Making multiple ‘online counsellings’ through policy and practice: an evidence-making intervention approach

International Journal of Drug Policy 53 (2018) 73–82

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International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo

Research Paper

Making multiple ‘online counsellings’ through policy and practice: an evidence-making intervention approach Michael Savica,b,* , Ella Dilkes-Fraynec,d , Adrian Carterc , Renata Kokanovice,f , Victoria Manninga,b , Simone N. Roddab,g , Dan I. Lubmana,b a

Eastern Health Clinical School, Monash University, Level 2, 5 Arnold Street, Box Hill,Victoria, 3128, Australia Turning Point, Eastern Health, 54-62 Gertrude Street, Fitzroy, Victoria, 3065, Australia Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Clayton, Victoria, 3800, Australia d School of Sociology, College of Arts & Social Sciences, Australian National University, Acton, Australian Capital Territory, Australia e School of Global, Urban and Social Studies, RMIT University, 411 Swanston Street, Melbourne, Victoria, 3000, Australia f School of Social Sciences, Arts, Monash University, Clayton, Victoria, 3800, Australia g School of Population Health, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand b c

A R T I C L E I N F O

Article history: Received 4 September 2017 Received in revised form 6 December 2017 Accepted 8 December 2017 Available online xxx Keywords: Alcohol and other drugs Treatment Online counselling Policy Implementation science

A B S T R A C T

Online counselling services for a range of health conditions have proliferated in recent years. However, there is ambiguity and tension around their role and function. It is often unclear whether online counselling services are intended to provide only a brief intervention, the provision of information or referral, or constitute an alternative to face-to-face treatment. In line with recent analyses of alcohol and other drug (AOD) policy and interventions that draw on a critical social science perspective, we take an evidence-making intervention approach to examine how online counselling in the AOD field is made in policy and through processes of local implementation. In this article, we analyse how online AOD counselling interventions and knowledges are enacted in Australia’s AOD policy, and compare these enactments with an analysis of information about Australia’s national online AOD counselling service, Counselling Online, and transcripts of counselling sessions with clients of Counselling Online. We suggest that while the policy enacts online counselling as a brief intervention targeting AOD use, and as an avenue to facilitate referral to face-to-face treatment services, in its implementation in practice online counselling is enacted in more varied ways. These include online counselling as attempting to attend to AOD use and interconnected psychosocial concerns, as a potential form of treatment in its own right, and as supplementing face-to-face AOD treatment services. Rather than viewing online counselling as a singular and stable intervention object, we suggest that multiple ‘online counsellings’ emerge in practice through local implementation practices and knowledges. We argue that the frictions that arise between policy and practice enactments need to be considered by policy makers, funders, clinicians and researchers as they affect how the concerns of those targeted by the intervention are attended to. © 2017 Elsevier B.V. All rights reserved.

Introduction Online interventions for alcohol and other drug (AOD) concerns have proliferated in recent years, alongside the rise in the use of online platforms for the provision of health information and

* Corresponding author at: Eastern Health Clinical School, Monash University, Level 2, 5 Arnold Street, Box Hill, Victoria, 3128, Australia. E-mail addresses: [email protected] (M. Savic), [email protected] (E. Dilkes-Frayne), [email protected] (A. Carter), [email protected] (R. Kokanovic), [email protected] (V. Manning), [email protected] (S.N. Rodda) , [email protected] (D.I. Lubman). https://doi.org/10.1016/j.drugpo.2017.12.008 0955-3959/© 2017 Elsevier B.V. All rights reserved.

treatment (Cunningham, Kypri & McCambridge, 2011; Gainsbury & Blaszczynski, 2011). As in other areas, such as mental health (Meurk, Leung, Hall, Head, & Whitehead, 2016) and gambling (Rodda, Lubman, Dowling, Bough & Jackson, 2013), online AOD interventions are often seen as a cost-effective way of overcoming barriers to treatment access, facilitating help-seeking and addressing AOD problems (Cunningham, Kypri & McCambridge, 2011; Gainsbury & Blaszczynski, 2011). Online counselling, whereby counsellors engage in real-time web-chat with clients, is one such example. While authors have suggested that online AOD counselling holds promise (Garde, Manning, & Lubman, 2017; Swan & Tyssen, 2007), few empirical studies have examined client experiences of online AOD counselling, the counsellor-client

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encounter, or its effects on clients’ consumption practices, wellbeing or future treatment-seeking. In the Australian context, two studies have described the characteristics of people accessing Counselling Online, Australia’s national online AOD counselling service, which provides singlesession, anonymous and 24/7 online support (Garde et al., 2017; Swan & Tyssen, 2007). Both reported that the service is highly accessed after-work hours and by groups who are less likely to seek help from face-to-face services, including younger people, family members and women. Due to the anonymity and 24/7 support provided, the authors of both studies concluded that Counselling Online can help to overcome barriers to treatment access including stigma, lack of face-to-face treatment options in particular geographical areas, and day-time child-caring, work and other responsibilities (Garde et al., 2017; King et al., 2006; Rodda et al., 2013; Swan & Tyssen, 2007). While increasing access to support for those who need it is likely to be useful, it is unclear from these studies what support people are receiving in practice, how helpful they find it and what other kinds of support or intervention online counselling may provide. It is not clear whether online AOD counselling acts in practice as a treatment similar to face-to-face AOD counselling, a brief intervention, and/or an avenue for the provision of information or referral. Despite this ambiguity, several AOD policy documents in Australia recommend expanding online AOD counselling services (Council of Australian Governments, 2015; Ministerial Council on Drugs Strategy, 2011 ; State Government of Victoria, 2012). In this article, we aim to untangle the uncertainty around the role and function of online counselling to suggest ways forward for working with the multiple intervention objects that emerge in policy and practice. In order to take account of these varied enactments online counselling, we take an evidence-making intervention approach, as proposed by Rhodes, Closson, Paparini, Guise, and Strathdee (2016). The benefits of this approach lie in its focus on how interventions are ‘made’ through processes of local implementation, and can thus take on different meanings and produce different effects to those intended at their inception or outside the local ecologies of their implementation (Rhodes et al., 2016). Rather than suggest that online counselling is only, or should be, one thing or another, we aim to draw attention to the multiple interventions online counselling can be as it is emerges through policy and practice. To do so we critically analyse how online counselling is enacted in the National Drug Strategy 2010–2015 (NDS) – Australia’s national AOD policy at the time of conducting this analysis (Ministerial Council on Drugs Strategy, 2011). We then analyse service information, usage data and transcripts of online counselling sessions from a national online AOD counselling service to compare policy enactments with local implementation processes and client experiences of the service. While the policy enacts online counselling in relatively narrow terms, we highlight some alternative and unexpected ways online AOD counselling acts when implemented in practice. We argue that the frictions that appear between the multiple enactments of online counselling need to be considered as they affect how the concerns of those affected by the intervention are attended to.

Evidence-making intervention approach The evidence-making intervention approach we take here departs from conventional evidence-based intervention and implementation science discourses, which “tend to imagine a stable intervention object with universal effect potential” if implemented fully and ‘properly’ irrespective of the context in which the intervention is implemented in (Rhodes et al., 2016, p.

17). Such discourses assume that an intervention will have a singular, predictable effect if implemented correctly, such that promises can be made about an intervention’s likely effectiveness prior to its implementation on the basis of evidence generated in other intervention contexts. However, several scholars have critiqued the assertion that AOD clinical tools and interventions are stable objects with predictable effects through criticallyinformed empirical analyses of, for instance, the implementation and use of AOD diagnostic and outcome monitoring tools (Dwyer & Fraser, 2015; Dwyer & Fraser, 2017; Savic & Fomiatti, 2016), online AOD screening and automated feedback interventions (Savic, Barker, Hunter & Lubman, 2016), and methadone (Rhodes et al., 2016; Fraser, Moore, & Keane, 2014; Fraser & valentine, 2008). This body of work illustrates that clinical tools and interventions are not stable or singular but are made (and made multiply) through their interaction with networks of other human and non-human actors in local contexts. Thus, as the configuration of the networks at play in different implementation situations will differ, so too will the intervention object and its effects (Rhodes et al., 2016). Extending this critique, Rhodes et al. (2016) propose an evidence-making intervention approach as a way of analysing and engaging with interventions from a critical social science perspective. Their approach draws on work on problematisation (Bacchi, 2009, 2012) and actor-network theories (Latour, 2005; Law & Hassard, 1999) that highlight the “relationships between problems and interventions as things in the making” (Rhodes, et al., p.19). Bacchi’s (2009) Foucault-inspired approach to policy analysis centres on how texts construct ‘problems’ through their representations of them, and brings into question the processes of problematisation and the making of solutions in evidence-based policy frameworks. Actor-network theories (Latour, 2005; Law & Hassard, 1999) investigate how action and ‘social’ effects are generated through the momentary coming-together of diverse networks of human and non-human actants, highlighting the specific contexts and collective processes involved in producing effects such as intervention outcomes. Each feeds into the aims of an evidence-making intervention approach, which seeks to investigate “how an intervention and the knowledge which constitutes it, is made locally, through its process of implementation”, and how an intervention’s effects are contingent upon a vast array of actants that make up dynamic local networks (Rhodes et al., 2016 p. 17). The aims of this kind of investigation are firstly to understand “how intervention is constituted through the frictions between the various forms of knowledge which make it” and secondly “to understand the lived health and other effects of such intervention in relation to local economies of capital and care, including in ways beyond those foreseen or fixed by an intervention’s evidencing a priori” (p.19). Inspired by Rhodes et al.’s (2016) proposal, in this article we draw on the evidence-making intervention approach and its first aim in particular, to examine how the online counselling intervention is constituted in AOD policy, implementation processes and practice. In line with Rhodes et al.’s (2016) articulation, our aim is to “make visible the variable and multiple enactments” of online AOD counselling “which can be generated other than those presumed to be stable ‘in translation”' (p.19). The notion of multiple enactments of intervention objects is central to our discussion here, and hinges on work around the performativity of knowledge practices in science and medicine by Mol (2002) and Law (2004), in which knowledge practices are seen to perform and ‘enact’ realities rather than describe pre-existing realities and objects. Various enactments reify different knowledges, and the practices through which these enactments are performed are made possible by the various actants at work in generating the local context. We take up this approach here as attending to multiplicity enables us to explore how the various enactments of online AOD counselling hang

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together or sit in conflict, with implications for how online counselling acts in practice and may be done in future. In the absence of considerable evaluation research on online AOD counselling beyond that already mentioned, we focus our analysis on policy, implementation and lived experience knowledges to compare how various enactments of online counselling emerge and co-exist. While there is some evaluation research on online counselling in a mental health context (Chardon et al., 2011; Cook & Doyle, 2002; Callahan & Inckle, 2012; Leibert, Archer, Munson, & York, 2006; King et al., 2006) which is likely to have informed how online counselling is implemented in AOD services, a detailed investigation of this material is beyond the scope of our current analysis. Rather than taking a broad approach to studying the implementation of online counselling on the whole, we focus specifically on the friction between policy and practice knowledges and enactments in AOD online counselling. Methods In this article we trace how online counselling is made in and through policy, and local implementation processes and practice. To do this we analyse three data sources: 1) Policy; 2) Information about the Counselling Online service; 3) Service usage data and transcripts of counselling sessions from the Counselling Online service. We then compare the various enactments of online counsellings that emerge through these data sources and the friction between them. While we acknowledge that there are other data sources (e.g. counsellor training materials, funding specifications, internal service implementation documentation) that would be useful in exploring local implementation processes, practices and in tracing complex actor-networks, we did not have access to such data sources. Thus, our analysis is particularly focussed on policy and practice enactments and the types of knowledges and actants at play in each. In spite of not having access to other data sources, we illustrate the role of a range of actants in the making of online counselling including policy, prevention science, funding arrangements, the online medium, counsellors and their training and professional knowledges, organisational philosophies and practices, and clients and their local knowledges and concerns. Data sources Policy For the first part of our analysis, we examined enactments of online counselling in the NDS 2010–2015 (Ministerial Council on Drugs Strategy, 2011). While the NDS has been subject to considerable critical analysis (Lancaster & Ritter, 2014; Lancaster et al., 2015; Moore, Fraser, Törrönen, & Tinghög, 2015), how online counselling is constituted in the NDS has not been explored. Other policy documents, such as the National Ice Action Strategy (Council of Australian Governments, 2015), also recommend the expansion of online counselling services. However, they do little to define its role and aims, reflecting that its purpose is often taken-for-granted and falling back on the definition provided in the NDS. While this absence could itself be productive, we focus on the NDS here as it goes the furthest towards defining the aims and scope of online counselling for AOD issues. One of the actions in the NDS is to “increase awareness, availability and appropriateness of evidencebased telephone and internet counselling and information services” (p. 11). While the NDS 2010–2015 has been superseded by the National Drug Strategy 2017–2026, the NDS 2010–2015 was in place during the period when the service usage data and transcripts of counselling sessions were collected. Therefore, the policy knowledge contained within the NDS 2010–2015 is more applicable for the purposes of this article.

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Information about the counselling online service In order to obtain an indication of how online counselling is made when it is implemented in local contexts, we analysed publically available information about the Counselling Online service. Counselling Online (www.counsellingonline.org.au) is funded by the Australian Commonwealth Department of Health to provide free single-session web-chat support to people who may be concerned about their own or someone else’s AOD use (Garde et al., 2017). To date there are no publically available evaluation reports about Counselling Online. However, the Counselling Online website provides useful information about the service, its aims, and how it purportedly works, and thus we focused on this material for our analysis. Service usage data and counselling online transcripts In order to examine the enactments of online counselling in practice, we analysed service utilisation data and transcripts of Counselling Online. Individuals provide consent prior to the counselling session for the transcript of the session and a brief demographic questionnaire to be saved and used for quality assurance and research purposes. We analysed specific variables from routinely collected service utilisation data (n = 2686) for the 2015–2016 financial year, that provide clues about how people were using the service in practice. These variables included session duration, whether clients had sought help before and what form that help took, and how clients had heard about the service. We also utilised selected cases from our ongoing analysis of 243 transcripts involving young people concerned about their AOD use (n = 83), people aged over 55 (n = 70), and people who identify as Aboriginal and/or Torres Strait Islander (n = 90). Transcripts contain the typed text between a counsellor and a client and provide a unique and rich insight into how online counselling services are delivered and experienced in practice (Savic, Ferguson, Manning, Bathish & Lubman, 2017a; Wilson et al., 2017). Research utilising this data has been approved by Eastern Health (Reference numbers: LR53-1112; LR101/1314) and Monash University (Reference numbers: CF14/1929–2014000980; 8685) Human Research and Ethics Committees. Data analysis The policy document, Counselling Online website materials and session transcripts were imported into qualitative data management software, NVivo, where they were analysed by MS and EDF using an iterative inductive approach, which was also guided by our critical social science approach. This involved reading through and familiarising ourselves with all three data sources in light of our reading of the evidence making intervention approach. We then identified different enactments of online counselling in the policy document and Counselling Online materials, as well as the knowledges and assumptions, which emerged. We selected cases from our sample of online counselling transcripts that illustrated or extended the identified enactments from other data sources further to provide an indication of how Counselling Online was being produced in practice. As per the case-approach employed by Savic et al. (2017a), in working with these selected cases our analytical and theoretical interest was in the particularities and factors at play in each counselling session rather than chunking data into discrete themes divorced from the encounter in which they emerged (Jackson & Mazzei, 2011). The service usage data were imported into SPSS, where means and frequencies were generated for the aforementioned specific variables. These variables were selected as they provided an indication of how Counselling Online was being enacted by service users in practice, and thus pointed to additional possibilities for what online counselling could be. In the analysis to follow, we

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begin with the enactments of online counselling in policy, before incorporating insights from the various data sources related to the lived and local experience of service implementation. In performing this analysis we are participating in the making of particular knowledge, and thus online counselling interventions. Specifically, by foregrounding local knowledge practices and the ways in which research evidence and policy knowledges are not straightforwardly translated into practice, we seek to generate knowledge that will enable alternative enactments of online counselling to come into being and afford new possibilities for the service, its clients and staff, and those who may access online counselling in the future.

individual accessing counselling. Other concerns become peripheral where a problem is enacted as personal, putting the responsibility for change within the hands of the person with the ‘problem’, and discounting the role other factors play in consumption practices and one’s desire and ability to change. The NDS can be seen here to play a role in the way AOD use is problematised, and how particular solutions become seen as viable responses to the particular problems they enact.

Enactments of online counselling in policy

The second enactment of online counselling in the NDS is as a tool to facilitate referral and access to face-to-face AOD treatment. The NDS states that “it is important to ensure that appropriate treatment is available and accessible” (p. 10) and one of its stated actions is to “improve access to screening and targeted interventions for at-risk groups” (p. 11). Brief interventions including online counselling are constituted as ways “to refer people to specialised services where necessary” (p. 11). Thus, rather than a ‘treatment’ in its own right, or an alternative or complement to face-to-face treatment, online counselling is constituted as a nonspecialist intervention that acts as a conduit to specialist care. In establishing a binary between specialist (face-to-face treatment) and non-specialist online counselling interventions, in which movement only occurs in the direction of non-specialist to specialist interventions, the possibility of other non-linear and multi-directional movements are discounted. For instance, online counselling is not constituted as an intervention to which face-toface AOD treatment providers could refer clients to if/when they need additional support between treatment appointments or after treatment finishes. According to the NDS, and the prevention science knowledge it draws on, a lack of awareness by the person using drugs of the “harms caused by drug use” and that they have an AOD problem are major challenges to treatment-seeking and reducing harms (p. 18). Thus, as the logic goes, persuading people that AOD use is harmful, that they have a problem with alcohol or other drugs and then motivating them to seek face-to-face treatment are key functions of online counselling and other internet interventions as constituted in the NDS. For instance, one of the policy actions for reducing harms in the NDS is to “develop and implement internetbased approaches to target individuals with problematic drug use who do not think they have a problem and encourage them into treatment and/or other services supports” (p. 19). This rests on the assumption that through expert knowledge, an AOD ‘problem’ can be objectively identified and measured, and that feeding this information back to an individual will make them more motivated to do something about it (Savic et al., 2016). As Savic et al. (2016) illustrated in relation to people completing an automated online screening and feedback intervention, diagnosis of a problem can contribute to the enactment of pathologised or stigmatised subjectivities (e.g. as an addict). This can be productive for some but can also be distressing and obscure other concerns beyond AOD, or may act a site of resistance for others. In these ways the policy, and the prevention science knowledge it draws upon, enacts a particular kind of online counselling, one that aims to provide early and brief intervention to groups at risk of AOD ‘problems’ to facilitate referral into face-to-face treatment. Notably, the policy does not enact online counselling as an AOD treatment in its own right, nor as an intervention to attend to people’s needs and concerns beyond AOD use. Acting as the national drug policy, the NDS forms part of the local context of the implementation of online counselling in Australia, framing the funding arrangements, intended uses and functions of online counselling, counsellor training, and the design of programs such

We identified two key enactments of online counselling in the NDS: 1) as an early and brief intervention to target AOD use; and 2) as a tool to facilitate referral to face-to-face AOD treatment. As we will illustrate, both of these enactments emerged through public health, psychology and biomedical knowledges – which together can be characterised as ‘prevention science’ knowledge (Duff, 2003) – about AOD use as inherently risky and as potentially leading to dependence or addiction. Online counselling as an early and brief intervention to target AOD use Online AOD counselling is enacted in the policy as a means of brief and low-intensity intervention for people at risk of developing AOD problems. In the NDS online counselling is first mentioned in relation to the objective of “reducing the use of drugs in the community” (p. 10) where it is discussed as a means of brief (early) intervention “before harms and long-term dependence occur” (p. 11). Here the NDS relies on the prevention science notion of a linear addiction career or trajectory (Hser, Hoffman, Grella & Anglin, 2001) in which dependence is seen as the potential consequence of long-term AOD use, which is singularly constituted as harmful (Fraser, Moore & Keane, 2014). Consistent with prevention science concepts and knowledge around early intervention (see Savic et al., 2016), the aim of online counselling and other brief interventions is to provide a cost-effective way to prevent long-term AOD use (and therefore harms and dependence) from occurring by cutting this trajectory off early and to prevent the need for more costly face-to-face AOD treatment in the future. This aim assumes that those accessing online counselling will not have already developed long-term patterns of consumption, and that they will access the service sooner than they would a face-toface service. The policy’s enactment of AOD use, as the central problem online counselling should seek to address has two significant implications. First, it enacts AOD use as inherently harmful (Duff, 2003), ignoring the potential pleasures or benefits many derive from AOD use and the complex interplay between pleasures and harms (Duff, 2007; Holt & Treloar, 2008; Manton et al., 2014; Pennay, 2015). Second, it relegates other psycho-social concerns and contextual factors to the background where they cannot be serviced, despite other evidence that these concerns and contextual factors are likely to be linked to a person’s drug consumption, and an increasing awareness of the need for holistic care (Savic, Best, Manning, & Lubman, 2017b). This enactment is further reiterated in the NDS where it states that brief interventions, which “range from five minutes of brief advice to 30 minutes of brief counselling . . . aim to identify current or potential problems with drug use and motivate those at risk to change their behaviour” (p. 10). Consistent with the focus on individual behaviour change in prevention science (Savic et al., 2016), the focus on motivating an individual to change their behaviour places the locus of responsibility for change within the

Online counselling as a tool to facilitate referral to face-to-face AOD treatment

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as Counselling Online to fit with these stated aims. However, while the NDS enacts online counselling in relatively narrow ways, insights from our analysis of Counselling Online materials point to a multiplicity of ‘online counsellings’ made through the implementation of online counselling in practice. As is evident in the next section, the priorities of the policy and the evidence informing it are not easily transportable into practice, where other lay practice knowledges are produced, and where networks of actants coalesce during implementation to influence the shape of the intervention. Making multiple ‘online counsellings’ in practice While the empirical data on Counselling Online reiterates elements of the policy enactments identified, here we illustrate the emergence of enactments not accounted for in policy to draw attention to the unexpected ways in which online counselling has emerged in practice. In particular we discuss three enactments: 1) online counselling as attempting to attend to AOD use and interconnected psychosocial concerns; 2) online counselling as a potential form of treatment; and 3) online counselling as supplementing face-to-face treatment. Online counselling as attempting to attend to AOD use and interconnected psychosocial concerns While online counselling is enacted in the NDS as an intervention to address AOD use, the implementation of online counselling hints at the potential for a broader focus. For instance, on the frequently asked questions page of the Counselling Online website the following response is provided to the question “what services are offered?”: Our counsellors work from the individual’s identified needs. We’ll help you assess your situation, provide information and support, and provide referral options that will respect your ability to make informed choices for yourself. In keeping with treatment discourses around person-centred or holistic care (Savic et al., 2017b), this indicates that if a person has other “identified” psychosocial needs beyond or connected to AOD, which notably is not mentioned here, then the service could potentially attend to those needs. Similarly the “Who we are” section of the website mentions that Counselling Online is operated by Turning Point, which strives “to promote and maximise the health and wellbeing of individuals and communities living with, and affected by alcohol and other drug-related harms.” This illustrates how online counselling, when implemented, may be influenced by organisational values and aims, which focus not only AOD but also on broader health and wellbeing. When these broader discourses about holistic care and organisational values interact with particular clients concerns and counsellor knowledge and practices, a more wellbeing-focussed online counselling intervention emerges. Our analyses of counselling-session transcripts indicate that people also access Counselling Online with a range of psychosocial concerns and goals that may be related to their AOD consumption. These include mental and physical health concerns, employment and financial stressors, relationship issues, and anxiety related to life events such as bereavement or retirement. Not only do some clients express psychosocial concerns but some also express goals around improved wellbeing, mental health and physical health in conjunction with addressing AOD concerns. In raising these broader psychosocial and wellbeing concerns and goals in online counselling sessions, clients draw the various factors usually sidelined as context into the counselling encounter, inviting an additional type of intervention to the narrowly defined AOD problem intervention as enacted in the NDS.

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Julie’s online counselling session provides an illustration of the potential of Counselling Online to emerge as a more holistic and wellbeing focussed intervention. Julie was in her late 50 s and had never sought help before. She was prompted to seek help after the death of her son as she explained in her opening passage of text: [Julie] Hello. I hope you can assist. I am looking for assistance with my alcohol problem. I have never been a heavy drinker but I lost my son [ . . . ] in a road accident, and now find it difficult to get through a day without some alcohol to take the edge off the pain. I am in full time employment, but sometimes I feel I am not as efficient as I could be as I often feel tired or a little hungover. I would like to be able to function without the alcohol, but I find it very difficult to do so. Julie’s remarks illustrate a web of concerns that is more complex than her initial rendering of her situation in terms of an “alcohol problem”. For instance, her alcohol use seems to have escalated in response to the loss of her son in a road accident, which is a source of pain for her. She indicates that she uses alcohol to help “take the edge off” and “function”, but that she’s also concerned that her use of alcohol is affecting her energy levels and performance at work. Rather than narrow in on alcohol as ‘the problem’ as the online counselling that emerges through the NDS might encourage, the counsellor hones in on Julie’s grief: [Counsellor] I am really sorry to hear about the loss of your son. Coping with grief can take many forms and it appears that alcohol is your way of coping. Have you considered grief counselling? While drawing on a familiar narrative of AOD use as a way of coping, the counsellor’s question foregrounds Julie’s grief as the “identified need” (in the language of the Counselling Online website), that requires addressing. Julie then responds: [Julie] I don’t feel I can talk to anyone who hasn’t experienced the loss of their own child. Even though Julie’s response indicates that she doesn’t feel that a grief counsellor would be appropriate at this point in time, the counsellor persists with attempting to assist Julie with her grief as the session comes to an end: [Counsellor] who is supporting you? [Julie] I have a caring daughter and a loving partner. Neither of them live with me. [Counsellor] you have a wonderful daughter who I’m sure are also going through the grieving process. And great to have a loving partner. However, it is important for you to get support to work through the grieving process. Grief counselling staff are trained to support you. Until you start addressing your grief, it will be near impossible to address the alcohol use. Even though the counsellor insists on grief counselling as the most appropriate response, the counsellor also provides Julie with positive reinforcement around her informal sources of support. We have commonly observed variations of the counsellor’s concluding statement, in which counsellors establish concerns around AOD as connected to, symptomatic of, or sustained by larger and more pressing psychosocial issues. In such cases a different online counselling emerges – a holistic and wellbeing-focussed online counselling, that assists people to address broader contextual factors that may be related to AOD use rather than simply seeking to convince them that drugs are harmful and it is their responsibility to stop or seek treatment. In some instances, however, the stated aim of the service to attend primarily to AOD concerns was reflected in sessions in which counsellors referred clients to other services for support with other concerns such as legal, mental health, relationship counselling or child protection issues. If policy and funding arrangements enabled

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longer discussions that explored the bundle of factors that may influence, or be influenced by, AOD use, this might enable other concerns to be attended to and allow client knowledge about the factors related to their consumption to become a larger part of their counselling experience. Local knowledge about how the intervention works in practice, and how clients would like it to work, may provide the impetus for service amendments that enable a wellbeing-focussed online counselling intervention to emerge more readily. The generation of this local knowledge may also be used to advocate for the removal of policy and funding impediments to the realisation of online counselling as a more holistic wellbeing-focussed intervention for those affected by alcohol and other drug use. Online counselling as a potential treatment intervention Our analysis of Counselling Online website content, transcripts and service utilisation data suggests Counselling Online may also be constituted as a potential treatment intervention when a range of actants come together. These include professional knowledges, the service’s appeals to operating inside established treatment guidelines, counsellors using motivational interviewing therapeutic techniques, longer session durations, the online medium and the unique therapeutic possibilities it can afford, and clients using the service as a way of receiving care. Firstly, the Counselling Online website’s explanation of the service articulates it as a formal, specialist and professional service even though the website’s disclaimer (located on a less visually prominent location on the website) also states that “it is not a substitute for independent professional advice from your own or another health professional”. While the page on the website entitled “What is Counselling Online?” does not specifically use the term “treatment” to refer to Counselling Online, it makes Counselling Online a treatment-like service by detailing the qualifications and experience of counsellors employed by the service: Counselling Online services are provided by counselling staff with professional qualifications and experience in alcohol and drug counselling and treatment. These staff are employed by Turning Point in Victoria. Our staff have a range of qualifications in health sciences, including Psychology, Social Work, Nursing, Psychiatric Nursing and Welfare Studies. Counselling Online staff also have specialised experience in alcohol and drug treatment delivery. This often includes experience in face-to-face alcohol and drug treatment services in the community. Here staff are not only established as having professional qualifications but also as having experience and knowledge, in both the provision of treatment and face-to face AOD treatment specifically. Drawing on the professional knowledges of various disciplines not only enhances the service’s credibility but also points to the different disciplinary knowledges of the people staffing the service. These too enact the intervention multiply as they are likely to make a difference to the counselling provided even if there is hope to make the service consistent across counsellors through counsellor induction and in-service training processes (Savic et al., 2017a). As well as enacting counsellors as “professionals”, the website also establishes Counselling Online as a treatment-like service by detailing the policy and clinical practice frameworks and standards it works within: Counselling Online services are delivered within a harm minimisation framework. Our counselling and support services are provided with reference to current clinical practice standards and guidelines for alcohol and drug service delivery.

By positioning the services provided by Counselling Online as being “within” the policies, standards and guidelines (and hence dominant scientific and professional knowledges) that apply to, and shape, face-to-face AOD treatment, Counselling Online is established as similar to face-to-face AOD treatment services. Secondly, the session length, which is influenced by client desires and needs, counsellor practices, funding arrangements and pressures to see as many clients as possible, is often consistent with a more therapeutic encounter. Our analysis of the 2686 counselling sessions provided in 2015–2016 indicates that the average session length was 28 min (SD = 20.7), although when the 173 sessions under 5 min in length are excluded (as these are often where a client ceases the session before typing anything), the average length of a session is just over 30 min (SD = 20.4). Furthermore 41% of all sessions were longer than 30 min, with 9% of sessions lasting over an hour. Albeit a crude indicator, the length of many sessions was beyond the “five minutes of brief advice” or “30 minutes of brief counselling” (p.10) that the NDS suggests is a brief intervention. Thirdly, our analysis of online transcripts illustrates that these longer sessions contain more than the simple provision of advice, information or referral that the NDS and the Counselling Online website, in places, suggests. They contain considerable discussion, dialogue and counselling techniques that are often used in face-toface AOD treatment, including motivational interviewing techniques (Miller & Rollnick, 1993) such as open-ended questioning, development of a therapeutic alliance, and exploration of clients’ beliefs, accounts, AOD experiences (both positive and negative), and proposed solutions to their concerns (Savic et al., 2017a,b). Tom’s one and a half hour-long online counselling session provides a useful illustration of this. Tom who was in his early 20 s and had previously accessed the Counselling Online service before, struggled initially to articulate his concerns: [Counsellor] Hi there. [Tom] I’m worried I can’t kick it. [Tom] It’s at the back if my mind. [Counsellor] Ok – what is “it” – alcohol or another kind of drug. [Tom] Ice. I hate to write it down. The counsellor, then responds by empathising and attempting to normalise Tom’s concerns: [Counsellor] We talk to a lot of people who take Ice . . . what do you hate about writing it down? [Tom] It makes it feel even more of a problem. [Counsellor] Yeah I get that it can be quite confronting to see it written down – makes it more real somehow. However, you are obviously anxious about your use so lets talk about how its affecting aspects of your life. The counsellor’s responses here and elsewhere in the session, concord with motivational interviewing principles and practices such as reflective listening, non-judgement, expressing empathy and asking open-ended questions (Miller & Rollnick, 1991). The counsellor’s suggestion that writing concerns down “make it more real” than verbalising concerns also points to the unique features and potential affordances of the online counselling medium. In this sense online counselling not only emerges as like treatment, but also a unique form of treatment with added potential benefits. These are discussed further mid-way through the session, when Tom enquires about what he can do about his methamphetamine use: [Tom] How do I even start to try . . . . Start stopping I guess [Counsellor] . . . you’ve already started just by making contact tonight. There are lots of supports available to support decisions you make. Which state are you in?

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[Tom] . . . [name of state removed]. People have suggested rehab but that doesnt seem like a good idea to me. [Counsellor] For some people these first steps help them decide if there is a problem to tackle. Whether it’s cutting down, stopping altogether or that its other issues that need to be addressed primarily. Rehab isn’t the only way to go esp if it doesn’t sound OK to you – it’s impt that you’re happy with the decisions you make. [Tom] I think talking about it online like this is a good way to start. I feel so much more comfortable talking to someone about it online. When people talk to me about it to my face I just instantly panic. As well as encouraging and affirming Tom’s initial steps in seeking help via Counselling Online, the counsellor’s statement about exploring what ‘the problem’ is, illustrates the potential value of online counselling in assisting in this exploration. Furthermore, the fact that the counsellor does not automatically presume that ‘the problem’ that online counselling or treatment addresses is necessarily drug use per se – that it could be “other issues that need to be addressed primarily” – reiterates the previous enactment of Counselling Online discussed. It is also notable, that Tom, indicates a preference for online counselling over face-to-face treatment, as he feels more comfortable expressing his concerns online. As the session concludes, the counsellor invites Tom to contact the service again if he desires: [Counsellor] You can do this as often as you like. You can sign up as a regular “caller” or remain anonymous. There is someone here 24/7 who’s available. it’s a good way to understand your substance use, chewing the fat about whether changes need to be made without pressure of someone being in your face. [Tom] Especially when it is a person who doesn’t actually care for your state of mind. I think I give off the wrong impression though when given advice. [Counsellor] Thing is most people don’t need advice – most people [ . . . ] know what needs to be done. and when given advice it can back us into a corner. What you can do with us is work on building your motivation and setting some goals. Again online counselling emerges here not just as a service that provides information, advice and referral as established in the NDS, but like treatment, becomes a place to talk, set goals and determine solutions potentially over several sessions. In longer sessions, like Tom’s, in which motivational interviewing knowledge and techniques are employed and in which clients preferences are for exploration and discussion, online counselling is enacted as a form of treatment. Although the service is not currently set up to allow for an ongoing therapeutic relationship with a single counsellor as one might expect in face-to-face counselling interventions, there is a small proportion of people, like Tom, who repeatedly use the service. According to the 2015– 2016 service use data analysed, 11% of the 1166 people who had sought help from any source before were registered, repeat users of Counselling Online. A higher proportion of overall service users may repeatedly access the service, but data on repeat users who don’t register is not currently collected. However, the experiences of repeat clients potentially points to Counselling Online as a possible ongoing source of support akin to longer-term face-to-face counselling where the client and counsellor work towards addressing a client’s goals over a number of sessions with the potential for the development of a similar kind of therapeutic alliance (see also Sucala et al., 2012). Currently the service is not well set up to effectively identify and accommodate repeat users due to policy and funding frameworks but if these were different, the service could potentially be amended so that it can better act as an ongoing source of support and counselling.

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Online counselling as supplementing face-to-face treatment Our analysis suggests that Counselling Online interacts with face-to-face AOD treatment services in more complex ways that go beyond the limited interactions proscribed in the NDS. The service’s stated aims and knowledges, the lack of availability of face-to-face services at particular times, clients’ desires and service use experiences, and counsellor responses to these, all act in the enactment of online counselling as supplementing face-to-face treatment. For instance, the stated aims and target groups on the Counselling Online website include: We aim to provide services for people at all stages of help seeking:  for first time help seekers  for people waiting for treatment  people in treatment that require additional support, particularly after hours  people who have completed treatment and want to stay on track  for people in recovery wanting to connect with others or prevent relapse  for people supporting a significant other with a drug and alcohol problem. Here Counselling Online is enacted variously and multiply as a potential source of bridging support for people waiting for face-toface AOD treatment, as an adjunct to treatment for people who are already in-treatment, and as a form of aftercare or continuing care when people have finished treatment. The ways clients use Counselling Online in practice also produces knowledge to indicate that the service acts as a supplement to faceto-face AOD treatment. In our analysis of service usage data for 2015–2016, 27% of people had sought help from face-to-face services before accessing Counselling Online and 8% had heard about Counselling Online through a service provider. This suggests that online counselling not only acts as a gateway to face-to-face treatment, but also supplements face-to-face treatment as the aims articulated on the website suggest. As per the service’s stated aims, one possibility to explore further is whether Counselling Online is being used as a form of support (e.g. aftercare) once people leave AOD treatment. Another possibility is that Counselling Online is being used in some cases as an adjunctive intervention to provide additional support to people who are already accessing face-to-face AOD treatment services. Garde et al. (2017) reported that over two-thirds of clients who accessed Counselling Online in 2013–2014 did so outside of standard business hours, which underscores the potential of online counselling to extend the care provided in face-to-face treatment at times when this is typically unavailable (Swan & Tyssen, 2007). Marlee, is one such example. She connected to the service after 1:30am when she was having difficulty sleeping since stopping drinking alcohol three weeks earlier. She had previous experience with both face-to-face and telephone AOD helpline services and was seeing a psychologist for mental health issues: [Marlee] Hi. I am three weeks sober [from alcohol]. Do you know how long until I stop sleeping all day and awake all night? [...] [Counsellor] Three weeks is a great effort. Are you linked with a support service or your GP? [ . . . ] [Marlee] i see a psychologist for depression and anxiety. They do not know anything about addiction counselling. I am not on any alcohol withdrawal meds. I tapered gradually.

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[Counsellor] do you know the ADIS [Alcohol and Drug Information Service telephone] line in [your state – phone number removed]? Have you had sleep problems before? [Marlee] ADIS phoneline is only available till 10pm. I have had hypersomnia with depression for a long time but it is worse now that I have stopped drinking. [Marlee] I contacted ADIS and got into detox in April this year. I did[n]’t give up after that but reduced my alcohol intake since then onwards. [ . . . ] [Counsellor] it takes a while for the mind and body to get used to not having the alcohol in the system especially after a long time of use. ADIS would be able to refer you to some alcohol specialists in your area when you ring them. The sleep issue sounds really frustrating. [Marlee] I don’t know if they can help cos Im already sober now. It makes me feel like drinking again [ . . . ] Online counselling was available at a time when the telephone helpline was not, and at a time of the evening when she was motivated to make contact by her insomnia, but at risk of returning to drinking to help her cope. While she had already been to “detox” and was attending Alcoholics Anonymous (AA) meetings, she was unsure of her options for other AOD treatment now that she was no longer consuming alcohol, and had not received adequate information from her GP or her psychologist: [Marlee] i go to AA 3 times a week at evenings. [Marlee] i can’t shut my mind off now that I’m not drinking. [Counsellor] It’s hard to stay awake and exercise when you don’t feel that good but just by making some effort (even 3 10 min walks a day) can help. There a[r]e lots of things in the internet about sleep hygiene. You can try the [government health] website. It is very good. [Marlee] thanks. that looks good. [Counsellor] The thing is to not try and stop the [chatter] but just “observe it”. It’s exhausting being in a tug of war with your mind. [Counsellor] going to a GP might be of help. [Marlee] i saw a GP today. they couldn’t help me. they hadn’t even heard of naltrexone when I mentioned it. [Marlee] would talking to a local drug/alco counsellor help? [Counsellor] the gp shoud be able to refer you to an addiction specialist. ADIS probably can tomorrow. Yes, defintiely contact a drug counsellor. [ . . . ] What about a rehab? [Marlee] I dunno about rehab. I [used to be] a middle-class professional woman. I feel weird about rehab. I don’t think i would belong. [Counsellor] there are private and public ones. Maybe get the info on them and then decide. You get [all] types in them. [Marlee] ok i will look into rehab. [


I will] ask ADIS if they know of any good GPs or counsellors to talk to thanks. [Counsellor] good on you for contacting. The more you reach out, the more likely you will find the help you need. Good luck. The counsellor was able to provide Marhee with some suggestions and other resources for support with ‘sleep hygiene’ and encourage her to seek out further AOD treatment options. In this way, the service was able to provide a bridge between her detox stay and other treatment options, and provide support and information at a time when other services were unavailable. Other clients contacted the service as a supplement to various face-to-face treatment services, for example, after receiving inadequate aftercare after leaving hospital for AOD related admissions and seeking support to remain abstinent, when their AOD counsellor was on leave, the service was closed for the day, or while waiting for an upcoming appointment. Some clients also contacted the service to supplement their contact with mental

health services who did not specialise is AOD issues, as in Marlee’s case. The counsellors were able to encourage people to stay in contact with the services when they were at risk of ceasing, to reconnect with counsellors they had stopped seeing, or to find new support services. In many cases, the counsellors encouraged clients to recontact Counselling Online between their appointments with other services, or at times when they needed support outside business hours. In these examples, Counselling Online was enacted as an adjunct to face-to-face treatment services, particularly because of its ease of access and immediacy of contact in times of need outside business hours. However, in some cases there appeared to be an overemphasis on referral to other services, which is inadequate for people seeking support to supplement other treatment as they may already be in contact with other services. In this case, Counselling Online could be better tailored to provide counselling without a focus on referral to those already in contact with other services. Conclusion Through the utilisation of an evidence-making intervention approach (Rhodes et al., 2016), we have illustrated the multiple enactments of online AOD counselling in policy and practice, and how various knowledges feature in the local implementation context through which these enactments emerge. By highlighting the roles of local implementation contexts and knowledges at work in generating intervention objects, this approach has allowed us to critically examine the constitution of multiple ‘online counsellings’ and consider how these might work together or act in friction. Rather than a stable intervention object, online counselling is enacted variously and multiply as a brief intervention targeting AOD use, an avenue to facilitate referral to face-to-face AOD treatment, a holistic and wellbeing-focussed intervention, as a potential treatment itself, and as working in conjunction with faceto-face treatment. Multiple ‘online counsellings’ emerge due to different enactments and knowledges at play in policy and the practice of online counselling, as they interact with networks of other relations, discourses, and actants, such as various problematisations of AOD use, policy documents, treatment funding arrangements, the online medium, and how clients actually use the service. We have pointed to friction between the prevention science knowledges and narrow enactments of online counselling in policy and the multiple and various unexpected ‘online counsellings’ that emerged through the implementation of a national online counselling service in Australia. Drawing on prevention science that frames AOD use as inherently risky and problematic, online counselling was enacted in policy as exclusively attending to AOD concerns, but in practice online counselling was sometimes constituted as a wellbeing-focussed intervention, which attempted to attend to AOD concerns in a more holistic fashion. While the narrow focus on AOD concerns may be considered necessary for a policy document that addresses AODs specifically, the framing in the NDS goes on to inform AOD treatment system funding models and outcome monitoring measures which focus on AOD use as the primary outcome of interest (Moore & Fraser, 2013; Savic & Fomiatti, 2016). At this point of translation, the policy enactments become problematic for the ability of services to address the multiple and interconnected concerns that people who seek AOD treatment and support often have, which was reflected in how people used the Counselling Online service (Lubman et al., 2016; Manning et al., 2017; Treloar & Holt, 2008). The narrow focus in policy also limits the ability of the service to respond to calls for more holistic, person-centred and integrated approaches to treatment and care that service clients appear to desire (Ferguson, Savic, Manning, & Lubman, 2017; Savic et al., 2017b; Treloar & Holt,

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2008), and which the NDS acknowledges in advocating for a “no wrong door approach . . . so that people are provided with, or are guided to, appropriate services regardless of where they enter the system of care” (Ministerial Council on Drugs Strategy, 2011, p. 11). While the “no wrong door approach” encourages referral to other treatment services that may be of relevance to the client, in the case of online counselling, this does not always translate to addressing people’s concerns holistically, but rather providing multiple referrals to disparate services. As we have argued in this paper, there is greater potential for local implementation of online counselling programs to more effectively meet a wider range of client needs. However, this is only feasible where funding, staffing and training arrangements reflect a wider service focus, such that staff are not called on to provide a wider range of services than they are trained and funded to deliver. Another point of friction between policy and practice enactments centres upon whether or not online counselling is a potential treatment intervention. In constituting online counselling as a brief and non-specialist intervention consistent with AOD care guidelines (Haber, Lintzeris, Proude, & Lopatako, 2009; Marsh, O’Toole, Dale, Willis, & Helfgot, 2013), the possibility that online counselling can act as a form of more substantial AOD treatment is relegated to the background. While the policy enacted online counselling as a referral pathway into face-to-face treatment, in practice online counselling is sometimes constituted as a potential treatment intervention in its own right, in which motivational interviewing techniques are utilised and significant time-intensive discussion can occur. Other researchers have also conceived of online counselling as a “viable treatment alternative” (Swan & Tyssen, 2009, p. 52) or a “wide-reaching treatment option” (Garde et al., 2017, p.4), while also recognising its potential to supplement face-to-face treatment, facilitate access, referral and early intervention. In the spirit of the reflexivity that a critical social science encourages (Rhodes et al., 2016), it is also important to acknowledge the role of researchers, like ourselves, as actors in the production of evidence and interventions. By tracing how online counselling emerges across policy and practice we have drawn out the frictions between the various enactments and knowledges that emerge, and brought local implementation practices into conversation with the policy. In doing so, our aim has been to improve the ability of the service to act well multiply by generating the knowledge that will enable alternative enactments of online counselling to emerge. Thus, although implicated in different ways, we are no less implicated in the evidencemaking project than researchers who aim to establish the ‘efficacy’ of interventions and/or their “apparent potential for transportability across (often largely unknown) contexts” (Rhodes et al., 2016, p. 19). In line with the evidence-making intervention approach, we suggest that online counselling emerges as multiple interventions in different situations including as a potential treatment intervention and as a brief intervention. Clients appear to be using it to overcome treatment access barriers in multiple ways, and these client knowledges need to be fed back into the service design rather than aiming for a direct translation of narrow policy formulations into practice. Retaining this multiplicity is necessary for responding to the various concerns clients present with and seek support for, rather than attempting to reduce and unify the scope of the intervention. We argue that policy makers, funders, clinicians and indeed researchers would similarly benefit from an awareness of the multiple enactments of online counselling, and the knowledges and local contexts through which these are made, rather than viewing it as a singular and stable intervention. If online AOD counselling services are funded to provide a brief intervention only, then this may discourage online counselling

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from performing other roles that clients seem to desire, and meeting a diverse array of needs. Furthermore, online counselling services may not be able to financially sustain the cost of serving the multiple roles that they appear to do in practice if they are only funded as a once-off brief intervention. We are not suggesting that funders should shift support from valuable face-to-face AOD treatment services to invest in online counselling as the primary or only form of treatment. Rather we argue that policy and funders need to appreciate the multiple roles that online counselling plays if it is to be afforded the potential to be responsive to the needs of various client groups, provide an effective high-reach service that supplements existing treatment service structures and addresses barriers to access as demand for treatment grows.

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