with the recovery world as a modern day solution.
According to the American Telemedicine Association, telemedicine and telehealth have been around for almost 40 years, but the exponential growth during the past five years (76%) has garnered the attention of researchers, service providers, and users. This is particularly true of digital technology use in substance use disorder recovery.
Terminology for recovery resources available through the internet or downloadable onto a smartphone or tablet ranges from “technology-based recovery applications” (McClure, Acquavita, Harding, & Stitzer, 2013) to “technology-enhanced treatment and recovery resources” (Dugdale, Elison, Davies, Ward, & Jones, 2016). “Tele-SUD” (Huskamp et al., 2018) refers to the use of telemedicine for substance use disorders and is distinct from online applications for the public. There is no single term used for technologically based resources, resulting in confusion about what is meant by recovery in a digital world.
The distinction to be made in variations of the nomenclature is the difference between a static “recovery app” such as Hazelden’s “24 Hours a Day” or Alcoholics Anonymous’ (AA) “AA Big Book” and the interactive algorithm-driven or participatory platforms utilized by persons seeking recovery resources. The former are usually books, inspirational quotes, or resources for recovery meeting locations. “Digital recovery” is more dynamic in nature and includes interactional, sophisticated, evidence-based computing grounded in the science of addiction. In this sense, “dynamic” means ever evolving, changing, and asymmetrical in nature.
Instinctively, the availability of digital recovery could be a major breakthrough for connection to services for those most in need—remote communities and underserved populations—and remove one of the greatest barriers to accessing treatment—stigma. However, for those who are economically disadvantaged who might not own a phone for SMS or text messaging, the costs of a smartphone or tablet for availability of web-based applications may not be an option. In many ways, digital recovery has yet to bridge the economic divide.
Perhaps even more compelling, social workers and health care professionals can peer into these platforms and learn much about how recovering persons are interacting with one another and facing individual and group challenges, and how they are not only solving their own problems but also helping solve those “of the whole.” As one member posted on the message board: “The wisdom of the we is greater than the knowledge of the I.”
SMART Recovery: www.smartrecovery.org
A. Thomas Horvath, PhD, is one of the original SMART board members and was president of SMART Recovery for 20 years. He is also the founder and CEO of Practical Recovery, a San Diego–based outpatient treatment center that offers an alternative to residential treatment, one based on multiple individual sessions per day. Horvath is also the past president of the American Psychological Association’s Society of Addiction Psychology (Division 50).
Horvath explains that when SMART Recovery first began, there were “few face-to-face meetings available, but [there was] the need to have thousands of these meetings” in America. As people learned about the existence of SMART, many requested access to its services. The internet had barely begun, but “very quickly, SMART Recovery had a message board and online meetings” that “became a lifeline to SMART members.”
Horvath says, “SMART Recovery would not have been what it is today had the internet not been around.”
Connection is a vital element of SMART Recovery’s success. From its early days to today, thousands of individuals have connected to a recovery process and each other for support. Horvath says, “SMART Recovery can reach and connect people who are not connected, filling a need for thousands across the U.S., who don’t have face-to-face meetings available to them.”
Research conducted by Dugdale et al. (2016) found that the majority of online resources relating to treatment and recovery from substance use disorders suggest “online recovery forums are the most highly accessed type of online resource.”
In addition to online community meetings and message boarding, SMART Recovery offers self-assessment opportunities for individuals and professionals as well as a “toolbox” of worksheets, podcasts, rational coping statements, relapse prevention, articles, reading lists, and a SMART Recovery dictionary. A Facebook page enhances the online community with more than 17,000 members.
According to Horvath, his treatment center, Practical Recovery, “was the first to put artificial intelligence for mental evaluation (AIME) in place,” expanding the evidence-based resources offered. Additionally, there is interest in SMART hosting a virtual reality platform to improve connection. In the future, he hopes to explore conducting online SMART meetings using a bot (software) that would eliminate the need for volunteers to lead the meetings, making meetings available worldwide, 24/7.
“Substance use disorders can come from a lack of connection, so offering connections is one way to reduce that issue. Having said that, there is a segment of the population that does not feel secure in their ability to connect, so they might find the online relationship more challenging,” Horvath says.
Dugdale et al. found qualitative data to “suggest that face-to-face, physical contact with others in the offline world may not be as necessary as previously assumed for creating a sense of connection between people” (2016). Many in the Dugdale research cohort reported they were “in recovery” and utilized digital technology to “help sustain abstinence” and “give back to the community” by supporting others.
Christi Alicea, assistant executive director of SMART Recovery, oversees the central training and development and works with SMART volunteers for continued education and resolving conflicts in meetings if they arise. Alicea says, “In 2014 we had 17,150 registered users, and today in 2019 we see 22,231.” Meetings have increased from “26 meetings per week in 2014 to 36 per week in 2019.” Data gathered from online surveys reflect a demographic of “almost evenly balanced male to female ratio (52% to 46%, respectively). The largest age group was in the 50s and 60s, and we are even seeing a presence of individuals 70s and above,” Alicea says. She adds, “A small percentage of our users participated in the survey; we know that we have a broader demographic than what our numbers reflect and are looking to capture that information.”
SMART transitioned to a new web platform in 2016 that included expanding online meetings to a free video-conferencing platform called Zoom. Alicea says, “Zoom allows our users to connect visually as well as voice-only, and use SMART on an iPhone, tablet, laptop, or desktop. With technology improving rapidly, the availability is expanding and the connections are strengthened.” With these options, the online community is able to reach younger populations and those in rural areas, as well as daily commuters who can connect while on a bus or train.
CheckUp & Choices: www.checkupandchoices.com
Hester, director of CheckUp & Choices’ research division, says, “From the start we had a vision to have an integrated protocol for people that would be soup to nuts,” offering to “help them resolve ambivalence.” People who are unsure whether their drinking is a problem can engage a process that can help them resolve their ambivalence and then “help them identify the triggers, and guide change-plans to deal with them,” Hester says.
CheckUp & Choices uses the elements of motivational interviewing to determine the user’s stage of change and then create a customized plan that “provides detailed feedback and is anonymous, with no stigmatization, no labels, and no problems with child care,” Hester explains. “Two-thirds of our subscribers are women. Those with children are less likely to seek help. There are no labels attached and the confidential assurance gives them an opportunity to seek an evaluation in the privacy of their own home.”
Once a user has engaged in the full assessment phase, the choices modules in CheckUp & Choices asks subscribers to set up customized e-mail and text messages “reminding them of the change plan. These can be empowering messages, encouraging, and positive feedback” supporting “wise decisions,” Hester says. Subscriptions are offered at three-month increments, or one year, with a 100% money back guarantee. According to Hester, 40% to 50% of users renew each year. CheckUp & Choices has a significant Facebook presence with daily articles, posts, and shares.
Hester sees technology as an opportunity to reach a wider and more diverse audience to help with mental health and particularly alcohol problems. Hester says, “Alcohol kills more people annually than drugs, and one-quarter of clients in the mental health field engages in hazardous alcohol use.” CheckUp & Choices can be used by a broad spectrum of providers: doctors, nurses, social workers, and other health care professionals, to name a few. One simple screening question will provide enough information to recommend directing an individual to the site. From there, “If they have an interest in changing, they have numerous resources to use. But if they don’t want to change, nothing will help,” Hester says.
Referred to as the “health club for your mind,” myStrength was developed as a complement to in-person sources of care in the behavioral profession. Accessibility devoid of stigma, including clinical assessment, emotional health goals, wellness focus, and inspirational and/or spiritual options provide an integrated and individualized experience for the user.
The Central Kansas Foundation for addiction treatment (2018) has chosen myStrength as part of a continuum of care by offering mobile phone- and web-based behavioral health care solutions. The foundation offers its services to more than 1,900 clients across central Kansas in four locations. Each location has integrated myStrength into their current treatment and discharge plans to “empower clients with additional recovery supports via mobile devices and laptops.”
Research conducted by Hirsch et al. (2017) utilized myStrength for a 26-week randomized controlled trial to assess the effectiveness of the digital application. The results “demonstrated significantly steeper and more rapid reduction in depressive symptoms over time” compared with the control group.
Recovery 2.0: www.R20.com
The platform offers online and in-person experiences. There is an annual weeklong free online conference consisting of notable recovery experts addressing a variety of topics. In-person recovery retreats in Costa Rica and weeklong immersions at Esalen Institute or Kripalu Center for Health comprise a range of in-person offerings. Members have 24/7 access to the Recovery 2.0 Power Hour podcast, a certified coaching program, and an opportunity for an intensive spiritually based recovery immersion in India. The R20 Facebook community has more than 19,000 participants.
Recovery 2.0 attracts a large audience. Free online resources are made available for a broader audience, and Rosen offers limited scholarships to the Coaching Program and Retreats.
In The Rooms: www.intherooms.com
In The Rooms is a global resource and consists of live meetings, discussion groups, and specialty meetings such as “codependency,” “trauma and recovery,” “sexual addiction,” and “yoga recovery.” Representing dozens of “fellowships” ranging from SMART to 12-Step based groups, Refuge Recovery and Life Ring (secular-based recovery), participation is free and user friendly. Of note is the availability of specialty group meetings to serve underrepresented populations such as LGBTQ individuals. Its Facebook community is one of the largest in the field with more than 145,000 members including multiple resource feeds, articles, and daily inspirations.
Using a 24/7 web-based platform, individuals can augment their face-to-face meetings with a worldwide community. Employees staff 24/7 phones to give individuals directions to meetings in their area, answer questions, or just talk. Key is the underlying but silent message: You are not alone.
The Future of Digital Recovery
How many of these could have possibly been saved? We don’t have a conclusive answer, but we can demonstrably show hundreds of thousands of people are getting help and participating in the new digital recovery journey.
The availability of technologically based services for those who seek help for substance use disorders is far from where it could be. Access is restricted for those who cannot afford platforms that have membership fees, much less a smartphone. There is debate as to whether connections made online can be considered equivalent to the impact of face-to-face relationships. “Digital addiction” plays into arguments of overreliance on these platforms, particularly because a good deal of digital recovery also involves social media.
By becoming familiar with the benefits and risks of this domain, social workers can better educate their clients, guide them to valuable resources, and learn from the online interactions. Technology is advancing and likely will make recovery options more accessible than ever before. Knowing the limitations and the advantages will enable social workers to help empower those most in need.
— Kimberley L. Berlin, LCSW, CSAC, MAC, SAP, is an integrated addiction specialist. Her private practice, Compassionate Beginnings, LLC, is located in Leesburg, VA.
Central Kansas Foundation. (2018, September 25). CKF Addiction Treatment adds myStrength’s digital self-care resources to aid in recovery support [press release]. Retrieved from https://www.einnews.com/pr_news/462967295/ckf-addiction-treatment-adds-mystrength-s-digital-self-care-resources-to-aid-in-recovery-support.
Dugdale, S., Elison, S., Davies, G., Ward, J., Jones, M. (2016). The use of digital technology in substance misuse recovery. Journal of Psychosocial Research on Cyberspace and Cyberpsychology, 10(4), article 5.
Hirsch, A., Luellen, J., Holder, J., Steinberg, G., Dubiel, T., Blazejowskyi, A., et al. (2017). Managing depressive symptoms in the workplace using a web-based self-care tool: A pilot randomized controlled trial. Journal of Medical Internet Research, Research Protocols, 6(4), e51.
Huskamp, H., Busch, A., Souza, J., Uscher-Pines, L., Rose, S., Wilcock, A., et al. (2018). How is telemedicine being used in opioid and other substance use disorder treatment? Health Affairs, 37(12), 1940-1947.
McClure, E., Acquavita, S., Harding, E., Stitzer, M. (2013). Utilization of communication technology by patients enrolled in substance abuse treatment. Drug Alcohol Dependency, 129(1-2), 145-150.
National Highway Traffic Safety Administration. (2017). Most wanted safety list of transportation safety improvements. Retrieved from https://www.nhtsa.gov/risky-driving/drunk-driving.
National Institute on Alcohol Abuse and Alcoholism. (2018). Alcohol facts and statistics. Retrieved from https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics.