Embracing Change: Audio-Only Telehealth: Expanding Access to SUD Treatment/Recovery Services

By Nancy Roget, Cindy Juntunen & Trisha Dudkowski, Mountain Plains ATTC

The onset of the COVID-19 Public Health Emergency (PHE) in 2020 forced many Substance Use Disorders (SUD) treatment and recovery support providers to rapidly switch to virtual and/or telephone-based services. For some providers, as their proficiency and confidence grew, their adoption of videoconferencing and telephone to deliver services increased.

Shore (2020) predicted that lessons learned during the quick virtualization of behavioral health services, due to the PHE, would create a new hybrid model of service delivery that benefits patients. In this hybrid model, treatment services are inclusive, providing a combination of in-person, online, and telephone sessions, including check-ins or consultations.

The following narrative includes literature support for telephone-based services; guidance from the Office of Civil Rights (OCR) and recommendations for a new term; and a novel product for SUD treatment/recovery support providers in delivering telephone-based services created by the Pacific Southwest and Mountain Plains ATTCs.

The use of telephone to provide behavioral health treatment and crisis intervention (think hotlines) services is not new. 

Moreover, Lin’s (2022) analysis of studies examining virtual service delivery found that clients participating in telephone therapy had lower attrition rates (dropping out) than in-person therapy or videoconferencing sessions. Researchers attribute the lower attrition rates with telephone sessions to not needing Internet access or specialized equipment like monitors, laptops, or tablets.
This finding underscores the importance of providing training on client engagement strategies for both virtual and in-person service delivery.
In summary: 

• Clients/patients/peers like hybrid service delivery including AOTs. 

• Outcomes for AOTs are as good as in-person/videoconferencing sessions. 

• Some studies showed that drop-out rates were lower with AOTs. 

• Mastery of engagement strategies are helpful when using AOTs A majority of clients/patients have access to mobile phones. 

• Challenges to implementing AOTs exist but can be addressed through training and policies/ practices.

Telephone-based mental health services for individuals with psychiatric disorders has strong literature support. Leach and Christensen (2016) identified 14 studies that found positive outcomes due to telephone-based services.

More recently, Varker et al. (2019) conducted a review of telepsychology studies and found that in ten out of eleven telephone studies, telephone delivered therapy was as effective as traditional in-person therapy. Another systematic review conducted by Irvine and colleagues (2020) found telephone sessions tended to be shorter in duration, and demonstrated no significant differences in therapeutic alliance, client disclosure, empathy, attentiveness by the counselor, or client participation. Several studies included in this systematic review (Irvine) noted that clients gave telephone-based services higher ratings identifying how closely counselors listened.

Finally, a study by Zin and colleagues (2021) identified that newer therapists had higher client attrition rates than more experienced therapists in both videoconferencing and telephone sessions. The authors posit that experienced therapists were more proficient in client engagement strategies and utilized/relied upon these strategies frequently in virtual service delivery. 

A survey by Pew Research Center (April 2021) found that 97% of the U.S. population owned mobile phones. Likewise, clients/patients with substance use disorders (SUDs) reported high mobile phone ownership. Two studies found mobile phone ownership rates for SUD patients were 93%--95%, matching national data (Ashford et al., 2018; Winstanley et al., 2018). However, patients with SUDs may have unique phone ownership characteristics that present considerations.

For example, Milward (2015) found that almost three-fourths of clients/patients had ‘pay as you go cell phones’, and more than half had their phone numbers had changed in the last year. This information can prompt SUD treatment/recovery support providers to check with clients/patients regarding changes to mobile phone plans to ensure minutes are available for sessions and if mobile phone numbers changed.

In June, The Office of Civil Rights (OCR) recommended strategies to protect privacy/security and suggested using a new term for telephone-based services: audio-only telehealth services (AOTs). The utility and benefits of AOTs for clients and treatment providers are notable. Nevertheless, challenges exist to effective, safe, and ethical services delivery using AOTs requiring specific policies and practices, compliance monitoring, and ongoing training. A seminal article by Brenes (2011) identified challenges provider faced when implementing AOTs which serves as the foundation for these sample policies/practices. This new PSATTC/MPATTC product addresses these challenges, along with specific AOTs tips. The AOTs product can be found here.

Author bios:

Nancy Roget is the Co-Director of the MPATTC and Executive Director of CASAT at the University of Nevada. She’s also a licensed marriage and family therapist, addiction counselor, and trainer on telehealth and digital health technologies.

Cindy Juntunen is Co-Director of the MPATTC and Dean of the College of Education & Human Development at the University of North Dakota. She is also a licensed psychologist in North Dakota, and has a long history of training and education in rural behavioral health and ethics. 

Trisha Dudkowski is a Senior Project Coordinator with the Mountain Plains ATTC and has been part of the ATTC network for nine years. She does logistical organization for training/TA activities, such as facilitating online events, planning in-person state/regional/national training events, and preparing/editing training materials.

Embracing Change: Mapping Problems and Solutions in Troubled Times—The South Carolina Cognitive Behavior Therapy Training Initiative

By Pamela Woll, Southeast Addiction Technology Transfer Center

Like much of the substance use disorders (SUD) treatment field, South Carolina’s providers experienced the early impact of COVID-19 as a steep rise in the need for services combined with a steep decline in capacity to meet that need. In communities, fear, isolation, loneliness, and financial stress escalated, while social support diminished. Traditionally marginalized populations were disproportionately affected.

Many individuals were already deeply troubled long before the pandemic hit. For decades, more and more people had been: 

• suffering the effects of early, chronic, intergenerational, historical, and/or racial trauma; 
• deeply affected by inequities and disparities in the social determinants of health, diminishing their resilience and resources;
• afflicted with multiple substance use disorders, mental health conditions, and chronic physical health conditions; and/or 
• bearing the social, psychological, and financial burdens of years spent in the foster care, juvenile justice, and/or criminal justice systems, or on the street.

 Meanwhile, the pandemic made in-person services more dangerous, so the field experienced severe reductions in resources, treatment capacity, time to connect with clients, and face-to-face mentorship and peer support for staff. Clinicians needed training in interventions that would: 

• be easily transferrable to Zoom and telehealth; allow practitioners to make more progress in shorter sessions; 
• provide coping skills to help clients solve problems even with reduced clinical and social support;
• and include clinical supervision, booster sessions, mentorship, training of trainers, and support for fidelity.

One category of interventions that fit all those criteria was Cognitive Behavior Therapy (CBT), a well-supported evidence-based approach that helps people learn to work with the thoughts, feelings, and actions that keep them stuck in counterproductive patterns (Carroll & Kulik, 2017, p. 847).

The South Carolina Cognitive Behavior Therapy Training Initiative

In 2020, Roberta Braneck, State Opioid Response Director for South Carolina’s Department of Alcohol and Other Drug Abuse Services (DAODAS), requested intensive training on CBT across the statewide system. The Southeast Addiction Technology Transfer Center (SATTC) responded through the efforts of James Campbell, LPC, LAC, MAC, AADC, Training and Technical Assistance Manager.

Together they identified a trainer for the series, R. Trent Codd, III, EdS, LCMHC, Executive Director, CBT Center of Western North Carolina. The team developed a strategic training plan, using implementation science principles to foster sustainability and maintain clinical gains far beyond the end of the formal initiative.

The series began in the first five months of 2021, with multiple sessions in each step of a process that included:

• Initial Training (four hours), Skill-Building Sessions (six hours), 
• Clinical Supervision Sessions (eight hours), 
• Booster Sessions (four hours), and 
• Training of Trainers (four hours).

 A total of 170 participants logged into the initial general content session, with subsequent sessions tailored to smaller groups to increase opportunities for discussion and skill practice. 

 A Focus on Conceptualization

The training subject might not be on the cutting edge, but the trainer’s approach has been innovative and well-tailored to our contemporary challenges. According to Codd, the series has focused, not on the activities that most people think of when they hear “CBT,” but on the conceptualizations that guide clinical decision making.

“I’m a big believer that the conceptualization is one of the biggest things that defines CBT,” Codd said. “The interventions are almost secondary to how people conceptualize what is maintaining the client’s problems, and how they use that conceptualization to develop their treatment targets. If you focus on the technique itself, that’s just the shiny object. Outcomes are really related to the conceptualization, not the interventions.”

The CBT conceptualization process helps clinicians encompass the many thoughts, feelings, and actions that clients disclose, allowing them to isolate those that offer the best opportunities for intervention. If clinicians work in teams, conceptualization can help the team create a shared “map” for more effective communication.

According to Codd, one of the most important reasons for a focus on conceptualization is the complexity of the internal, relational, and environmental challenges that many clients are facing. “Conceptualization tells the clinician how to modify the treatment based on all these factors,” he said. “It’s not a magic pill, but it gives clinicians a good working map that they can flexibly adapt across a wide range of factors.”

Participant evaluations and individual feedback showed strong positive responses to Phase One, though the most valuable data will not be available until the Initiative’s next phase. It starts with a six-hour CBT Fidelity Training in October 2022, with registration still open to South Carolina practitioners.

Reference

Carroll, K.M. and Kiluk, B.D. (2017). Cognitive behavioral interventions for alcohol and drug use disorders: Through the Stage Model and back again. Psychology of Addictive Behaviors, 31(8), 847-861.