WHY HAVE COMPUTERAIDED PSYCHOTHERAPY (CP)?




Advantages of CP

Climbers  may  scale  mountain 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   urinar 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   investmen 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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