SUD Teletherapy — Bridging the Treatment Gap
Treating substance use disorders via teletherapy is growing, meeting the needs of hard-to-reach individuals and communities, and social workers are part of that expansion.
If you had asked Sherrie Rager, PhD, CADC II, BSW, MATS, whether teletherapy would be an appropriate treatment model for substance use disorders (SUD) when she first began working in the field, she admits she would have said “no way.” But that was 30 years ago and today Rager says she prefers the modality and often even sees better progress with it. Rager is the California lead counselor for WorkIt Health, which offers telehealth treatment for SUD.
Teletherapy (a form of “telehealth”) or video counseling is performed through a live video connection over the internet. It has also been referred to as “virtual counseling,” and in general, it’s the direction that the field seems to be moving. Though that’s scary for some—and raises some issues—overall, it appears that most see it as a positive.
“It’s comparable to other challenges that we face in our health care system right now where supply and demand do not always match up,” says Chuck Ingoglia, MSW, president and CEO of the National Council for Behavioral Health. “Most often this comes down to a distance problem—treatment centers being too far for many to reach. Teletherapy is a way to bridge that gap.”
AJ Peterson, vice president and general manager at Netsmart, an information technology partner to human services and postacute health services providers and organizations, says that another major challenge is that many individuals with SUD present at high-acuity settings or in emergency departments—or are found engaging with law enforcement. But he says these should not be the only entrance into treatment options. Peterson says the question is, “How can we create a wider front door for individuals with SUD to receive the services they need outside of those settings alone?”
He says one of the answers is a “digital front door.”
Peterson continues: “This new emerging model of teletherapy is providing a front door to treatment that meets individuals where they are—allowing them to receive services where and when they’re ready.”
Beyond accessibility and overcoming geographical barriers, Rager says she has witnessed an additional benefit to telehealth—treatment progress.
“When I started out, I was worried about not seeing the individual’s body language and what that would mean for our session,” Rager shares. “However, I have found that when I am meeting with someone on video, they tend to be more comfortable and actually disclose more because they are sitting in their living room or a personal space of their own. That has had a huge impact on the progress that we make and has led me to prefer this modality in many ways. We can be incredibly successful.”
Given the rise of opioid use disorder (OUD), Rager says that teletherapy can play an especially vital role.
“Looking at how widespread OUD is in this country, the last thing that we want to do is put up any barriers that would prevent individuals from receiving the treatment options they need,” Rager says. “Telehealth, in general, takes away those barriers. As social workers, we need to meet people where they’re at in order to truly help them—and that’s exactly what’s happening with these tools.”
Robert D. Ashford, MSW, executive director of Unity Recovery, a recovery community organization serving the Philadelphia area, and a recovery scientist at the University of the Sciences Substance Use Disorders Institute, says that “meeting people where they’re at,” is what it’s all about.
“As social workers, we have a responsibility to address systemic inequities that have targeted disenfranchised communities,” Ashford says. “Teletherapy and telerecovery [posttreatment care] services are one way to do that. It doesn’t matter if they’re hundreds of miles away or right down the street; with these services we can truly meet people where they’re at. It doesn’t fix the system, but it does allow us to address some of the symptoms, at a minimum—and perhaps, even one of the root causes of why these concerns are growing.”
“There are still social workers and therapists who believe that teletherapy doesn’t work as well as face-to-face therapy,” Ashford says. “But emerging research suggests it is equally as effective. It is the same standard of care and therapists are following the same code of ethics and providing the long-term engagement that people need.”
Ashford says that experiencing teletherapy firsthand will bring more social workers on board.
Ingoglia says this is already starting to happen. He sees an increasing number of social workers who are accepting that telehealth is a suitable way for people to access care.
“Most people are so used to going online for their needs—so why should accessing health care be any different?” Ingoglia says. “We have to make sure we are making these resources available when and where people need them. I think social workers have come around to that idea.”
There is also acceptance on the patient side.
“We are seeing more and more people who are already incredibly connected online, and that doesn’t vary between the general public or those engaged in SUD services” Ashford says. “Because of their comfort level with using online tools, they’re willing to receive support this way.”
But in addition to social worker acceptance, Ashford says another barrier to expanding telehealth has been payment models. Fortunately, that’s also starting to change.
“I’ve noticed with my own insurance company that telehealth is a covered option,” Ingoglia adds. “I think as coverage expands, telehealth will continue to grow.”
All things considered, if telehealth can support social workers, it will naturally be better received. It circles back to the social determinants of health, Peterson adds.
“At the end of the day, social workers are focused on caring for the individuals they serve to the best of their ability and telehealth supports that effort,” Peterson says. “Even looking at the high rates of no-shows and missed appointments. So often, clients are challenged by transportation or other barriers. If we can offer a them a telehealth session, we can help overcome that barrier. We help the social worker to be even more effective in their treatment approach.”
Peterson says this also helps social workers to best use their time. Often, they are required to be at multiple facilities in a single day. Peterson says that telehealth “cuts down windshield time” and allows social workers to not only see more individuals in a day but also spend more time caring for individuals.
“I believe that as social workers see how efficient and effective telehealth can make them, they will be increasingly inclined to accept that help,” Peterson says.
Sean Erreger, LCSW, MSW, author of the Stuck on Social Work blog, says that social workers can protect their patients’ privacy by “vetting telehealth providers” that they may be referring them to.
“You should look for their privacy statement and understand how they are going to protect patient information,” Erreger says. “How will they use that data? Will they ever sell it to a third party? We really do need to be asking a lot of questions about our health data—particularly any time that we are giving it to a company.”
Erreger ultimately sees telehealth as a positive but says that should not mean that we become complacent with privacy concerns.
Ashford agrees that privacy issues are valid but is also wary of them being used to hold people back from vital services.
“Privacy is a valid concern and as social workers, we really are committed to the privacy of our clients,” Ashford says. “For some, being HIPAA compliant is not enough. But 42 CFR Part 2 is more stringent—and as a field, we are calling for even more compliance with not only HIPAA but also 42 CFR Part 2.”
According to the United States Department of Health & Human Services, the 42 CFR Part 2 regulations serve to protect patient records for those in treatment of SUD. A revision of Part 2 specifically aims to facilitate better coordination of care for SUDs—which may enhance care for OUD, according to some advocates for the change.
Peterson says he believes there is more of a movement within segments of the industry to form legislation that aligns 42 CFR Part 2 with HIPAA as a means to be able to help treat individuals more holistically.
“As we move more toward value-based care, I think there is more recognition of looking at the individual as a whole,” Peterson says. “That means not only their physical health but [also] their behavioral health and their history of SUD. There is a demand for a more complete view and the only way to do that is through sharing data across providers—the integration of electronic health records with a telehealth component.”
Peterson says he sees the solution coming as a balance.
“The best quality of care will come when we can share information that allows providers to sustain a collaborative manner of care while continuing to adhere to consumer rights,” Peterson says. “We must find that balance.”
While Ashford admits that privacy is rightfully a concern that social workers have, he says we must not let it hold us back; rather, those concerns should be used to leverage change.
“We have a fundamental responsibility to support this marginalized group of people with SUD, and technology is a valuable way to do just that,” Ashford says. “But there are those who are reluctant and who fall back on the privacy issue as a reason that we should not move forward. It’s being addressed real-time and the best way to push the issue forward is to get involved in the process. We are doing a better job at supporting privacy than ever before. So while we should certainly do what we can to advocate for our patients’ privacy, we should not let those concerns hold us back from getting them the help they need. Ultimately that is a great disservice.”
Telehealth Delivers Solutions on the Posttreatment Side, Too
However, the other is the “telerecovery” side of services, Ashford explains. Telerecovery focuses on posttreatment care and utilizes those telehealth capabilities for case management or peer-based recovery support services. The latter has more of a long-term component to it and may be utilized by patients for years to come. Both are critical for social workers to know about.
WEconnect Health Management, a digital solution for SUD, has been looking at the recovery piece. Its founders—Daniela Luzi Tudor and Murphy Jensen—were both in long-term recovery and struggling with support that they needed to thrive. Tudor has said that after a 28-day treatment period, you’re left with a piece of paper and pretty much told, “Good luck! Find your way through recovery.”
From that desire for a better solution to preventing relapse, WEconnect was born.
“What we found was that there were three main barriers to remaining in long-term recovery—a lack of connection with a support group, accountability, and a lack of an incentive,” explains Paul Campbell, chief operating officer. “Our solution is a mobile application that addresses those three main barriers. When we started looking at what would solve the most challenges, we thought about the fact that everyone has a mobile device on them—and that’s powerful. It’s something that is in everyone’s pocket at all times.”
WEconnect creates accountability by having users enter data about appointments they are scheduled to attend as part of their care plan. When they follow through, they can earn Amazon gift cards for staying on track with accountability.
The connection piece is also addressed with a HIPAA-compliant messaging platform that allows the user to connect with a case manager, a counselor, or even a peer. WEconnect also maintains a peer recovery support specialist on their team who can provide suggestions to people on the recovery journey.
“All of this data is connected in a dashboard feature which would allow the individual’s care team to have some visibility into their path to recovery,” Campbell shares. “This might bring to light areas where someone is struggling and needs more support.”
On the Path to the Future
“I see telehealth and social workers as working together, with telehealth capabilities providing valuable support to social workers where they need it most,” Ingoglia says. “I don’t know of anywhere in this country where we have too many behavioral health professionals on staff. Social workers are in increasing demand. In general, there is a shortage of qualified health care professionals out there. But telehealth is providing solutions.”
There’s no doubt that technology is advancing, and social workers need to stay abreast of changes. But Erreger adds that he does not see technology as the “be-all, end-all.”
“I don’t think there will ever be a time when it’s appropriate to replace all face-to-face connection with telehealth options,” Erreger says. “Even so, I think telehealth can be a very valuable tool for our industry. It can help social workers reach even more clients and it can help those in treatment to receive additional support.”
The bottom line, Ingoglia says, is that technology is going to continue to advance—and potentially disrupt the way that things have always been done. It’s already happening in so many other sectors and social workers must be prepared for the way in which it will change the field.
The time has come for that change, Ashford adds.
“It’s time to do something different,” he continues. “We have relied on an antiquated system of care for too long now. It asks people to overcome so many barriers just to receive care. It’s 2020, and social workers as a profession must begin to recognize that true change is going to come on the back of technology.”
“The question is, do you want to be on the front lines of that change or standing in the back?” Ingoglia asks. “I think the majority of social workers are ready and willing to learn about and accept change as it comes.”
— Lindsey Getz is a Royersford, PA-based freelance writer.