Stigma and difficulty accessing services may prevent people from seeking treatment for alcohol misuse, but digital tools can overcome some of the barriers they experience
Many people with alcohol problems find it difficult to access traditional services, due to stigma or practical difficulties. Online tools offer the option to avoid face-to-face consultations and can be made available at convenient times, overcoming some of these issues. This article reports on two services that have increased access to alcohol services and attracted users who are less likely to access traditional services.
Citation: Holmes M, Jones H (2016) Using online tools to treat alcohol misuse. Nursing Times; 112: 17, 12-14.
Authors: Mark Holmes is digital health coordinator; Hugo Jones was, at the time of writing, digital manager, both at HAGA Action on Alcohol.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here
The challenge of overcoming stigmatisation is well recognised in mental health services. People with mental health problems may refuse treatment because they are worried about partners, family members or friends finding out, or because they are too embarrassed to ask their employer for time off work to attend appointments. It is therefore important to understand the barriers that prevent their group from accessing services and find ways to overcome them. Taking alcohol treatment as an example, this article suggests that digital tools can be used to broaden access to therapies. This approach has a significance beyond the field of alcohol, as many of the principles underpin all person-centred health work.
Problems accessing treatment
Alcohol Concern (2010) estimates that just 6% of dependent drinkers in England are accessing support. With about 1.6 million people in England with alcohol dependence (Health and Social Care Information Centre, 2015), this means more than 1.5 million are unsupported. Retention is also a problem, as 40-60% of those who do enter alcohol treatment drop out within two sessions (Hoffman et al, 2011; Alcohol Concern, 2010).
In addition to the human costs of alcohol misuse are the huge financial costs: alcohol-related health harms cost the NHS £3.5bn every year (Her Majesty’s Government, 2012).
One reason for the low uptake of support and treatment is that many services offered by healthcare providers do not meet the needs of, or practical challenges faced by, those experiencing alcohol problems. This issue is encapsulated in the fear of stigma that many potential service-users face.
Numerous reasons may explain why fear of stigma prevents those needing support for alcohol misuse from accessing services; indeed, many will not even want to admit to themselves that they have a problem. To access an alcohol service, people typically need to speak to their GP – someone they might have known for many years and who might also know their family and friends.
Treatment may be disruptive to family life and work, and difficult to keep confidential. It often involves attending what feels like a secure (or “air-locked”) alcohol facility, in which after walking through the main door, you are met by a further door, creating what feels like a holding area; it might also be located some distance from their home.
In addition, many users of alcohol services have multiple co-dependencies that may make service users without these additional problems feel alienated. Other concerns that discourage them from accessing services include:
- Fear of the unknown;
- Conflicts with caring;
- Conflicts with work responsibilities.
These issues are not inevitable and should be tackled (Holmes, 2015).
Increasingly, digital tools offer solutions that allow anyone to go online and obtain information about their drinking and link to support services. Examples include two services developed by national alcohol charity, HAGA:
- Don’t Bottle It Up– a complete online screening, advice and self-referral pathway for people concerned about their alcohol use;
- Online Brief Treatment (OBT) – delivered via Skype.
The Don’t Bottle It Up online service avoids the need to physically enter conventional alcohol-misuse treatment. This is hugely advantageous in terms of initial engagement and encourages hard-to-reach groups, who may have accessibility problems – such as work or childcare constraints – or fear the stigma associated with accessing help.
At the start of the pathway, service users have the opportunity to learn about their alcohol use using the World Health Organization’s Alcohol Use Disorders Identification Test (AUDIT) (Babor et al, 2001). This is presented with built-in interactive educational elements, such as how to calculate units of alcohol. Users are then told their AUDIT risk category and offered helpful resources, including tips on cutting down and personalised reduction plans. The portal is also integrated into local alcohol services, so requesting a follow-up phone call or email from a local professional is just a click away.
Don’t Bottle It Up engages people via social media who otherwise may not have thought about their alcohol consumption, and who might not have been able or willing to access traditional services.
With the OBT service, users identifying themselves as risky drinkers can book an appointment with an alcohol specialist worker – who may also be a nurse – at any time between 07.00 and 19.00 Monday to Friday, or 07.00 and 16.00 Saturday. Most service users have four sessions, each lasting 40 minutes and based on the principles of motivational interviewing. A follow-up takes place a few months later and outcomes are recorded.
Outcomes from the service are being reviewed and should be published in 2017 but some clear themes are emerging:
- Users appear to be making similar reductions in alcohol consumption as those completing traditional brief treatment;
- The cohort reached appears quite different from typical alcohol treatment clinics: 47% of clients are women (compared with 38% in conventional treatment (PHE, 2015), 34% are 35 years old (compared with 19% in conventional treatment) (PHE, 2015), and 91% are in employment (compared with 27%) (PHE, 2015).
Service user feedback from a pre-launch trial of OBT highlighted several benefits that have wider significance across the health and care sector. Many were attracted by not having to travel. As one user said:
“The main appeal was that it was easy; I didn’t have to go anywhere. For me, it was the only option, when other options weren’t available.”
In addition, some users appreciated not having to be in the same physical space as the nurse, as well as being able to arrange appointments around their existing commitments. Service users also felt the power balance in the therapeutic relationship was shifted; the option to exit the conversation at the push of a button meant they felt in control of the relationship:
“It feels like a safe space – you can terminate the conversation at any moment. I felt I wasn’t intruding on anyone’s space or time.”
In our experience, service-user self-disclosure occurs earlier in the therapeutic relationship than in face-to-face consultations and a sense of trust is often developed quickly. Service users can relax, have their pets close or have a cup of tea – all of which helps put them at ease. The same can also be true for the health professional; rather than rushing between centres, they can have a stable, comfortable base.
The online experience also changes how health professionals interact with service users. The slight time lag means linguistic affirmation with service users, such as saying “hmm” and “yes”, breaks the flow of the conversation, so they tend to listen more and talk less. They also spend the time analysing the conversation, and so ask more relevant questions when the service user stops talking.
Online tools also appear to tackle health inequalities. While typical users of face-to-face alcohol services are mostly male, 47% of visitors to Don’t Bottle It Up are female, as are 50% of people using the OBT.
Substantial training is required to ensure staff can use online video conferencing effectively. This not only focuses on the technical (how to set up cameras or lighting), but also communication skills. For example, to achieve a natural conversation experience at the user’s end, health professionals must look directly at the camera rather than at the user’s image, while hand gestures must be emphasised to replace linguistic affirmation. These small touches add up to a lot, and need substantial practice and guidance.
When service users and health professionals meet for the first time face to face, they instantly assess each other through observation. Alcohol clinicians, for example, may check whether users have dilated pupils, smell of alcohol or are steady on their feet. Many opportunities to establish rapport are removed when using Skype; icebreakers like handshakes, cups of tea or haptic feedback are not possible.
Many benefits of online tools can also become burdens if left unchecked. Service users may be more trusting, but also expect more in return. Personal questions to the health professional appear to be more common; staff have had to be supported on how to give an appropriate response to questions like “are you married?”, “do you drink alcohol?” or “where do you live?”
There are undeniable difficulties associated with digital tools, but people are increasingly comfortable using them at work; an Ipsos Healthcare (2015) survey found that 72% of European doctors had recommended an app to a patient in the past year. When the benefits for service users can be so great and the potential for cost savings so high, we must increase our use of technology in healthcare.
The potential is startling: HAGA has treated 15,000 people in 30 years face to face, but the same number completed its alcohol screening online in 2015 alone. Online services will not, and should not, replace face-to-face services, but are a necessary complement.
Mark Holmes won the Nursing Times 2012 Nursing in Mental Health Award
Box 1. Case study
Hannah Jenkins*, aged 29, works full time in marketing. The drinking culture at work meant her alcohol consumption gradually rose to the point where she was drinking most evenings with colleagues, as well as at weekends with friends. One night she fell over while drunk and fractured her wrist. Accident and emergency staff found she had hypertension and told her that her alcohol use was high.
Ms Jenkins had never thought of herself as having a problem with alcohol. She considered traditional alcohol treatment or visiting her GP, but was worried about taking time off work and people finding out. Having searched online for help, she accessed Don’t Bottle It Up and completed the Alcohol Use Disorders Identification Test online; Ms Jenkins scored 19, suggesting she is a high-risk drinker.
She then began online consultations with an alcohol worker via Skype. Although nervous at first, Ms Jenkins soon felt comfortable talking about her alcohol use and appreciated the informal setting. After six sessions, she completed treatment with her drinking falling to a lower-risk level.
* The service user’s name has been changed
Box 2. Further reading
- Barak A et al (2009) Defining internet-supported therapeutic interventions. Annals of Behavioral Medicine; 38: 1, 4-17.
- Khadjesari Z et al (2011) Can stand-alone computer-based interventions reduce alcohol consumption? A systematic review. Addiction; 106: 2, 267-282.
- Riper H et al (2014) Effectiveness of guided and unguided low-intensity internet interventions for adult alcohol misuse: a meta-analysis. PLoS One; 9: 6, e99912.
- Wallace P et al (2011) On-line randomized controlled trial of an internet based psychologically enhanced intervention for people with hazardous alcohol consumption. PLoS.One; 6: 3, e14740.
- White A et al (2010) Online alcohol interventions: a systematic review. Journal of Medical Internet Research; 12: 5, e62.
- People who misuse alcohol may avoid treatment for fear of friends and family finding out
- Digital tools offer home-based access to support and treatment at a convenient time
- Service users may find it less daunting to discuss issues online
- Interacting with patients via tools such as Skype can mean health professionals listen more, talk less and provide more appropriate treatment
- Apps and digital tools may be used to treat problems in which access to healthcare may be a barrier to treatment
Alcohol Concern (2010) Investing in Alcohol Treatment: reducing costs and improving lives.
Babor TF et al (2001) AUDIT: The Alcohol Use Disorders Identification Test: guidelines for use in primary care.
Health and Social Care Information Centre (2015) Statistics on Alcohol: England, 2015.
Her Majesty’s Government (2012) The Government’s Alcohol Strategy.
Hoffman KA et al (2011) Days to Treatment and Early Retention Among Patients in Treatment for Alcohol and Drug Disorders. Addictive Behaviors; 36: 6, 643-647.
Holmes M (2015) Avoiding the Airlock. Drink and Drugs News; February, 8-9.
Ipsos Healthcare (2015) The Digital Doctor: Report 2015.