WHY HAVE COMPUTERAIDED PSYCHOTHERAPY (CP)?
Advantages of CP
Climbers may scale mountains just because they are there, but better reasons than the mere advent of computers drive the development and use of CP. Not all patients need the same type and intensity of help (Haaga,
2000). Some benefit from reading a self-help book, watching an instructional video, or doing CP, others by joining a brief educational group run by a paraprofessional, and still others by long-term individual therapy from a highly trained professional therapist with specialized expertise. Patients should get all the time, expertise and individual attention they need, but not more. CP is a new self-help arrow in our quiver of care options.
Access to help widened
CP widens sufferers' access to help by taking over routine aspects of care, so freeing therapists to help many more patients than before and to focus on issues which a computer cannot handle. In most countries the demand for psychotherapy exceeds the supply of trained therapists. One- to two- year waiting lists for CBT are common in the UK and elsewhere. During that time the burden grows on sufferers, their families and communities and the problem gets more entrenched and harder to help.
Different CP systems vary in how much they deliver different aspects of care and hence how much time they free for the therapist. The treatment tasks that CP might take over can include education about the patient's problem and what its treatment involves, screening (assessment) for therapy, helping patients to describe their personalized problems with individually tailored homework tasks to overcome those problems, diaries of tasks done, troubleshooting, monitoring of progress through therapy, and rating (evaluation) and display of clinical status and outcome. Some CP systems consist largely of screen pages like a book with little interaction, while others store entered data and give appropriate feedback. The more that a CP system is interactive and individually tailored, the more the therapist can delegate tasks to that CP system.
Access is further widened by the convenience of home use of certain CP systems via the internet (net, web) or phone-interactive-voice-response (IVR, see below). Home access to CP systems:
1 Empowers sufferers who prefer it to work at self-help at their own pace in their own time without having to spend hours in the company of a therapist. Some clients prefer dealing with problems by CP rather than personal interaction. When users want a rest or time to think they can leave the computer or phone-IVR link without the embarrassment of prematurely exiting the consulting room or putting down the phone during a live phone interview or moving out of camera range during a video interview. Home access by net or phone-IVR is available daily round the clock and the most common time of user access is outside usual of®ce hours.
2 Abolishes the need to schedule appointments with a therapist: though brief phone helpline or email support may be scheduled during of®ce hours until support becomes economically feasible at other times too.
3 Stops the bother and expense (and panic with agoraphobics) of having to travel to a therapist which is especially hard for those in rural areas, in unusual settings such as oil rigs, or with impaired mobility.
4 Lessens the risk of stigma involved in visibly visiting a therapist which
is widely felt by many people, including people engaged in healthcare, the police, ®re service, politics, media etc., and by people who are sensitive to having obvious dis®gurements or to talking about secret sexual or other problems.
5 Eases help for the hard of hearing as CP works more with visual than auditory information.
The bene®ts of no travel and less stigma also apply, of course, to ordinary telephone, videophone or email consultation from home, but those save no therapist time and an appointment time must usually still be scheduled for telephone, videophone, or online email consultations. CP can cut stigma further by being seen not as psychotherapy but as a computer lesson similar to an evening class, a means of self-improvement rather than a sign of de®cit or dysfunction. When applying for a job, sufferers can truthfully write and say they've not seen a therapist, as they merely used a machine.
Linked to the lessening of stigma is the greater con®dentiality of secure CP than human therapy. Users commonly con®de sensitive information more to a computer than they do to a human interviewer, e.g. about sex, illicit drugs or excess alcohol, or suicidal plans (cited in Marks et al., 1998b). Con®dentiality is not a straightforward issue. When a patient used a system in a primary care centre a nurse asked her permission to watch the com- puter screen while standing behind her. On seeing information appearing on the screen the nurse exclaimed, `But you didn't tell me that!' to which the patient replied, `Of course not. This computer's con®dential' and went on happily entering further information knowing the nurse was continuing to watch. Con®dential can mean `I can't tell it face to face' rather than `I don't want my clinician to know'.
CP reduces inhibition
CP overcomes inhibition from therapist cues in direct contact ± gaze, voice and gesture when face to face or on a videophone, voice when on the telephone, writing when contact is by letter or email. Such inhibition is why psychoanalysts sit out of view of their patient and Catholic priests taking confession sit hidden from view. Computers have no eyebrows. Patients have found it easier to tell computers about sensitive issues such as high alcohol consumption, impotence, a past criminal record, being ®red from a job, and attempted suicide (reviewed by Slack, Porter, Balkin, Kowaloff, & Slack, 1990). CP systems can be carefully devised to avoid any hint of disapproval and to encourage disclosure without worry about the tone of the therapist's voice and other contextual cues. The complexity of the cues which affect self-disclosure is vividly attested by how some people may conceal intimate personal problems in a face-to-face interview yet broadcast them widely on radio and television shows or tell them to a newly met passenger on an airplane whom they are unlikely to see again and who has no acquaintances in common.
Earlier access to care
Widening and easing access to care also allows earlier access to care, thus reducing the disability from, and chronicity and intractability of, mental health problems and reducing their cost to sufferers and health services. Patient samples in many treatment trials for anxiety disorders tend to have had their problem for a mean of about nine years, testifying to the barriers facing sufferers seeking help. If access is delayed by making prior screening by a health professional mandatory, such delay might be cut by also allowing self-referrals who email or post completed screening question- naires which staff can assess within a couple of minutes.
CP can unfailingly convey inbuilt therapists' expertise and ask all the right questions at the right moment without forgetting because they are bored, tired, hungry, or distracted after a row with someone shortly before. `No doctor has ever been as thorough with me as your machine' a woman said about a self-help program concerning urinary infections (Slack, 2000). CP can be programmed to have endless patience without ever delivering con®dence-damaging scorn or reproach, and to give completely consistent responses without excessive expectations or undue investment in the patient's progress or inappropriate reward for not doing vital homework tasks. And computers can't be unduly attracted to or have sex with the patient (www.kspope.com/sexiss/index.php).
CP may be programmed to enhance patients' motivation by presenting a wide range of attractive audiovisual information with voices giving instructions in whichever gender, age, accent, language and perhaps game format the client prefers. Little is known of exactly which presentational features of CP best inspire patients to complete self-help and improve, apart from the therapeutic appropriateness of the instructions (e.g. to do expo- sure rather than just relaxation or self-assessment for anxiety disorders). In a rare RCT on this issue postpartum women in an obstetric hospital increased their desire to reduce drug misuse after using a CP Motivational Enhancement System (Ondersma, Chase, Svikis, & Schuster, 2005). CP probably has much to learn from the advertising industry on how to spur sufferers to do effective self-help.
Certain CP systems can quickly and automatically report patient progress and self-ratings to (a) users who can print out their progress charts; and (b) a central computer displaying to a manager reports, without personal identi®ers, of the progress of a user or group of users. Such rapid and large- scale audit is impracticably expensive without computers.
Research into aspects of psychotherapy process and outcome is advanced by CP systems which record users' every keystroke for subsequent analysis. Compared to human therapy, CP gives better control of which therapy components it can insert or delete to speed dismantling studies that can test which ingredients are effective and which redundant (e.g. Osgood-Hynes et al., 1998; Richards, Klein, & Austin, 2006; Schneider, Schwartz, & Fast,
Education of practitioners
CP can facilitate the education of psychotherapists and other healthcare staff if they go through CP systems as pretend patients (Gega, Norman, & Marks, 2006; McDonough & Marks, 2002).
Therapy content can be updated far more quickly with CP (especially net- or IVR-based CP) by modifying a central server than it is by retraining therapists and rewriting manuals.
Isaac M. Marks, Kate Cavanagh and Lina Gega
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