Supporting Those Left Behind
By Bill White
Citation: White, W. & Stauffer, B. (2020)
Posted at www.williamwhitepapers.com
Recent essays 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. Such support will be crucial if physical distancing mitigation measures are prolonged or if the COVID-19 pandemic morphs into cycles of dormancy and reactivation.
The transition from face-to-face to e- recovery support platforms occurred so quickly, it was not possible to engage recovering people in the design and implementation of new or expanded recovery support platforms. 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. These include people who are homeless, people in rural and frontier communities who lack reliable internet access, people who cannot afford internet access, and people who have relied on public libraries and other facilities for internet that are now closed to the public. Many older adults in recovery and others who lack knowledge and skills in navigating online resources may also be potentially lost in the digital transition. Communities suffering “diseases of despair” long before the arrival of the COVID-19 pandemic could experience amplified consequences of limited digital recovery support access. We must keep such communities in mind as we seek to expand recovery support resources.
Problems of Comfort Studies to date reveal that digital recovery support is particularly attractive to women, youth, people with mobility challenges, status-conscious professionals, people with social anxiety, and people lacking regular access to face- to-face recovery support meetings. Those who find digital recovery support less attractive include people who tend to resist anything new, those fearing online technology, and those who fear embarrassment or humiliation due to their lack of sophistication with such media. People in recovery who purposely choose to live a digital free or digital limited lifestyle may be particularly vulnerable when faced only with digital recovery support options.
We have a lot to learn about the brave new world we are entering. It may take some time before we know the size of this “digital- discomfort” population, but attraction to and comfort with e-recovery support will likely wane to some degree as its novelty wears off and access to face-to-face meetings returns. 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. The proportion of people who find the quality of digital support equivalent or superior to face-to-face meetings compared to the proportion who find the quality of the digital recovery support experience inferior to face-to-face encounters remains a critical recovery research question.
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. Digital media can be tools of manipulation, exploitation, or harassment. Examples of such include “13th stepping” (using online contact as a means of sexual seduction of the most vulnerable help-seekers), unauthorized disclosure of shared information, stalking, bullying, and exposure to hate speech. Financial exploitation is also possible via exposure to unethical advertising, collection and monetization of personal information of those using online recovery support platforms, and excessive fees or appeals for financial contribution.
As we expand digital forms of counseling and support, we need to explore how we can protect those receiving such services and supports. 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. There is a danger that large online meetings will expand our number of recovery connections while reducing the number of people with whom we have particularly close communication.
When humans connect, something vital happens that brings us together in a powerful manner. The recovery experience often involves feeling understood by and connected to an entire room of people. We are only beginning to understand the science behind how and why these connections occur. As this paper on autonomic mimicry and neurocognition suggests, one key element may be that we experience emotional contagion. Body language, eye contact, and the subconscious sharing of information between humans underpins the process of emotional contagion—this feeling of being connected. 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 we develop digital recovery platforms, we need to understand what we can do to bridge the gaps in current technology to enable recovery-inspiring connections.
As creatures of excess, there is also the 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 risk would be abandoning the work of recovery in the real world in exchange for self-absorption in the e-universe. And of course, there are the risks of hacking, ZOOM bombing, and digital fatigue.
The future of e-recovery support hinges to a great degree on 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 cost less with many provided by peers in recovery rather than by paid service professionals. The depletion or loss of existing service elements would be particularly detrimental to those who benefit most from combinations of intensive professional and peer-based support— those with the most severe, complex, and chronic substance use disorders. E-recovery support should represent an expansion rather than a contraction of choices within the service menu.
Digital support combined with available medical and psychosocial support may help us move our care systems to better aid the processes of long-term personal and family recovery. 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 more of us reach that critical five-year benchmark mark.
Reaching Those at Risk of Being Left Behind
Digital recovery 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 making the transition to these new recovery support media. 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 telephonic recovery support meetings facilitated by recovery coaches
*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.
It remains unclear whether the surge in digital recovery platforms will attract and sustain the attention of the majority of people seeking recovery support meetings once the novelty of these new resources wears off and access to face-to-face meetings returns. It also remains unclear how the quality of the recovery meeting experience will evolve within these new platforms. The challenges we face include how to warm up e-recovery support (e.g., telehugs in the telehealth recovery space) for those capable and comfortable with such platforms, how to facilitate and support people making the transition from face-to-face to digital recovery support, and how to assure that we do not lose people in the transition into what may be a predominately digital future.
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.