A Talk With the Creator of eGetgoing, the First and Only Accredited Online Recovery Program

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By Robin Jay, BHC Editorial Director

In today's world of advanced technology, there's not much you can't accomplish virtually through the internet. It has even evolved as an effective medium for some forms of healthcare consultation, such as therapy for addiction. A study at Johns Hopkins University has shown that online addiction treatment programs can prove just as effective as in-person group therapy. In fact, in some cases they can lead to better outcomes because they side-step common barriers to effective treatment such as stigma, convenience and cost.

Joining us today to talk about the benefits of the online therapy alternative is Dr. Barry Karlin, CEO of CRC Health Group, the largest addiction treatment center in the country. He's also the inventor of CRC's eGetgoing online group counseling program, the first and only online recovery program accredited by JCAHO and CARF.

BHC: Dr. Karlin thank you for talking with us today.

Barry Karlin: You're welcome. CRC treats about 30,000 people a day in 31 states and 145 facilities across the nation. So, I have a tremendous amount of experience in dealing with people who need help for addiction. Around 2000, I was studying treatment statistics and one of the things that came to my attention was how many people would actually call us seeking help, seeking treatment for chemical dependency that one way or another did not end up being admitted. Typically at the time, given the facilities that we had, about one in six people that called us seeking help were actually admitted by the end of the day. And so I began to examine the reasons that they were not being admitted for treatment and there were really four or five factors behind that.

1. Resources. First of all, of course, was that often they simply didn't have the resources - the funds to pay for treatment. They didn't have insurance coverage in some cases or else they couldn't afford to pay for treatment themselves. They didn't qualify for government aid. So affordability was a big factor. Of course, if you can't afford to pay for treatment then you can't be admitted.
2. Anonymity. The second thing was anonymity. There remains a stigma attached to the world of alcoholism and drug abuse, despite the fact that this is unquestionably a disease, a disease that's being scientifically established for 40 years now. At the end of the day, there's still the perception out there amongst those who are uninformed in the public that this is sort of a moral [failing] rather than a disease. And the result is that many people are concerned about their anonymity. The minute you go into a treatment program, be it an outpatient program or residential, you're essentially opening up yourself to the fact that people now know who you are. And so a lot of people remain nervous about that - perhaps they're a member of the PTA at a local school, a pilot [or] a physician, so anonymity is a factor that often discourages people from getting treatment.
3. Denial. Even though people are calling us and therefore are obviously getting to a point where they recognized that treatment would be helpful, when it came right down to it, a lot of people were still kind of in a denial mode.
4. Lack of convenience. The idea that just all of us can drop everything and go into a program on a moment's notice is not realistic. I mean a great majority of people - 70 percent of people that get treatment - are functioning people in society. They have jobs, families, kids and they have obligations. And the idea that they can just take off from work and go into a program or even an outpatient program, which requires transportation, [may be a barrier].
5. Lack of capacity. Frequently, even if you were to get treatment and have the means to pay for it through insurance or some other means, sometimes there simply isn't a bed available at a facility that makes sense for you. Often through adolescence, by the way -- adolescence is where it all starts.

So I started looking at these five things and said, "What can I do as a treatment provider to try and overcome these five factors, all of which prevent people from getting treatment?" And then I had an idea, kind of one of those things when you have a "Eureka!" moment. And I said, "Well, the key is, instead of requiring people to come to us for treatment - I mean physically come to us - how about if I came up with a way to take treatment to wherever they happen to be?"

And of course, the solution to that is the internet. The internet at that time, of course, was exploding. So the basic idea was an outpatient program through the internet to deliver an experience wherever they happen to be. Most likely it's in their home, but it could also be a hotel room or anywhere. We deliver an outpatient treatment experience over the internet which emulates as closely as possible what that outpatient program would look like in a traditional face-to-face setting.

And so the concept was we'd have a group meeting over the internet. Typically there will be, let's say, eight patients who are together on the internet in a session with a counselor that we provide. There is live audio over the internet so that everyone can hear them talking. They can all hear each other just like a teleconference over the Internet. There is live video - you can see the counselor; you cannot see each other. (By the way, seeing each other is easy because nowadays with web cams, we can do that, but we have chosen not to do that to preserve anonymity.)

The beauty of the internet is you have all of the power of the computer available to the counselors, so the counselor can pull up things like slides, they can put up data, they can put up little videos and snippets, they can have a whiteboard capability so that people can participate in the whiteboard as though they're all sitting in a room with a whiteboard.

And so you have all of the power of the computer readily available to you and when you think about what's happening here, all of the forces that I described to prevent treatment are overcome by these solutions. It's very convenient because you can pick and choose a session at a time that meets your own personal schedule -- after work, in the evenings, whatever makes sense for you. That's the first thing. There is, of course, no capacity limitation because the internet has infinite power, infinite availability. There are no geographical boundaries. We've done sessions with people who live in New Zealand and Africa. You can live in rural areas and [in] this country, as you well know, a tremendous limitation is people who live in rural areas and there really is no treatment available, even an outpatient basis, near to where they live. But of course the internet has no limitation.

So no capacity limitation and no geographical limitation. Anonymity is preserved because you can hear one another but you can't see one another, but you can see the counselor. It often overcomes denial because it's a way for a person to try it out at very little cost. They give it a shot and if they like it, often it gets people to a place where they're going to say, "Wait a minute, this is actually working!" And often they will seek a more intense form of treatment. So it helps to overcome denial.

It's much cheaper, obviously. We charge about $50 a session for a program of 24 sessions. That's $1,200. A traditional outpatient program runs you $3,000 or more. So it's about a third of the cost. Literally, when you go down the list [of barriers], it overcomes each and every one of the limiting factors that I described earlier.

So we invested significantly in the original development, and that was about eight or nine years ago, and it took a long time getting this thing going obviously because it's revolutionary, very innovative. And the most exciting thing was that we realized that, eventually, even though we had tremendous sort of anecdotal evidence showing this thing would work, ultimately to get insurance companies to pay for it and to get acceptance into the marketplace, what we needed to do was to actually have a study by an independent, well-renowned, reputable organization that would analyze the efficacy of this thing without CRC involvement. This is where Johns Hopkins came in.

And so we worked with Johns Hopkins. They actually did an independent study involving a total of 50 outpatients in a methadone clinic. Johns Hopkins has their own methadone clinic. So what they did was compare half the patients who were getting traditional counseling face-to-face and the other half who were getting outpatient counseling basically using a random study. The results were published about a year ago. And then Barry McCaffrey and I went to Washington, D.C., to announce the results, which were very, very exciting. They showed that internet-based counseling through e-Getgoing was equally efficacious to traditional outpatient.

BHC: That's fantastic!

BK: That was no surprise to us, because we of course had the benefit of a very large number of sessions having been done prior to the study, and we knew what people were saying and the internet results. But of course, internal results are not the same as having a completely randomized study done by a third-party organization as reputable as Johns Hopkins. And the other exciting thing is that besides being equally efficacious to outpatient, in both cases there was significant improvement in the situation. One of the things that is particularly exciting is that all of the patients - 100 percent of the patients who did the e-Getgoing - had familiarity with traditional outpatient, and they preferred the e-Getgoing. That was no surprise to us. The reason for that was because it was so much more convenient and so much easier. And Johns Hopkins did all the usual things in testing. They did repeated drug urine testing and all of them in both traditional and e-Getgoing had marked reductions of drug use during the six-week trial. So again, that was no surprise to us.

Internet-based treatment is quite sophisticated. It's not just any internet program. It's quite significant. It's efficacious.

BHC: Dr. Karlin, let's talk more about the experience that the patient has. Is it similar to an online meeting in which the person can ask questions, and is that via a voice transmission on the phone, or is that done through some sort of instant messaging or electronic message sending?

BK: Great question. Actually e-Getgoing is very, very sophisticated in this respect. We are far ahead of the marketplace and we are very proud of that. Here's what happens:

Let's say you have eight people in the session, plus the counselor. So it's very much like a business meeting on the internet. Everyone can talk and everyone can hear each other, so it's as though you are all sitting together in the room having a conversation being facilitated by the counselor. I'm sure you're aware that doing telephone calls through the Internet is very inexpensive. We just use straight, voice-over-internet telephonic communication, which makes it very easy.

The video of course is on the internet, as well. Everyone is sitting in front of their screens, typically at home, and in the top left-hand corner is the video image of the counselor. It took special training for the counselor, because there's a world removed from doing live counseling versus doing it on the internet, and in video, as you well know. It takes a counselor who's very comfortable being on video because you can see everything the counselor is doing. We've discovered that not all counselors can do this well. Some counselors are very, very good in real life, in a face-to-face thing, but are not nearly as good on the internet. So it takes a person with appropriate training.

So you're sitting in front of your screen, you can see the live counselor, who of course is facilitating the conversation, and you can talk. There's a list of people that the counselor can see, and the participants will typically have pseudonyms. Everyone is signing in with a name that they feel comfortable with. If you want to use your real name, you can (the counselor of course knows exactly who you are in reality).

There's a whole process you need to go through to sign up, and we need to be certain that this is an appropriate form of treatment for you. If you need a more intensive, structured program like residential, you need to go to that. This is an outpatient program by definition.

So you can see on the internet who is speaking. The counselor will highlight the person's name. And when you want to speak, you press a button and communicate with the counselor that you would like to speak, and then when the counselor wants you to speak, the counselor will then open up the microphone for you. So it's controlled by the counselor in a way that's appropriate for a typical traditional treatment session.

Also, let's suppose you suddenly have a situation where you are getting at something inappropriate. The counselor can cut you off because they control the microphones of each person. But, we have what is called a "private room." So lets suppose that in the middle of a session someone suddenly starts dealing with a topic that goes outside the boundaries of what's appropriate in that session, but it's clearly something which we need to discuss with the individual person. We can open up a private room and call in a second counselor who will immediately engage this person in a private room in a private conversation. No one else can hear the conversation - just the second counselor and the patient. So for example, if a topic such as sexual abuse suddenly comes up, which goes outside of the boundaries, that's clearly something we should talk about. We immediately put you in a private room. By the way, this is not something you could do in a traditional outpatient face-to-face session. And furthermore, in a traditional face-to-face session, it is highly unlikely that a person would even bring that topic up because he's sitting in front of other people.

So you can see the power of this thing. It allows you to do things that wouldn't otherwise be possible in other normal face-to-face sessions. They feel completely safe and comfortable. Women, for example - one of the things they say when you discuss it with them is that they feel very safe. And of course, it is safe, because no one can see you. So when it comes to issues like domestic abuse, they could never dream about talking about it in a traditional face-to-face session, [but] because it's a safe environment, people are much more comfortable to bring up those issues, which of course are oftentimes intimately connected with the fact that you have alcoholic and drug abuse issues.

So from a clinical standpoint, strangely enough, even though you would think a face-to-face somehow has advantages, it turns out that actually what we discovered is that in many situations, the internet approach allows you to do things that aren't otherwise possible.

BHC: So you have the personal relationship-building that you would face-to-face, yet you have the anonymity that actually gives the patient more freedom and more access to feel that they can talk about issues that they wouldn't.

BK: Think about a personal conversation that you might have on the phone. Often, it's easier to talk on the phone to somebody than it is to do it face-to-face. Because once it's face-to-face, in front of a group of people, that becomes an inhibiting factor because suddenly you know how people are judging you because they can now see you. Judging people is easy to do face-to-face. It's much less of an issue when it's strictly voice and they don't actually know who you are.

The other thing is we have things like whiteboards and everybody can draw on the whiteboard. So the counselor might pull-up the whiteboard and ask everyone to write on the whiteboard.

BHC: Now how does something like that work?

BK: Well, let's suppose there's some topic under discussion, and let's say you're dealing with a topic such as physical pain. And you're experiencing physical pain in different parts of your body under certain circumstances. So the counselor pulls up a whiteboard and draws a graphic of a person on the whiteboard, then instructs before everybody writes, "I would like you to indicate on this whiteboard where you experience physical pain when you take a certain drug."

BHC: You can just use your mouse to indicate the location on the whiteboard, right?

BK: Right. Now the beauty of this is that everyone is doing this at the same time, so the group gets the benefit of seeing everybody clicking. They'll all probably click in the head presuming your experiencing a discomfort in your head. But other people might feel discomfort in other parts of the body - your stomach, your hands.

To do that in a traditional outpatient session would be difficult. You're all sitting in a room, and then how do you do that? Well in a room, people would shout out "head" and the counselor would click on head. This allows you to do it yourself, and instantaneously everyone can see what everyone else is doing and where you're experiencing your physical discomfort. Just much much faster, much more efficient.

More importantly, it engages people directly because you yourself are doing it. In a traditional session you have to shout it out and then, remember. what would happen in a traditional session [is that] some people are very verbal and some people are not. So what happens in a traditional session [is that] 80 percent of the talking is done by a small, let's say, 20 percent of [the people]. The usual 80/20 rule. The majority of the people are less engaged and some people are very much engaged.

In this environment, because it's controlled more directly by the counselor, what you see is a much more even distribution amongst participation and people are more engaged. So it's a very interactive environment and everyone gets involved and it's much easier to get involved with a counselor controlling who can speak, and the counselor will say things like, "I want person number eight. What do you think about this?" So it's a very interactive, engaging thing, which of course, is where the power of a computer comes in.

BHC: And of course engagement and interaction is going to lead to higher adherence and compliance.

BK: Exactly. So the result of this that we've observed over time is that when people are up to attending group session, if they stay beyond the first session, 90 percent stay throughout the entire length of the program. To give you a flavor of how that compares to traditional outpatient, in traditional outpatient you have at least 30-percent drop out rate - at least 30 percent, and often 50 percent over the course of six weeks. Let's say you're in South Florida, and an unbelievably hot day and the last thing you want to do is get into your car and drive to an outpatient session. So you just bag it one day. You're feeling fine. It's very easy in outpatient just not to show up. It takes commitment. It takes a world of determination to [show up].

But when something is over the internet, it's just so much easier. So dropout rates tend to be much lower. And of course, one of the single biggest predictors of relapse is the dropout rate. To the extent that the people do not drop out, that is a key factor in preventing relapse. So the result of all this is that we think this type of approach has the potential to fundamentally alter this industry. And how will it do that? I think in three or four ways.

Number one, a great many people who otherwise would not seek treatment or get treatment have the potential to get treatment through this type of technology. Number two, tremendous potential in reducing relapse rates because it offers a powerful way to provide not just primary care but in particular, continuing care. So I think, continuing care is the key to reducing relapse rates in the long-term. Number three, on the educational side (I'm now speaking about things in a much broader level) it has the power to educate and inform people who try it out. Number four is the potential to actually reach people in rural areas who otherwise would never get treatment. The potential to get adolescents to treatment in a big, big way. Adolescents love the internet. They're comfortable with the internet. I think the potential [is there] to reach people who refuse treatment.

Another factor that I haven't mentioned is this thing has the potential for much more tailored treatment to specific populations. When you think about a normal treatment center, there's a limit of what you can do. So let's say for example, you are a Spanish-speaking person. Well okay, how do you get treatment in Spanish? It's difficult to find treatment centers that offer Spanish-speaking programs. It's difficult to do that because you have to find counselors that speak Spanish and also the economics of offering that simply don't work.

But on the internet, where you have a nationwide audience, and you're delivering treatment from a remote location right where you have Spanish-speaking counselors available, no problem. Or you might have tracks or programs specifically designed for pregnant women with children. Or native Americans. Or a program for people who are elderly.

The internet's reach knows no boundaries. Let's say you have a program for pregnant women with children. In a specific physical location, there simply may not be enough demand to justify that program. I mean you have to have hundreds of pregnant women with children who are interested in going to a program, right? And the trouble is, that's just not a likely possibility in a single physical location. But on the internet, of course, nationwide, there's more. All you need is eight people to justify a session. And obviously there are going to be hundreds across the country, and therefore you can offer programs tailored to their specific needs.

At the end of the day, it's something which is revolutionary, it's innovative, it's different, so it's going to take time for this thing to get traction in the marketplace, but I think eventually it will be a very, very key form-driven vehicle for this type of program.

BHC: Dr. Karlin, you had mentioned the importance of specialized treatment for subgroups, which is just great, especially with the application of the internet, and the availability to reach people that may not normally be able to find treatment for that subgroup. Is it also important to treat the same type of addiction together? For example, people who are dealing with alcohol or with cocaine or with some other type of addiction - is that an application also?

BK: No, not necessarily, it's a matter of degree. Clinically speaking, the factors which drive alcoholism and which drive drug abuse are very, very similar and really quite compatible. And so the result is that typically whether you have an issue with drug abuse or alcoholism, it is quite reasonable and feasible to combine people in the same treatment group. In fact, sometimes it even helps to have some diversity in that particular respect.

But having said that, once this thing gets traction in the marketplace, I will certainly expect that ultimately there will be programs tailored to specific drugs and alcoholism specifically because there are some factors which are unique. So I think that's a matter of building up enough scale. But right now all treatment centers routinely combine people suffering from alcoholism or drug abuse, and treatment is very, very effective and works really well.

BHC: Dr. Karlin, do you know how many patients CRC currently uses this modality with?

BK: At this point it's quite small. It's just starting to get traction. We have about 100 patients. We've been taking it slow at this juncture, but over the next couple of years, we expect to escalate in a dramatic way. We've probably done 10,000 sessions since this thing first started.

What has really limited the traction so far - and that's about to change, I think, in a significant way - is, number one, insurance coverage. Ultimately, having a third party payer is a big factor because a third party payer will pay for additional outpatients. Clearly, if you have a choice between having someone pay for it or having to pay for it yourself, you're going to have someone pay for it.

BHC: Sure.

BK: That's just beginning to change. We've now contracted with Cigna, for example, a big insurance company. So as third-party coverage from insurance companies grows, that will be a big, big factor in driving usage. That's number one. The same is true with government, and government is often a key force in driving these kinds of things.

The other thing, which of course has now finally happened, is we we really needed to demonstrate the efficacy of this from a third party, and the Johns Hopkins study was a really big factor in that respect, so that's been enormously helpful.

My expectation is in the next couple of years, we are going to need to drive up this thing and promote it in a much bigger way. And I think five years from now, you will see a tremendous amount of usage in the use of online treatment.

BHC: I believe you're right. I even think that another great application - you've probably already thought of it - is college campuses.

BK: Absolutely.

BHC: You know, where we have the stigma and we have the great increase in alcoholism among that age group and people who are on the internet daily. How can behavioral healthcare professionals listening to this or health plan administrators or other payers who are interested in this, how can they find more information about your program?

BK: The Website is eGetGoing.com, which has a tremendous amount of information there, and then of course calling us directly at our headquarters. The particular individual that heads up this program is Alden Romney, Vice President of Strategic Planning.

BHC: Thank you very much, Dr. Karlin.

BK: Thank you.

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