The website “Alcoholdebaas.nl” (lookatyourdrinking.org) has existed since March 2005. It was developed by Tactus, anaddiction treatment institute whose aim it is to help people with various addictions. This paper focuses on participants’ use of Tactus’s on-line counseling program for alcohol addiction. A special feature of this program is that the participant may choose among four treatment options: self-paid, anonymous (free), insurance-paid, and employer paid.
Because of the limited patient capacity of the anonymous treatment option, however, Tactus wants to motivate more patients to choose the insurance-paid option. This option requires that they disclose their personal identification information, but allows them to start treatment immediately rather than waiting for an indeterminate time period before an opening becomes available in the anonymous treatment option.
Tactus has found, however, that even after informing clients that choosing to remain anonymous will cause a delay in treatment, most clients still choose to remain anonymous. Tactus is seeking to discover why these clients choose to remain anonymous, and how they might be influenced to choose the non-anonymous, insurance-paid treatment option. The purpose of this investigation is to find a starting point for achieving this goal.
Sinds maart 2005 is de website Alcoholdebaas.nl online, ontwikkeld door Tactus, een instelling voor verslavingszorg die hulpverlening aan mensen met verslavingen ten doel heeft. Dit rapport richt zich op mensen met een alcoholverslaving die hulp zoeken bij de on-line behandeling, Alcoholdebaas.nl. De populariteit van internteinterventies is voor een belangrijk deel toe te schrijven aan de anonimiteit, waardoor de drempel naar hulp wordt verlaagd.
Al vrij snel na de start van de internetbehandeling in 2005 was er veel animo voor de anonieme versie van Alcoholdebaas.nl. Vanwege de beperkte anonieme behandelcapaciteit, wil Tactus meer mensen stimuleren hun gegevens bij de zorgverzekeraar bekend te maken om de behandeling vergoed te krijgen. Door de inkomsten kan er meer capaciteit aan behandelaars worden ingezet en kunnen meer clienten worden behandeld. Een belangrijk voordeel van de zorgverzekeringvariant is dat de deelnemers gelijk kunnen starten met de behandeling in plaats van een onbekende wachttijd te ondergaan. Na het informeeren van alle geinteresseerden over de mogelijkheid van vergoeding door de zorgverzekeraar kozen de meeste mensen er toch voor om te wachten.
Het doel van dit onderzoek is inzicht krijgen in de redenen van deelnemers aan AdB om niet voor de zorgverzekeringvariant te kiezen bij het inschrijven voor een behandeling. Tactus wil daarmee achterhalen hoe deelnemers het best gestimuleerd kunnen worden tot het inschrijven voor de zorgverzekeringsvariant van de behandeling. Deze kennis is nodig om meer mensen met alcoholproblemen hulp te kunnen bieden via internet.
After reading an interesting article about mental e-health, I searched through the available research offers and contacted Nicol Nijland, a PhD student at the University of Twente to ask her about the possibility of writing my Bachelor thesis in this area. I then met with Nicol to discuss my interests, and she forwarded to me a couple of relevant research orders from different organizations in the area. From these research requests in different topics I chose to apply for one placed by Tactus concerning the online treatment of people with alcohol problems.
Following this decision, I did an extensive literature search for the purpose of constructing a questionnaire to examine the motivation for their clients’ treatment option choices.
During this period I was also able to personally visit the Tactus offices, and to do much of my research from there. This was quite helpful since it allowed me to meet many of their employees who were all very supportive of my research efforts.
I am very glad that I chose the research request from Tactus, and would like to thank all the kind people there for helping me with this project.
I would like to thank my supervisors, Dr. Nicol Nijland and Dr. Marloes Postel for their kind support, input, and guidance throughout the duration of this work.
I would also like to thank Heleen Westendorp for arranging, assisting, and carrying out the research project. I found it to be a very interesting project which gave me insight into many of the operational processes in a large organization such as Tactus.
Finally, I have to express my utmost gratitude to Steve Crosby and Stefan Schweizer for their willingness to invest time and effort to review my thesis and helping me correct my language.
Hopefully, my research will help to shed some light on the intention of Tactus’s clients, and that it will helpful to Tactus in guiding their clients toward the choice of appropriate treatment options.
It is a goal of the Prevention and Consultation Department of Tactus Verslavingszorg in Twente, (Dutch Institute for Addiction Care) to increase participation in the insurance paid option of their internet alcohol treatment program. In this paper the insurance paid option will be referred as non-anonymous option. Although information about each of their four treatment options is available on the Tactus website, most clients sign up for the anonymous option in which they do not have to disclose personal identifying information. Since the treatment capacity for the anonymous option is limited, however, this choice results in waiting periods of one week to six months or more before treatment is initiated.
The frequent choice of the anonymous option might be due to clients being unaware that they could start treatment immediately by choosing a non-anonymous option, or it could be a conscious preference for anonymity based on some personal reason. In order to better guide client treatment choices, Tactus would like to have a better understanding of the motivation of their clients in choosing this anonymous treatment option.
The goal of this research project, therefore, is to identify the underlying reasons and influencing variables affecting client choice against the non-anonymous option.
Composition of Alcoholdebaas.nl
Alcoholdebaas.nl (“lookatyourdrinking”) is a Dutch website which provides extensive information about alcohol and alcohol related topics. It also offers online therapy for individuals who have problems with excessive drinking. Treatment is provided by professional, experienced social workers on the staff of Tactus. Treatment recommendations are determined by a team of counsellors, an addiction-specialised physician, and a psychologist.
The aim of the alcohol counselling program is to motivate clients to change their drinking habits and, if necessary, to get treatment. The ultimate goal is for clients to reduce drinking or to stop drinking altogether.
Alcoholdebaas.nl is a comprehensive treatment program composed of five elements: an informative website, an online forum for discussion of issues with like-minded individuals, an online treatment program, a scientific research section and a chat module geared toward prevention. The design of this website is based on a “Stages of Change” model whose purpose is to explain or predict a person’s success or failure in achieving a proposed behaviour change (Prochaska & Diclemente, 1983).
This method of treatment is grounded in Cognitive Behaviour Therapy (Lange et al., 2003). The therapy is based on the principle that certain ways of thinking can trigger health or psychological problems. The counsellor helps the patient to understand his/her current thought patterns, and to identify harmful thoughts which might trigger problem alcohol behaviour. The aim is then to change this thinking and to avoid harmful ideas.
The internet treatment is available to everyone from eighteen years of age or older who wants to cut down on or stop drinking alcohol. Before filling in the intake questionnaire, the client must agree to the rules of participation. Those rules contain the “Wet op de Geneeskundige Behandelovereenkomst” (WGBO). This law contains several legal agreements about the rights and obligations of consultant and client, including that the client must be eighteen years of age or older, and must check in with the consultant at least every four weeks (otherwise treatment will be cancelled).
After completing the intake questionnaire, the participant can log onto the website and determine his/her own username and password to access his/her own private dossier. The clients can then send and receive messages with a consultant. Homework tasks and the daily registration of an alcohol scripts/diary are also made via the dossier. The intent of the alcohol diary is to enable the client to describe the moments when he feels the demand for consuming alcohol and also to record the times when he/she does drink. After drinking alcohol, the client reports the amount and kind of alcohol consumed.
The treatment consists of two parts, with an average total time duration of 3.5 months. The first part is focused on motivating the client to change their drinking behavior, and on analyzing his/her drinking habits without being asked to change anything. Part one closes with the personal recommendations of the counselor regarding the participant’s drinking and a proposal for follow-up treatment. The participant then decides if he /she wishes to continue with the online counseling.
The client will be determined as ineligible for the second part if the counselor thinks that there is a serious medical risk or an acute danger; if the client doesn’t understand the housework tasks; or if he/she is not able or willing to formulate reasoned goals. If any of the latter conditions are apparent, the client is referred to another, more appropriate form of treatment.
In this second part, the client sets his final goal with regard to alcohol use, and works on changing his/her behavior by using the homework tasks (Keizer et al., 2007).
For six months after finishing the program, the client may continue to use his personal information on the website, may continue to keep his/her alcohol use log, and may continue to stay in contact with his/her fellow clients via the communication forum on the website.
Since 2008 there has also been an option to obtain treatment paid for through the individual’s health insurance, provided that the individual was willing to document the required personal identification information to substantiate their insurance coverage. Through this additional insurance reimbursement money, Tactus is able to employ more therapists and to serve more clients. At the moment there are four options available to choose from regarding the online-therapy.
The first option for the client is to pay for the program himself. This option grants an immediate start of the treatment and it is completely anonym to participate in this way. The cost of the internet-treatment is approximately 2700€ for both parts.
Another possibility is to participate via the anonymous variant which is free of charge and doesn’t require a physician referral. With this option the participant will be asked to leave his email address and then will be receiving an email when there is a place available to be treated. This option is chosen by most people but the problem is that there are not enough places to treat everyone immediately and therefore there is a waiting list. It is rather unpredictable how long the waiting time for the treatment will be.
The third option is to get the treatment paid from the health insurance. Therefore, participants have to publish some personal details to assure the payment from their insurance. This option enables the participants to start immediately with the treatment. After introducing this alternative to all the interested people on the waiting list of the anonymous treatment, this possibility didn’t seem to be an option for most of them, because fewer than 10% of the people agreed to publish their personal details to receive the paid treatment. Most of the people chose to wait for the anonymous, free treatment without knowing when it will start.
There is also the possibility register through the employer. Some companies and government offices offer their employees the opportunity to follow the program free of charge and anonymously, covering the costs of treatment themselves. Clients choosing this option may start right away with the treatment.