Journal of Substance Abuse Treatment 36 (2009) 331–338

Brief article

Assessing the effectiveness of an Internet-based videoconferencingplatform for delivering intensified substance abuse counseling

Van L. King, (M.D.)a,⁎, Kenneth B. Stoller, (M.D.)a, Michael Kidorf, (Ph.D.)a,Kori Kindbom, (M.A.)a, Steven Hursh, (Ph.D.)b,

Thomas Brady, (M.D.)c, Robert K. Brooner, (Ph.D.)a

aJohns Hopkins School of Medicine, Baltimore, MD 21224, USAbInstitutes for Behavior Resources, Inc., Baltimore, MD 21218, USA

cCRC Health Group, Cupertino, CA 95014, USA

Received 28 February 2008; received in revised form 5 June 2008; accepted 22 June 2008

Abstract

Enhanced schedules of counseling can improve response to routine opioid-agonist treatment, although it is associated with increased timedemands that enhance patient resistance and nonadherence. Internet-based counseling can reduce these concerns by allowing patients toparticipate from home. This study assesses treatment satisfaction and response to Internet-based (CRC Health Group's e-Getgoing) groupcounseling for partial responders to methadone maintenance treatment. Patients testing positive for an illicit substance (n = 37) were randomlyassigned to e-Getgoing or onsite group counseling and followed for 6 weeks. Patients in both conditions responded favorably to intensifiedtreatment by achieving at least 2 consecutive weeks of abstinence and 100% attendance to return to less-intensive care (e-Getgoing: 70%vs. routine: 71%, ns). Treatment satisfaction was good and comparable across conditions. E-Getgoing patients expressed a preference for theInternet-based service, reporting convenience and increased confidentiality as major reasons. Integrating Internet-based group counseling withon-site treatment services could help expand the continuum of care in methadone maintenance clinics. © 2009 Elsevier Inc. All rights reserved.

Keywords: Videoconference; E-therapy; Internet psychotherapy; Adaptive treatment; Stepped treatment; Methadone maintenance

1. Introduction

Substance abuse treatment programs that offer methadoneor other long-term agonist medications routinely offer onceper week or even less-frequent counseling schedules (Ball &Ross, 1991). Although some patients respond well to low-intensity services, others do not, and many might benefitfrom at least brief episodes of more-intensive services(Brooner et al., 2004; McLellan, Arndt, Metzger, Woody, &O'Brien, 1993). Group counseling is a more effective way toincrease the intensity of treatment at a comparatively lowercost compared to adding more individual sessions. Unfortu-nately, enhanced counseling, whether delivered in anindividual or group therapy setting, is often poorly attended

⁎ Corresponding author. Johns Hopkins School of Medicine,Baltimore, MD.

E-mail address: kingvl@jhmi.edu (V.L. King).

0740-5472/08/$ – see front matter © 2009 Elsevier Inc. All rights reserved.doi:10.1016/j.jsat.2008.06.011

by patients (Kidorf, King, & Brooner, 2006). Although pooradherence to scheduled treatment services reflects one of thecommon features of chronic and severe substance usedisorder—and many other chronic health problems (Sabate,2003)—at least some of the problem may be related to theincreased frequency, intrusiveness, and inconvenience con-veyed by intensified counseling schedules on patients.Efforts to provide more-intensive counseling services in amanner that reduces some of the inconvenience associatedwith the intervention might prove very helpful to patientsand their programs.

One growing possibility to reduce the demands ofparticipating in at least brief episodes of intensified carehas emerged with the introduction of Internet-based plat-forms for delivering a wide range of counseling and healtheducation services. Internet-based treatment delivery plat-forms can reduce the demands of participating in increasedcounseling schedules by allowing patients to participate from

Table 1Baseline characteristics of participants enrolled in the study

Variablee-Getgoing(n = 20)

Routine(n = 17)

Withdrawn(n = 13)

Total(n = 50)

Mean age (years) 42.7 41.4 36.5 40.6Female (%) 65 47 77 62Minority (%) 40 41 54 44Married (%) 15 6 23 14Employed (% past 30 days) 50 29 23 36Employment

income/month ($)679 487 223 495

Mean methadonedose (mg)

90 85 NA NA

332 V.L. King et al. / Journal of Substance Abuse Treatment 36 (2009) 331–338

the relative comfort of their home, thereby improving boththe convenience and the privacy of the counselingexperience (Copeland & Martin, 2004; Postel, De Jong, &De Haan, 2005; Rochlen, Zack, & Speyer, 2004). Severalpublished studies have described efforts to treat individualswith substance use and other mental disorders using Internetand other telecommunication technologies (Cobb, Graham,Bock, Papandonatos, & Abrams, 2005; Copeland & Martin,2004; Griffiths, 2005), although the studies specificallytargeting substance use have largely been focused ontobacco and alcohol users rather than chronic and severeopioid and other illicit drug users. Further, the aim of thesestudies has largely been to evaluate brief self-help interven-tions that stand apart from any ongoing care (Christensen,Griffiths, Mackinnon, & Brittliffe, 2006; Koski-Jannes,Cunningham, Tolonen, & Bothas, 2007; Pull, 2006; Rochlenet al., 2004; Ruggiero et al., 2006) or treatments withminimal therapist contact (Carlbring et al., 2007; Litz, Engel,Bryant, & Papa, 2007) to more efficiently reach largernumbers of people who might not otherwise receive mentalhealth or substance abuse education or treatment. Nopublished studies have evaluated the effectiveness of usingInternet-based treatment delivery platforms to intensify thecare of partial and poor responders to low-frequencycounseling approaches.

This study presents pilot data on the first knownrandomized evaluation of the clinical response to and patientsatisfaction with an Internet-based videoconferencing plat-form (e-Getgoing, CRC Health Group, Inc.) to intensify thetreatment schedule of opioid-dependent patients with apartial and poor response to lower intensities of care. Patientsassigned to both treatment delivery conditions (Internet-based group therapy vs. on-site group therapy) received thesame manual-guided relapse control therapy group that wasconducted by the same group leaders. We hypothesized thatboth service delivery conditions would be associated withcomparable reductions in drug use and that patients assignedto the Internet-based group therapy enhancement wouldreport greater treatment satisfaction.

2. Methods

2.1. Participants

A total of 50 outpatients in the Addiction TreatmentServices (ATS) program in Baltimore, MD, were enrolled inthe study; 37 were ultimately randomized to study condi-tions. Patients were eligible for the study if they were beingadvanced to a more intensive treatment schedule because of apartial and poor response to lower steps of care, they self-reported access to a computer with Internet connection, andthey agreed to random assignment to one of the two servicedelivery options for the intensified services. Approximately20% of the patients approached for the study reported havingaccess to a computer with Internet connection. Allparticipants signed written informed consent for the study.

Participants were enrolled from February 2006 to February2007 and were followed for 6 weeks; data collection wascompleted in April 2007. The Johns Hopkins UniversityInstitutional Review Board approved the study.

Table 1 shows the demographic characteristics ofparticipants that provided consent to participate in the study(N = 50), categorized into those randomized to the two studyconditions (e-Getgoing, n = 20; on-site group counseling,n = 17) and those withdrawn from the study (n = 13). Severalparticipants were withdrawn from the study for the followingreasons: (a) failure to have a working computer in their home(n = 2); (b) recurrent problems establishing Internet con-nection with the e-Getgoing Web site (n = 2); (c) andnonadherence to the initial “registration” process necessary togain access to the Internet site, despite repeated opportunities(n = 9). Most of the participants with computer problems hadvery aged equipment with insufficient memory. Over thecourse of the study, we learned to identify this type ofproblem prior to study enrollment, and it became less of anissue. Those with Internet connection problems were usingstandard dial-up services, although this problemwas resolvedover the course of the study. The remaining problem wasnonadherence with the protocol. All participants assigned tothe Internet service delivery condition were required tocontact the CRC e-Getgoing Information Technology (IT)technician once to register and download any softwareupdates necessary to support the technology; this subgroupwas given multiple opportunities to make this contact andwere removed from study after missing three scheduledappointments. There were no statistically significant differ-ences in the baseline characteristics between participantsassigned to the two treatment delivery conditions (e-Getgoingvs. on-site enhanced treatment schedule), and there were nosignificant differences in baseline characteristics betweenparticipants who remained in the study (n = 37) versus thosewho were withdrawn (n = 13).

2.2. Routine care

Participants received daily methadone and were requiredto attend weekly individual counseling with their primarycounselor. Participants were also required to submit one

333V.L. King et al. / Journal of Substance Abuse Treatment 36 (2009) 331–338

observed urine sample per week on a random schedule;urine samples were tested for opioids, cocaine, benzodia-zepines, amphetamine, and cannabis. ATS utilizes anadaptive stepped-care counseling model as routine care inwhich patients with partial and poor responses to less-intense counseling, and monitoring schedules are system-atically advanced for brief periods to more intensivetreatment schedules (see Fig. 1); this treatment model(Motivated Stepped Care [MSC]) was recently honored byThe Joint Commission with the 2007 Ernest AmoryCodman Award. New admissions routinely begin treatmentat Step 2 and advance to higher steps of care in response toa priori guidelines and multiple objective indicators (i.e.,repeated missed counseling sessions, frequent weekly drug-positive urine specimens). They return to the lowerintensities (Steps) of care after attending all scheduledindividual and group therapy sessions and producing drug-negative urine specimens for at least two consecutiveweeks over a 4-week period (Step 3). Patients that do notmeet these positive response criteria are advanced to Step4, with a requirement to attend 8 hours of groupcounseling and one individual session each week. Theyreturn to Step 2 after producing four consecutive weeks of100% counseling attendance and drug-free urine speci-mens. Step 1 is reserved for patients that have beenadherent to their counseling schedule and produced drug-negative urine specimens for at least six consecutivemonths (please see the following reports for more detail onadaptive stepped care treatment and the MSC model;Brooner et al., 2004, 2007).

Fig. 1. MSC model. Patients begin in Step 2 and are moved to higher or lower stepsessions. Patients who continue to test positive for drug use and/ or miss counselinwith 1 week of full adherence to the treatment plan. Patients who finish the methadotreatment plan.

2.3. Study design

Patients that met routine clinical criteria for advancingfrom a less intensive to a more intensive step of care werecontacted about participating in the study by trained researchstaff. All patients who participated in the study advancedfrom Step 2 to Step 3. Patients who expressed interested inthe study and reported having a home computer with Internetaccess were provided detailed information on the require-ments of study participation and known risks and benefits.All enrollees provided informed written consent to partici-pate in the evaluation and were randomized to one of twoservice delivery conditions to enhance routine care: e-Get-going Internet-based enhanced counseling condition (n = 20)versus on-site enhanced counseling condition (n = 17). Thesame manual-guided relapse control therapy group was usedin both treatment conditions and is based on exposure andtraining to several recovery-oriented skills (e.g., awarenessand avoidance of triggers; warning signs; drug refusal;Marlatt & Gordon, 1985). Participants were scheduled toattend two relapse control group counseling sessions perweek (in addition to one individual counseling session at theclinic) and were followed for 6 weeks.

Participants completed a Patient Satisfaction Survey at theend of the study that assessed the following: (a) convenienceof attending group, (b) competence of the therapist, (c)usefulness of the knowledge you gained, (d) experience ofbeing in the group, and (e) overall group satisfaction.Responses were coded using a 4-point Likert scale: 1 = leastsatisfied and 4 = most satisfied. Participants assigned to

s of care based on urine test results and attendance to scheduled counselingg sessions in Step 4 are placed on a 30-day methadone taper that is reversedne taper are guaranteed readmission to Step 4 care if they agree to follow the

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e-Getgoing group counseling condition were also asked tocompare their preference for e-Getgoing groups versus on-site groups using the following question: “If you werereferred back to Step 3, would you prefer to attend the e-Getgoing groups or the on-site groups?” Participants wereasked to comment on the reasons for their preference.Finally, the group counseling leaders were asked to commenton their experience.

2.3.1. e-Getgoing Internet-based service deliveryE-Getgoing is a Joint Commission and Commission on

Accreditation of Rehabilitation Facilities accredited, Internet-based videoconferencing platform that was specificallydeveloped to deliver verbal- and visual-based therapy topeople with substance use problems. Patients assigned to thiscondition contacted the e-Getgoing IT technician and down-loaded required software to register for a 1-hour therapygroup that was scheduled twice per week. Most participantshad very little computer knowledge or experience at the outsetof the study. The initial downloads and technical assistanceneeded to access the e-GetgoingWeb site was therefore time-consuming for some participants (although this improveddramatically over the course of the study). Approximately30 to 60 minutes were required to complete the initialregistration and computer setup, which required access to atelephone as well as Internet connection. Some participantssought help from a friend or family member to help with theinitial computer setup; others used staff in the ATS programfor this purpose (i.e., brought their laptop computers to theclinic). Participants assigned to this treatment condition werealso provided with a low-cost microphone for their homecomputers to facilitate verbal communication during the e-Getgoing-delivered group sessions. Each participant had aunique log-on identification and password to ensure con-fidentiality and could only attend their assigned groupestablished at the time of initial registration.

The group leader could verify on his computer screen theidentity of all participants in the group, whereas the groupleader's video camera provided all participants a real-timevideo picture display of the group leader. Participants,however, could not view other members of the group.Participants were instructed to attend the group in a privatesetting, excluding any family members or housemates.Group sessions were led by one of the authors (V.L.K., M.K., K.B.S.); all had more than 5 years of supervisedexperience providing group-based therapy to substance-dependent patients and received specific training from CRCstaff on the use of e-Getgoing. Approximately one to fourparticipants attended the e-Getgoing group therapy sessionsat one time.

2.3.2. On-site group-based counselingParticipants assigned to this condition were scheduled to

attend on-site group counseling at ATS; the same staffleading the e-Getgoing group sessions led these sessions. Arange of 5 to 10 patients attended the on-site therapy sessions

at any one time, although not all group members wereparticipating in this study.

3. Results

3.1. Overall treatment response

3.1.1. Counseling adherenceCounseling adherence was calculated by dividing the

number of attended counseling sessions by the number ofscheduled counseling sessions over the 6-week study period.No condition differences were observed, although there wasa trend for higher rates of adherence to the e-Getgoing groupsessions (e-Getgoing: 92% vs. on-site: 76%, t = 1.90, df =35, p = .07). No group difference was observed in adherenceto scheduled individual counseling sessions during the studyperiod (e-Getgoing: 83% vs. on-site: 70%, p = ns). Takentogether, a trend was observed for higher overall (groupsession and standard individual session) attendance in thee-Getgoing condition (e-Getgoing: 89% vs. on-site: 74%,t = 1.87, df = 35, p = .07).

3.1.2. Drug useAll participants had repeated drug-positive urine speci-

mens at the time of enrollment, and all of them demonstratedmarked reductions in drug use during the 6-week trial. Nocondition differences were observed in percent of drug-positive urine samples submitted during the 6-week study(e-Getgoing: 37% vs. on-site: 42%, p = ns), althoughoutcomes did slightly favor the e-Getgoing group. Similarly,no condition differences were observed with respect to typeof drug class used. Cocaine use was most prevalent (21%cocaine-positive samples), followed by cannabis (11%),opioids (9%) and benzodiazepines (9%).

3.1.3. Step completionMost participants that advanced to Step 3 due to missed

counseling sessions and continuous drug-positive urinespecimens met the a priori criteria (i.e., two consecutiveweeks of drug-negative urine samples and 100% counsel-ing adherence) for return to a less intensive level of care(e-Getgoing: 70% vs. on-site: 71%, p = ns). Among goodresponders, no condition differences were observed in thenumber of weeks spent in intensified care before returning toa less-intensive treatment schedule (e-Getgoing: 3.95 weeksvs. on-site: 4.06 weeks, p = ns).

3.2. Treatment satisfaction

As depicted in Fig. 2, participants in both service deliveryconditions reported high and comparable satisfaction withtheir treatment. In addition, participants who completed thee-Getgoing condition were asked to report their preferencefor e-Getgoing treatment groups versus on-site treatmentgroups should they be advanced to a higher intensity of carein the future; all of these participants had prior experience

Fig. 2. Patient Satisfaction Survey. Patients rated their counseling experienceon a scale of 1 (least satisfied) to 4 (most satisfied) each week that theyremained in randomized care. Patients in both conditions were very satisfied.

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with intensified treatment delivered on-site in the treatmentprogram. Responses were obtained from 19 of the20 participants assigned to the e-Getgoing condition. All(100%) of them reported a strong preference for thee-Getgoing group counseling delivery condition. In general,participants linked their preference to the greater conve-nience and privacy associated with this service deliveryplatform, along with their view that the Internet-based settingwas both a novel and “fun” experience. Some specificexamples of stated preferences for e-Getgoing included aparticipant with an autistic son and limited child-careoptions. Another participant exposed to e-Getgoing had asignificant social anxiety disorder and found the e-Getgoingexperience considerably more comfortable than on-sitegroup counseling. Some full-time working patients couldmore easily attend the group from home versus the clinic.And lastly, all of the therapists conducting the manual-guided relapse control group via e-Getgoing reported that thetechnology was easy to learn and use without hindering theflow of the therapy.

4. Discussion

4.1. Use of Internet delivered psychotherapy is effective

The literature on use of computer technology tofacilitate the delivery of educational and therapeuticservices to people with substance use and other types ofpsychiatric disorder is rapidly expanding (Copeland &Martin, 2004; Day & Schneider, 2002; Griffiths, 2005;Myers, Valentine, & Melzer, 2007; O'Reilly et al., 2007;Pull, 2006; Rochlen et al., 2004; Spek et al., 2007).However, most of the published studies evaluate brief,self-help interventions (Koski-Jannes et al., 2007; Hester& Squires, in press; Rochlen et al., 2004; Ruggiero et al.,2006; Walters, Vader, & Harris, 2007) or treatments withminimal therapist contact (Carlbring et al., 2007). Theseinterventions are conceptualized as a way to more effi-ciently reach larger numbers of people who might nototherwise receive substance abuse education or treatment

or as a type of “pretherapy” that can prepare andmotivate persons who are concerned about their behaviorto access more intensive treatment after the intervention(Griffiths, 2005). Very few reports evaluate more in-tensive, professionalized interventions such as Internet-based individual or group therapy (Marziali, Donahue, &Crossin, 2005; Postel et al., 2005; Spence, Holmes,March, & Lipp, 2006).

This study appears to be the first published report on theuse of an Internet-based, real-time approach to deliverenhanced treatment services at a fixed-site treatment centerto patients with chronic and severe substance use disorder.Both the e-Getgoing and on-site groups were well attended,and most participants in both conditions achieved abstinenceand returned to a lower intensity of care within a period ofseveral weeks. These findings provide good preliminarysupport for using e-Getgoing and similar technologies toextend the health education and care of patients enrolled infixed-site treatment settings and intensify the treatment ofpatients with partial response to lower intensities of care(Marziali et al., 2005; Spence et al., 2006). Equally important,this study adds to the otherwise limited literature on theeffectiveness of online psychotherapeutic treatment servicesutilizing videoconferencing technology.

This study examined a less common type of Internettherapy communication—videoconferencing. However,using videoconferencing technology and related approachesto deliver treatment services in real time may have anadvantage over computer-based interventions that allowpatients to access and interact with preprogrammedcomputer modules that deliver education and basiccognitive–behavioral interventions. A recent meta-analysisshowed that Internet-based cognitive–behavioral therapyinterventions for anxiety and depression were moreeffective with versus without direct therapist involvement(Spek et al., 2007).

Marziali et al. (2005) describe the only real-timeInternet videoconferencing study published in the litera-ture. This project evaluated the acceptability and effective-ness of an online support group for family members ofpatients with cognitive impairment who lived in remoteareas of Canada. The intervention was highly valued by thegroup members, and group process measures showed goodgroup cohesion. These findings are notably similar to ourpresent findings that Internet therapy delivery wasassociated with excellent patient acceptability and clinicaleffectiveness and at least comparable to face-to-facedelivered group therapy.

Most of the studies describing efforts to treat substanceuse disorders using the Internet target tobacco and alcoholrather than illicit drugs such as cocaine or opiates (Cobbet al., 2005; Copeland & Martin, 2004; Griffiths, 2005;Murray et al., 2007). Although several Web sites offersubstance abuse treatment to persons with less severeforms of a range of substance use disorders, there isclearly a major gap in the literature describing the benefits

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of Internet therapy for drugs of abuse besides nicotine andalcohol (Griffiths, 2005).

4.2. Satisfaction with e-Getgoing service delivery

Participants assigned to the e-Getgoing condition wereclearly very satisfied with the service delivery platform,consistent with findings from other studies showing thatInternet-based therapy is associated with good patientsatisfaction (Knaevelsrud & Maercker, 2007; Pull, 2006;Rochlen et al., 2004). Participants with full-time employ-ment or substantial child-care responsibilities also notedthe increased convenience of the Internet-delivered inter-vention. Service delivery strategies that improve access toand satisfaction with treatment are especially important forpeople with chronic substance use disorder who will oftenrequire treatment for many years and who are frequentlypoorly adherent to low-intensity routine treatment sche-dules (Kidorf et al., 2006; McKay, 2005). The presentresults suggest that Internet-based interventions provide aplatform to both facilitate counseling attendance andexpand the continuum of care for people with opioid andother substance use disorders.

4.3. Study limitations

The primary limitation is sample size. Although theoverall pattern of findings was both orderly and clear,subsequent evaluations with larger samples and in othertreatment settings are next reasonable steps in the furtherdevelopment of this very promising approach to expandaccess to both routine care and enhanced services in patientsin fixed-site treatment settings. Another limitation is that thestudy was conducted over a relatively short period (6 weeks)in a population that routinely requires long-term care(McLellan, Lewis, O'Brien, & Kleber, 2000). Although thehigh level of patient satisfaction observed in participantsexposed to the Internet-delivered group therapy is clearlypromising, it is unclear how this technology would fare ifused with patients over a longer period.

Computer access and technical problems were a notablechallenge in the evaluation and at least as important alimitation as sample size. Fewer than 25% of the patientsbeing advanced to a more intensive treatment schedulereported access to an appropriately configured computer.Although this problem cannot be easily resolved, numerousbusinesses across the country routinely donate used butfully operational computers following upgrades to theirequipment. It may be possible to identify these opportunitiesand obtain used computers that could be distributed topatients in publicly supported treatment program, perhapsusing principles of behavioral reinforcement to improvetreatment participation and response (Brooner et al., 2004;Petry, 2000).

For lower socioeconomic and for the most partpoorly educated patients, computer technical difficulties

also add a potential problem. Many of the participantsassigned to the e-Getgoing condition required additionaltechnical assistance from CRC Health Group, the ATSclinic staff, and family members to register andestablish initial connection with e-Getgoing. In manyinstances, participants needed to download upgradedsoftware to support access to e-Getgoing. Marziali et al.(2005) managed this problem with on-site setup ofcomputer equipment and study-funded installation ofhigh-speed Internet service to allow videoconferencingcombined with specific training in use of the computer tonavigate the Internet and participate in the support group.The resources of this study were limited to telephone-basedtechnical support to participants from the IT staff at CRCHealth Group that was supplemented by some clinic-basedtechnical assistance. As the technology improves, it isconceivable that Internet-based service delivery willbecome more accessible to people of lower socioeconomicstatus with limited computer experience and skills. At thepresent time, these technical limitations may indicate thatInternet psychotherapy would be more applicable forroutine and intensified treatment of patients who are furtheralong in their recovery and have more resources to meetthese technical challenges.

Finally, the computer-based intervention was integratedwithin an existing program that involved individual andgroup counseling and other face-to-face contact. Priorwork with e-Getgoing has been focused on using it as a“stand-alone” treatment with a comprehensive package ofservices developed by CRC Health Group. Although thisis one outstanding use of the product, this study shows theremarkable opportunities that exist to use this servicedelivery platform to enhance the range and intensity oftreatment and health education services that could beprovided in fixed-site treatment clinics, including thegrowing number of physician office-based buprenorphinetreatment practices (Stoller, King, Clark, & Brooner,2006). Often, these physicians offer extremely limitedcounseling services, and community-based counselingservices are often not convenient for patient appointmentsor necessarily well informed about this treatmentapproach. A specialized, Internet-based psychotherapyprogram for these patients would complement the less-restrictive level of program contact that many of thesepatients seek when starting buprenorphine treatment.Integrated treatment planning between the physician andInternet therapist would likely improve the overallresponse to treatment, and Internet-based psychotherapymight attract patients who would otherwise not attendadditional substance abuse counseling sessions. Futurestudies might evaluate how this technology could bestenhance clinic and office-based pharmacotherapy modal-ities—including methadone medical maintenance andbuprenorphine delivery (King et al., 2006; Stoller et al.,2006)—by providing more convenient access to treatmentstaff overseeing these interventions.

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4.4. Conclusion

Internet-based psychotherapy is effective, and it isincreasingly used for a variety of psychiatric disorders.Additional work will be necessary to make Internetvideoconferencing more viable as a service delivery optionin community-based treatment settings managing patientswith severe substance use problems and a lower socio-economic profile. However, it is clear that patient satisfactionwith Internet therapy using the e-Getgoing platform is veryhigh, and acceptance by psychotherapists leading the groupsessions is also very good. Further research to determinebetter methods of integrating Internet-based group psy-chotherapy with on-site group counseling (or possiblyreplacing on-site counseling in some cases) to meaningfullyexpand the continuum of care in this patient population couldbe a significant advancement over current treatment options.

Acknowledgments

Special thanks to Kori Kindbom, Samantha Dibastiani,and Rachel Burns from Johns Hopkins University School ofMedicine; Cynthia Reinbach from CRC Health; and thepatients who participated in the evaluation. Portions of thisarticle were presented at the 70th annual scientific meeting ofthe College on Problems of Drug Dependence in San Juan,Puerto Rico, 2008. The project was partially supported by acontract between CRC-Health Group and Institutes forBehavior Resources, Inc.

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