Computer-assisted psychotherapy can be defined as (1) the application of computer tools as an adjunct to clinician-administered psychotherapy, or (2) the use of a computer to enhance the efficiency, cost-effectiveness, or delivery of psychotherapy. Attempts were made to adapt computers for use in psychotherapy applications as early as the 1960s (O'Dell & Dickson, 1984; Weizenbaum, 1966; Wright & Wright, 1997). The first program ("Eliza") was intended as an exercise in computer programming, not as a serious effort to conduct psychotherapy on a computer. Although "Eliza" was a fascinating demonstration project, it was not able to communicate reliably with humans using natural language (O'Dell & Dickson, 1984). Most subsequent developers have not attempted to program computers to conduct interviews that simulate communication with a human therapist. Instead, the unique attributes of computer technology have been tapped to design programs that use a variety of media (e.g., text, video and audio, interactive voice response, virtual reality) to educate, give feedback to, and involve users in highly interactive learning exercises (Wright & Wright, 1997).
It has been suggested that therapeutic software could lower the cost oftreatment by reducing the number or length of sessions with a clinician required for effective treatment (Wright & Wright, 1997). Several controlled investigations have documented this advantage of computer-assisted therapy (Kenwright, Liness, & Marks, 2001; Newman et al., 1997; Wright et al., 2001). Other possible benefits include improved access to psychotherapy; effective provision of psychoeducation; ability to store, analyze, and display data; systematic feedback to the user; and promotion of the self-monitoring, homework, and self-help components of treatment (Locke & Rezza, 1996; Wright & Wright, 1997).
One of the concerns raised about computer-assisted psychotherapy is that patients could experience being referred to a computer as a dehumanizing experience. However, research with therapeutic software has demonstrated that patients usually report high levels of satisfaction with their experiences in using a computer as part of treatment (Colby, 1995; O'Dell & Dickson, 1984; Wright, Wright, Salmon, et al., 2002). .Another concern is that a computer program could never be programmed to have the empathy, wisdom, or creativity of the human therapist. Contemporary developers of computer-assisted therapy programs agree with this observation, and thus do not attempt to simulate the traditional therapeutic interview (Wright & Wright, 1997).
Computers, unlike human therapists, do not have inherent values or ethical standards. However, developers convey their theoretical orientation, values, and ethics in writing software for computer programs. Sampson and Pyle (1983) have offered ethical guidelines for computerized psychotherapy programs that include the following: (1) adequate protection of confidentiality; (2) up-to-date and accurate information; (3) well-functioning hardware and software; and (4) supervision of the treatment process by a clinician. Some developers of therapeutic software have produced professional and self-help editions (Colby & Colby, 1990; Wright, Wright, & Beck, 2002). The professional edition is intended for use in clinician-directed computerassisted therapy, whereas the self-help edition is designed to be utilized in a manner similar to a self-help book.
Computer programs for psychotherapy have been based most commonly on cognitive and behavioral methods because these forms of treatment use specific interventions, emphasize psychoeducation, and employ self-help as a primary ingredient of therapy (O'Dell & Dickson, 1984). An example of a computer program oriented toward cognitive-behavioral therapy (CBT) is the software developed in the 1980s by Selmi and coworkers (Selmi, Klein, & Greist, 1982). This program relied completely on written text to communicate with users and is no longer produced. However, Selmi and coworkers demonstrated that computerized CBT could be as effective as standard CBT (Selmi, Klein, & Greist, 1990). Other early software not available for clinical use includes two behavior therapy interventions for anxiety disorders based on the book Living With Fear (Ghosh, Marks, & Carr, 1984; Carr, Ghosh, & Marks, 1988; Marks, 1978).
Colby and coworkers (Colby, Gould, & Aronson, 1989; Colby, Gould, Aronson, & Colby, 1991) developed software that integrates computerized instruction with group discussions. The Therapeutic Learning Program identifies problematic interpersonal situations and offers coaching for proactive behavior. It has been used extensively for employee assistance programs. Colby also developed "Overcoming Depression," which utilizes written text and a natural language-based dialogue format (Colby, 1995; Colby & Colby, 1990). A study of this software with depressed inpa-tients found that the dialogue component of the program did not always communicate effectively with patients and that use of the software did not enhance treatment efficacy (Bowers, Stuart, MacFarlane, & Gorman, 1993; Stuart & LaRue, 1996).
The most recent computer programs for psychotherapy have incorporated new technologies geared toward heightening the power of the learning experience and improving ease of use. For example, Wright and coworkers have designed and tested the first multimedia program for computerassisted CBT (Kenwright et al., 2001; Colby, 1995; Colby & Colby, 1990). Research with this software demonstrated high acceptance ratings by patients, significant increases in learning of cognitive therapy, and equivalent efficacy to standard CBT (Kenwright et al., 2001; Colby, 1995). Video, audio, and other multimedia elements are used to engage the user and stimulate affect. Users participate in a variety of interactive self-help exercises and are assigned homework to encourage use of CBT in real-life situations. Are-vised, DVD-ROM version of this software ("Good Days Ahead: The Multimedia Program for Cognitive Therapy") is now available (Colby & Colby, 1990).
Rothbaum (Rothbaum, Anderson, Hodges, Price, & Smith, 2002; Rothbaum, Hodges, & Kooper, 1995; Rothbaum et al., 2001) has pioneered virtual reality technology applications for fear of heights, fear of flying, and Post-Traumatic Stress Disorder (PSTD) in Vietnam War veterans. Controlled trials have found evidence for the efficacy of virtual reality based exposure therapy (Rothbaum et al., 1995, 2001, 2002), but the need for specialized equipment has limited the use of these methods. A more conventional computer program, "Fear Fighter," was developed in Great Britain by Marks and coworkers (Kenwright et al., 2001; Shaw, Marks, & Toole, 1999). This software utilizes text, graphics, and audio to help users plan self-exposure to feared situations and to endure anxiety until it diminishes. Preliminary research suggests that it can substantially reduce the amount of clinician time required for effective treatment of anxiety.
Hand-held computers also have been found to be useful for computer-assisted psychotherapy. Newman and coworkers (1997) found that long-term outcome of computerassisted CBT for Panic Disorder was equal to standard CBT, even though clinician contact time was reduced to four sessions in those that received the computer adjunct. Gruber and associates (2001) demonstrated the efficacy and cost saving potential of a hand-held computer program added to cognitive-behavioral group treatment for social phobia. Computer-controlled, interactive voice response systems are another possible application of computer technology to perform psychotherapy functions (Greist et al., 2002; Marks et al., 1998). These systems use a conventional telephone instead of a computer terminal or a hand-held device to communicate with the user. Interactive voice response programs for Obsessive-Compulsive Disorder ("BT Steps") and depression ("Cope with Life") have been developed and tested by a team of British and American investigators (Greist et al., 2002; Marks et al., 1998; Osgood-Hines et al., 1998).
Currently, computer programs are not used widely in psychotherapy applications. However, technological advances, increased use of computers in society, and changes in the economics of health care delivery may lead to growth in the use of computer-assisted therapy. If preliminary studies demonstrating patient acceptance, efficacy, and cost-efficiency are confirmed in future research, computerassisted treatment could become a standard therapeutic tool.
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