Stakeholder opinions of internet-delivered cognitive behavior therapy as a treatment option for alcohol use disorders

Internet-delivered cognitive behavior therapy has been found to be effective for treating alcohol use disorder in research trials, but it is not available as part of routine care in Canada. Recent recommendations in the literature highlight the importance of integrating perspectives from both patient and health care stakeholders when internet CBT is being implemented in routine practice settings. By integrating these consumer perspectives, the chances increase that systems will adopt this empirically supported technology-based intervention. This study sought to better understanding of how internet CBT is perceived as a treatment option for alcohol use disorder by interviewing diverse stakeholders that included patients, family members, academic experts, frontline managers, service providers, and health care decision makers.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

There are numerous evidence-based treatments for alcohol use disorder, yet less than 15% of individuals ever receive services. Many people refrain from seeking treatment because alcohol use disorder treatment is highly stigmatized. Internet-delivered cognitive behavior therapy (internet CBT) for alcohol use disorder has emerged as an effective form of treatment that increases access to services by overcoming barriers associated with face-to-face interventions by making CBT alcohol treatment available to people in their own home via a computer. Despite the mounting evidence supporting the efficacy of internet CBT (ICBT) for alcohol use disorder, it has yet to be implemented in routine care in Canada. Even the most effective interventions lose their utility if consumers won’t adopt and implement them into frontline practice settings. An important early step when implementing an intervention in a new setting is to determine the acceptability (extent to which the intervention is agreeable, palatable, satisfactory, or useful), appropriateness (perceived fit or compatibility of an intervention with its consumer’s needs), and adoption (consumer’s intention to use the intervention). The current study set out to assess acceptability, appropriateness, and adoption by gathering the perspectives of a wide range of stakeholder groups that included patients, family members, academic experts, frontline managers, service providers, and health care decision makers.

HOW WAS THIS STUDY CONDUCTED?

In this qualitative study, authors conducted semi-structured, audio-recorded, individual interviews with 30 participants recruited from six Saskatchewan stakeholder groups in Canada: patients with alcohol use disorder, family members of individuals with alcohol use disorder, academic alcohol research and education experts, frontline alcohol treatment managers, alcohol treatment service providers, and health care decision makers (i.e., individuals involved with government policy related to alcohol misuse). Additional information about the sample’s characteristics was not provided in the study. Interviews were guided by a set of 15 questions related to acceptability, adoption, and appropriateness of internet CBT for alcohol use in Saskatchewan. These interviews were then transcribed and coded to identify themes across interviews.

WHAT DID THIS STUDY FIND?

Figure 1.

The primary theme of internet CBT advantages included sub-themes of accessibility, convenience, privacy, relevance to technology-based culture, and fit with stepped care.

Stakeholders noted numerous advantages. Internet CBT allows clients with alcohol use who live in rural and remote locations to access cost effective care that is otherwise limited. Internet CBT also allows clients to participate in treatment from a private location, which reduces the chances of experiencing stigma related to alcohol use treatment and is congruent with today’s technology-based culture. They also appreciated that fits within a stepped-care model, wherein clients with less severe alcohol use or problems can use internet CBT, leaving more intensive in-person services for those with more severe alcohol use disorder.

The primary theme of internet CBT disadvantages included lack of internet access and technological literacy, isolation, less accountability, and unfamiliarity with internet CBT.

Stakeholders noted several disadvantages. Internet CBT requires clients to have access to the internet and ability to use a computer, tablet, or mobile phone, which may prohibit some individuals from participating. Internet CBT may also reinforce isolation that can be associated with alcohol use because clients can engage in treatment without leaving home. The Web-based nature of internet CBT could allow clients to be less accountable for their actions than they would be if they had face-to-face meetings with their service provider or peers. Clients might not be aware that internet CBT is an available treatment option for alcohol misuse.

Factors to consider when implementing internet CBT in routine practice were intervention design, intervention content, and population characteristics.

In terms of intervention design, stakeholders recommended a 6- to 8-week guided program that uses Web-based advertising, point-of-sale marketing, and large-scale captive audiences to recruit participants. As for treatment content, stakeholders recommended that the program focus on harm reduction rather than abstinence; be evidence based; appeal to the diverse residents of Saskatchewan; and use language that is simple, encouraging, and nonjudgmental. Finally, in terms of population characteristics, stakeholders felt that several features of the alcohol misuse population, such as psychiatric comorbidity, readiness for change, and stigma, should be considered when developing an internet CBT program for alcohol misuse.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

This project explored alcohol use treatment stakeholders’ perceived benefits and drawbacks of ICBT for alcohol use as well as recommendations they might have for implementing ICBT for alcohol use in routine practice. In doing so, the authors found a resounding endorsement for implementation from stakeholders and received numerous recommendations related to intervention design, intervention content, and the population being treated. The perceived advantages identified by stakeholders were consistent with previous internet CBT research and the disadvantages may be mitigated during the implementation process.

The perceived advantages of internet CBT for alcohol use were the accessibility, convenience, privacy, relevance to technology-based culture, and fit with stepped-care. One advantage that seems particularly relevant to the individuals interested in alcohol use treatment is the potential for increased privacy, given the strong stigma experienced by individuals with alcohol use disorder. Accordingly, the ability to participate in internet CBT from a private location might be of value to potential clients with alcohol use disorder. Virtually ubiquitous access could improve the public health of several groups, though perhaps none more so than individuals living in rural areas with limited access to in-person treatment and recovery support services.

In contrast, the perceived disadvantages of internet CBT were internet access and technological literacy, potential for isolation, less accountability, and unfamiliarity with internet CBT. These represent potential drawbacks that will need to be mitigated as implementation proceeds.

Perhaps the most addressable disadvantage is unfamiliarity with internet CBT. When implementing ICBT for alcohol use in routine practice, significant effort can be made to inform potential clients and referral sources about the nature and availability of the treatment. Other disadvantages might be mitigated by incorporating features into the internet CBT program to bypass potential problems. For example, designing a program that is downloadable and can be accessed through a variety of devices (e.g., computer, tablet, or mobile phone) may benefit those without a home computer or a consistent internet connection. Such a diversified approach would help reduce the disparity in household internet access experienced by racial/ethnic minorities and those in lower socioeconomic strata. Another suggestion presented by stakeholders was the potential of offering a therapist guided version of internet CBT. According to stakeholders, a guided internet CBT program with both email and telephone correspondence would be preferable as it would allow for greater support, increased accountability, and human connection compared to a self-directed approach. This suggestion is supported by previous studies that found guided ICBT programs for alcohol misuse to be both more engaging and more effective than self-guided ICBT.

In terms of treatment content, stakeholders recommended that the treatment goal of the program should be reduction of, rather than abstinence from, alcohol consumption. This treatment goal is also supported by previous research showing the benefits of harm reduction approaches to engaging more individuals than abstinence-based approaches. If a harm reduction approach were adopted, internet CBT would potentially have the greatest overall impact by engaging the maximum number of people from a public health perspective, while also catering to those who also want to abstain. Finally, stakeholders suggested that several common features of the alcohol misuse population, such as psychiatric comorbidity and readiness for change, should be taken into account given alcohol use disorder often co–occurs with other mental health disorders and that readiness for change is an important predictor of successful behavior change.

LIMITATIONS

As with most qualitative studies, it is hard to generalize the findings to the larger population. The sample size was quite small and were exclusively from the Saskatchewan region. Thus, it is unclear to what degree the observations made here will generalize to other areas.
Eight out of 30 stakeholders (27%) had professional or personal experience with other ICBT courses and thus a selection bias may have been present with some stakeholders already having favorable attitudes toward ICBT.
Semi-structured interview questions may have implicitly encouraged stakeholders to speak to certain topics and not to others.
The design and presentation of results does not allow opinions to be linked to specific stakeholder groups. While this increases anonymity, it decreases the ability tease apart the perspectives of the different stakeholder groups and whether there were any differences across them.

BOTTOM LINE

The major takeaway from this qualitative study is that Internet-Delivered Cognitive Behavior Therapy for alcohol use was viewed as having numerous benefits compared to traditional face-to-face interventions. Specifically, it was seen as having potential to increase accessibility, convenience, and privacy. This is particularly important right now given many frontline treatment programs have pivoted to virtual platforms or have a limited availability due to COVID-19 safety concerns. While such limitations in access are highlighted, and exacerbated, by the COVID-19 pandemic, they predate and are likely to persist well beyond the pandemic. Thus, this might be a viable evidence-based alternative to what is currently available in the addiction treatment landscape. The concerns detailed by stakeholders are noteworthy and should be considered while making choices about engaging with internet CBT or another form of digital treatment. They cited increased need for digital literacy, potential for increased isolation, and less accountability as important concerns. These concerns are mirrored in concerns related to the mental health impact of physical distancing measures. Therefore, individuals should think critically about which pathway to recovery makes the most sense for them during these trying times. Please see our guide to identifying quality addiction treatment.

For individuals and families seeking recovery: The major takeaway from this qualitative study is that Internet-Delivered Cognitive Behavior Therapy for alcohol use was viewed as having numerous benefits compared to traditional face-to-face interventions. Therefore, individuals should think critically about which pathway to recovery makes the most sense for them during these trying times. Please see our guide to identifying quality addiction treatment.
For treatment professionals and treatment systems: ICBT might be a viable evidence-based alternative to what is currently available in the addiction treatment landscape. Large scale adoption would require facilities to think critically about how to best overcome specific challenges cited by stakeholders such as potential for increased isolation and less accountability. Some of these concerns can be avoided by deploying a guided approach with both email and/or telephone correspondence as it would allow for greater support, increased accountability, and human connection compared to a self-directed approach. It is also important to note that stakeholder we clear that the treatment goal of the program should be reduction of, rather than abstinence from, alcohol consumption and needs to include options to address psychiatric comorbidity. These goals are not always consistent with the treatment philosophy of some facilities. However, many individuals continue to cite this as their preferred approach, and abstinence goals may remain primary for those who choose them, even within a harm reduction framework. Thus, facilities may want to think critically about how to best serve their respective communities.
For scientists: The major takeaway from this qualitative study is that Internet-Delivered Cognitive Behavior Therapy for alcohol use was viewed as having numerous benefits compared to traditional face-to-face interventions. That said, more research is still needed to best understand how benefit is conferred and ways to overcome potential downsides such as potential for increased isolation and less accountability due to potential synergistic effects with COVID-19 mitigation efforts.
For policy makers: The major takeaway from this qualitative study is that Internet-Delivered Cognitive Behavior Therapy for alcohol use was viewed as having numerous benefits compared to traditional face-to-face interventions. Thus, this might be a viable evidence-based alternative to what is currently available in the addiction treatment landscape. Taken together, there is value in funding research on the utility digital intervention tools. Additionally, critical evaluation of policies that govern telehealth will ensure access is commensurate with demand for services.