RAJESH RAJENDRAN NAIR
Recent essays in this series predicted the effects of the COVID-19 pandemic on the future of addiction recovery and celebrated the resilience of communities of recovery as they transitioned from face-to-face to online recovery support meetings. This brief article calls attention to those potentially left behind in this transition to digital support and explores the ethical and effective implementation of digital recovery support platforms. (For a more expansive version of this blog, click HERE.)
Transition Problems
To achieve an inclusive recovery community, we must be mindful of persons or communities for whom virtual platforms are unavailable or unsuitable. To achieve the maximum range of person-platform fit, we must insist on engagement of diverse recovery communities in the design, implementation, and evaluation of these new resources. PRO-A in Pennsylvania provides an example of standards for the delivery of ethical and inclusive e-recovery support in its 10 Assurances statement.
Problems of Access In our celebration of the explosive growth of online meetings and other virtual recovery supports, we should not forget those who lack access to such platforms. Those at risk of exclusion include: 1) people who are homeless, 2) people in rural and frontier communities, 3) people who rely on public facilities for internet access that are now closed due to pandemic mitigation measures, and 4) older adults in recovery and others who lack knowledge and skills in navigating online resources.
Problems of Comfort Put simply, there are many people who have access to digital recovery support but find the digital experience less helpful than face-to-face recovery support media. The potential size of populations using digital recovery support as a primary recovery support mechanism compared to those who use digital recovery support as an adjunct to face-to-face meetings remains unclear.
Recovery support comes in multiple media, including one-on-one communication, group interactions, print resources, and video/audio media. Successful recovery often involves combining and sequencing multiple activities across the stages of long-term recovery. The key for each person is to find a stage-appropriate fit between themselves and those ingredients that best serve to strengthen recovery initiation, maintenance, and enhanced quality of personal and family life. At a systems level, the key is to increase recovery prevalence within affected populations by assuring the broadest possible menu of recovery support options.
Problems of Vulnerability New e-treatment and e-recovery support media, like all digital media, raise privacy and security concerns. A particular concern is the potential of such media as tools of manipulation, exploitation, or harassment. In the delivery of e-counseling services, we must assure that the protections built into face-to-face counseling (e.g., informed consent, confidentiality, delivery of evidence-based practices, clinical supervision, standards of ethical practice, etc.) are not lost within the e-counseling process. In the delivery of peer recovery support, we must make group values, communication guidelines, and member expectations as transparent as possible (e.g., anonymity, crosstalk policies, etc.) at the outset of participant involvement and use our collective conscience as a guide to refine online recovery support norms and etiquette.
E-Recovery Limitations and Side Effects The transition from face-to-face to online recovery support has inherent limitations and potential risks. Much could be lost in this transition, such as pre- and post-meeting socializing, reduced depth of sharing from some and oversharing for others, erosion of sponsorship relationships to brief text exchanges, serial virtual performances without the sense of real connection and closeness, and a reduction or loss of service activities linked to face-to-face meetings.
When humans connect, something vital happens that brings us together in a powerful manner. We are only beginning to understand the science behind how and why these connections occur. As recent paper on autonomic mimicry and neurocognition suggestsone key that we experience emotional contagion through body language, eye contact, and the subconscious sharing of information. The digital medium available to us today may be limited in its capacity to transmit such subtle information and may result in a less powerful sense of connection.
As creatures of excess, there is a parallel risk of seduction into this digital world (e-addiction)?a risk enhanced by the now infinite number of online meetings and the advent of marathon meeting formats. Hyper-connection could result in an erosion of social skills and our comfort with face-to-face communication.
The future of e-recovery support hinges the pace of improvements in the technologies used in these media and the development of ethical guidelines to govern their operation.
E-Services within Larger Systems of Care and Support How will the rapid expansion of e-treatment and e-recovery support services effect larger systems of care for substance related problems? One concern is that funding authorities facing pandemic-spawned economic austerity may cut funding for traditional face-to-face services. The rationale for such action would likely be that online services can be delivered with less costs and by peers in recovery rather than by paid service professionals. E-recovery support should represent an expansion rather than a contraction of choices within the service menu. We know that 85% of us who are able to sustain recovery for five years stay in recovery for the rest of our lives. Digital support services may well augment and extend our current care strategies in meaningful ways to help even more of us reach that critical five-year benchmark mark.
Reaching Those at Risk of Being Left Behind
Digital recovery support is a "cool," low touch--medium of communication. Our challenges are how to warm it up to fit the existing culture of recovery and how to reach people who are unable or uncomfortable in the digital world. Below is a summary of what we envision as possibilities.
*Including the voices of people in recovery in all decisions related to the design and conduct of digital recovery support platforms
*Providing digital devices to people in recovery who cannot afford them
*Workshops and one-one-one tutoring by recovery community organizations on mastering online recovery support media
*Providing online access via recovery community centers
*Greater reliance on recovery literature, including manual-guided recovery protocol replete with personal recovery stories
*Renewed and expanded access to earlier-era resources, e.g., recovery talks on cassettes and CDs
*Expanded availability of e-counseling services (e.g., telephonic or video counseling)
*Smaller face-to-face meetings with modified meeting rituals (using physical distancing precautions)
*Home visits by recovery coaches (using physical distancing precautions)
*Telephonic recovery check-ups and smaller telephonic recovery support meetings arranged by recovery coaches
*Expanded recovery literature distribution
*Use of traditional mail service for recovery support communications
*Expanded use of recovery magazines and newsletters as vehicles of recovery support
*Creating and communicating consensual ethics and etiquette of online recovery support
*Creating ethical guidelines for organizations hosting e-counseling and e-recovery support services, and
*Creating ethical complaint and disciplinary mechanisms for e-recovery support services.
The key is that we engage the digital champions, the digital doomsayers, and everyone in between with viable recovery support choices. We must aspire to a recovery standard that supports all pathways of recovery, all platforms, all modes of recovery, and all people who seek recovery. The future is not at all clear in respect to e-recovery support, but what is clear is that it will be an increasingly visible platform of recovery support. What is not clear is how effective and authentic it will be and who it will include and exclude. The answers to those questions are up to us.