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.
Home access
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.
Confidentiality
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.
Therapist expertise
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).
Patient motivation
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.
Patient progress
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
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,
1995a).
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
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.
Hands-on Help
Computer-aided Psychotherapy
Isaac M. Marks, Kate Cavanagh
and
Lina Gega
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