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One major upside to the covid outbreak has been discovering the amount of things that we can do remotely rather than having to spend time and money doing them in person. Two good examples would be business meetings and support groups like AA or NA which are now readily performed online. And while there are obvious limitations to this approach, e.g. not being able to pick up on the subtle social cues or ‘energy’ from other people – there are also major upsides, such as not having to drive in rush hour traffic or spend money on transport. But are these virtual alternatives really effective when it comes down to it?

One major beneficiary of this shift towards video conferencing has been the healthcare industry. While there are obviously a number of healthcare interventions that cannot take place via video link (vaccinations and surgery for example) there are numerous other procedures which can – such as diagnosis, assessment and even prescribing.

So what about behavioural healthcare services such as counselling and psychology? From talk therapy to rehab – do these things stand up to scrutiny when they are conducted online, or are they lacking in some way? Is there some vital ingredient that is missing when it is not performed in-person?

Research shows that video counselling is effective

Numerous research projects have shown that online counselling is likely to be as effective as face to face psychotherapy and there is even some evidence to suggest that it may have advantages over in-person psychotherapy under certain circumstances.

According to researchers at the University of Marburg in Germany, clients who were engaged in video counselling programmes found the experience “just as intense” as in-person therapy, and that clients were just as easily able to “create an emotional bond with the therapist”.

This has certainly been my experience. I have found little difference working with people online than face to face. If anything, I have found people to be slightly more relaxed in the online sessions due to being in the comfort of their own home, while still being perfectly able to form a good quality therapeutic relationship.

Further, clinicians and researchers at Portland State University found that online psychotherapy clients “experienced similar results compared with control groups” and that the therapeutic alliance between the practitioner and the client was “unaffected by the medium of communication”. Again, this is unsurprising, because we know that the main ingredient in successful talk therapy is what’s known as ‘therapeutic alliance’.


The counsellor-client relationship

A therapeutic alliance is a positive and growth oriented relationship that exists between a counsellor, or other psychological professional, and their client. According to early therapy pioneers like Carl Rogers, if the therapeutic alliance is weak or non-existent then the therapy is unlikely to be effective. This is the magic ingredient in talk-therapies that provides the personal growth on the part of the client. All sorts of psycho-social factors contribute to the therapeutic alliance;

  1. Unconditional positive regard: Regardless of whether the therapist actively ‘likes’ the client or not, and regardless of what they done – the therapist nevertheless refrains from judging them and shows positive regard for them.
  2. Empathy and ‘rolling with the resistance’: Regardless of what ‘resistances’ the client brings to the process, the professional ’rolls’ with them rather than dismissing them or challenging them head on. This is empathy in practice. It is based on unconditional positive regard (above).
  3. Active listening: This is very different from just listening. Active listeners remember detail, and they tend to get an idea of the speakers position without being overly influenced by their own agenda.
  4. Congruence: In modern terminology ‘being real’. The therapist should present who they really are. They are not putting on a false front or persona and to a significant extent they should practice what they preach. Another way of putting it might be to say that they have ‘integrity’. If people sense that their counsellor or therapist is ‘real’ (not fake) they will trust them and the relationship then has healing potential.

So it is not the therapy model as such that makes the difference. Regardless of whether the client is receiving CBT, Person-Centred-Therapy, ACT, EMDR, Psychodynamic counselling, or any other type of therapy – what really matters is the client-therapist relationship. Multiple studies have shown that regardless of a counsellors clinical orientation, it is their own skill set and ability to empathise constructively that makes the difference, and this skill set can be wielded as effectively online as it can be face to face.

There is even some evidence to suggest that video counselling may have some advantages over face to face counselling. Research conducted by the National Centre for PTSD (Veterans Affairs) found that online counselling could become “an important component of the future of psychotherapy and clinical practice”. This is partly because of the lower cost but also due to increased accessibility.

So it is this increased accessibility that might really make the difference in the long term. People will be able to access more therapy for less money and with far less logistical problems due to being able to simply go online from the comfort of their home. And that can only be a good thing.


So do I need to go to rehab then?

So if talk therapy works online then what about more substantial psychological services like inpatient addiction treatment? Can that be done online? The answer seems to be that there are components of inpatient addiction treatment that can be done online but certain key areas that cannot.

As anyone who has been to rehab will know, the major part of any treatment centre’s program revolves around group therapy and one-to-one therapy. And as we have already discussed, both of these things can be done very effectively online. However, we also have to consider to why people are going to an inpatient residential setting in the first place.

First, many addicted people are in need of detoxification. In other words, they are physically dependent on a drug and they require medical intervention and supervision through the process of withdrawal. It is simply unsafe to do this at home (if you are a client) or to attempt to guide someone through this process (if you are a clinician). This is especially true for people who have been using three drug types in particular;

  1. Alcohol
  2. Opioids: like heroin, Tramadol, fentanyl and OxyContin<
  3. Benzodiazepines: like Valium, Klonopin, Xanax and Ativan

For anyone who has been using these drugs for an extended period of time, the most appropriate level of care is likely to be residential because these drugs cause physical dependence with long term use. Physical withdrawal symptoms from these drug types range from the unpleasant to the downright dangerous.


Dealing with drug withdrawal

For opioid withdrawal these symptoms might include (but are not limited to); sickness, vomiting, aching body, restless legs, high blood pressure, diarrhea, fever and so on. So it is easy to see why a clinical, hospital-type environment is best. It isn’t hygienic or pleasant to undergo this process unsupported in your own home if it can be avoided. If something goes wrong it is best to have medical back-up on hand.

For benzos and alcohol the process can be a good deal more risky. High doses of benzos or alcohol over a prolonged time frame can result in symptoms such as visual and auditory hallucinations, panic attacks, extreme anxiety, tremors, seizures and even death.

Consequently, people who have been using these substances for a sustained period and at high doses will require a slow taper using other more stable alternatives. E.g.

  • Methadone or Subutex might be used to withdraw from heroin
  • Librium or Valium might be used to withdraw safely from alcohol
  • More stable benzodiazepines might be used to withdraw from less stable benzodiazepines.

These types of drugs cannot be discontinued cold turkey. On occasion, GP’s/family physicians or outpatient psychiatrists may risk overseeing a ‘home detox’ but usually people with a physical dependence on these type of depressant drugs will be referred to detox units in local hospitals or residential addiction treatment centres. (Please note: the above is not medical advice. You must consult your own physician before deciding on how to withdraw from any type of drug dependence).

So for people who have physical dependence on a drug which is dangerous to withdraw from, inpatient treatment at an actual ‘bricks and mortar’ hospital or rehab is almost certainly indicated. The first port of call should be a medical professional, most likely your GP or a psychiatrist or substance abuse specialist who can assess you accordingly, and advise you on where you need to go.


Residential addiction treatment

Once detox is complete most clients who are seriously addicted to dependence-forming drugs will most likely stay in a residential setting for at least 28 days. This is because they are at high risk of relapse during those early days and it is best to be removed from familiar drug-using environments and temptations. It also allows the psychotherapeutic element of treatment to be more intensive. This is sometimes known as the ‘immersion’ factor.

The ‘immersion’ factor involves being immersed in a recovery community, where you will build bonds with your peers in recovery, e.g. through things like group therapy. Being in a residential rehab setting immerses you in a group. You live with other people who are in recovery every day and go through the same learning curves as they do. it is very valuable to be able to share this experience with others and have the appropriate professionals on hand 24/7.

However there are downsides to staying in a rehab. There may be people you don’t like among your peers and perhaps even some of the staff. There may be people who are more unstable than you. Especially in larger rehabs, it is not unusual for the behaviour of one or more clients to disrupt the program for several days at a time. This comes down to how well the rehab is run of course.

In cheaper rehabs, especially in the US, it is common for rooms to be shared. This is often justified for clinical reasons (e.g. it’s good for your development). But the reality is that it’s usually a financial decision on the part of the management to fit more clients into the program. Older adults in particular often find this situation uncomfortable because they are used to their own space.

Do you need to go to rehab to ‘get away from your addictive triggers’?

Whilst it is true that some people struggle in their home communities because they can easily access their drug of choice, it is also true that some people are able to stay clean and sober at home. The problem is maintaining it.

In fact, one argument that you hear a lot, is that going to rehab is like running away. Eventually you have to come back to reality. While I don’t agree with this – for all the reasons mentioned above – it is certainly true that a lot of people do relapse quite quickly after returning home and in some sense rehab is an ‘idealized’ environment. So what to do?

My opinion (having worked in the addiction field for more than 15 years) is that about 80% of people seeking rehab could probably do some part of that treatment pathway from home. Obviously not the detox phase (if they are physically dependent) but certainly some of the latter phases. So this is where video counselling opens up a wealth of opportunities for effective addiction treatment, especially in the domain of rehab aftercare.


Rehab aftercare

One of the things that has been very poorly provisioned in my experience, is the final stage of addiction treatment – which is aftercare. Aftercare is the support you get when you return home from rehab.

Studies on smoking cessation show that continued involvement with professionals for at least one year post-treatment provides better outcomes. Smokers were highly likely to relapse during their first year of abstinence. It is only after 5 years that relapse rates drop to virtually zero. In my experience, all addictions have similar relapse patterns to smoking.

There are even some monitoring programmes for drug and alcohol addiction that last for between 5 years. In fact, 5 years is the time mandated in the case of impaired professionals in the US (doctors, nurses and pilots who have been assessed as having problematic drug or alcohol use). Sobriety rates for physicians who are monitored for 5 years is around 90%. So long term monitoring works.

Many rehab programs, conduct their own aftercare. If this is well run then it is the best option because it is very valuable to be able to stay current with your peers that you were in treatment with as well as your own personal counsellor. However, many programs don’t pay as much attention to aftercare as they should, and many others (wisely in my opinion) are contracting aftercare work to online counselling practices such as Alpha Sober Living. This can work well especially when that counselling practice has good communication channels with the rehab in question.

So in sum, there are many options for video counselling within the world of addiction treatment and mental health in general. Initial consultations and assessments, as well as aftercare can all be performed very adequately by video link and for clients who are returning home to remote areas it may be the only option. Also there are a range of individuals whose addictive behaviour is not yet at the critical level where inpatient treatment is indicated. They can also benefit greatly from working online with a substance abuse specialist.