The prospect of using computers to deliver psychotherapy has been intriguing a number of investigators who have been studying innovative methods of bringing technology into clinical practice. The most dramatic form of computer-assisted therapy (CAT) is virtual reality exposure therapy in which patients are immersed in a virtual environment to help extinguish fears of flying, heights, social situations, or other anxiety-provoking situations. Other commonly used CAT methods are multimedia applications that use video, audio, and interactive exercises to convey therapy concepts and to build coping skills. Handheld devices encourage patients to monitor themselves and to use behavioral methods to manage symptoms. CAT can:
• Reduce cost and improve access to empirically tested psychotherapies.
• Reduce the need for therapists to perform repetitive procedures, such as psychoeducation or rehearsing basic CBT procedures.
• Enhance the therapy experience by providing engaging or unique learning opportunities.1-3
Other strengths include giving constructive feedback; promoting use of CBT homework; and recording, analyzing, and reporting data.4
The clinician’s role
CAT can be defined as psychotherapy that uses a computer program to deliver a significant part of the therapy content or to assist the therapist. Clinician involvement usually includes at least screening, supervision, and support of computer program use and may involve an integrated human-computer team approach to treatment.4 The amount of therapist involvement in CAT varies considerably in different studies but is substantially less than that in standard therapy. For example, programs that have shown efficacy for depression and panic disorder have reduced the therapist contribution to 4 hours or less for the entire treatment course.4,5
Several self-help computer programs that do not use clinician monitoring or involvement are available on the Internet. Although these programs may teach self-help concepts, a recent meta-analysis found that lack of support from a human therapist was associated with far less robust changes in symptoms than was therapy that integrated the work of the clinician and the computer.6
Completion rates of program content are usually quite low when a clinician is not involved. For example, a study of the use of Mood Gym, an Australian Web site, found that the vast majority of users appeared to be browsers who only viewed a small portion of the available content.7 In contrast, an Internet-delivered program for posttraumatic stress disorder (PTSD) that was directed and supported by clinicians was completed by 70% of the participants.8
Programs and formats
Early in the development of CAT, attempts were made to construct programs that used “natural language,” in which the computer would try to engage users with dialogue that was similar to that used in therapeutic communication between patient and clinician in nondirective or supportive psychotherapy.1,4 However, these programs were unable to duplicate therapeutic interviews accurately or reliably. Thus, contemporary CAT applications use a different approach—they present learning and skill-building exercises that can help patients better understand and manage symptoms.
Virtual reality applications have been found to be effective for a variety of anxiety disorders.9-12 For example, Rothbaum and coworkers9-11 studied programs for patients with PTSD, fear of flying, and acrophobia. Difede and associates12 recently showed that a program that creates a virtual environment of the World Trade Center attacks on September 11, 2001, was very helpful in reducing symptoms of PTSD. In these studies and others, virtual reality allows the therapist to implement graded exposure treatment in the office while simulating an in vivo experience of the anxiety-provoking situation. The clinician controls the pacing and intensity of the exposure therapy and uses CBT to help patients break patterns of avoidance and extinguish their fears.
Multimedia programs that have been developed for depression and anxiety are another potentially useful application for CAT. As with virtual reality therapy, these programs typically use a CBT approach, in which patients learn to revise dysfunctional thinking and reverse maladaptive behaviors. Examples of multimedia programs that have been tested for depression include the software Good Days Ahead: The Multimedia Program for Cognitive Therapy and Beating the Blues.4,13,14
In a study of Good Days Ahead in drug-free patients with major depression, there were no differences in symptom relief in patients treated with computer-assisted CBT and in those treated with standard CBT, even though therapist contact time was reduced by almost half.4 The computer program appeared to offer advantages over standard CBT in lowering dysfunctional attitudes and enhancing learning of CBT concepts. The Beating the Blues program led to improved outcomes in both depression and anxiety in primary care patients who had the computer training in addition to treatment as usual.14 Fear Fighter, another multimedia program developed in the United Kingdom, has delivered results similar to those of standard CBT for anxiety disorders despite use of modest amounts of clinician time.15
Handheld computers have also been used as treatment adjuncts. Newman and associates16 have used this type of CAT to treat panic disorder, and Gruber and coworkers17 have used it to provide CBT for social phobia. Both groups demonstrated that a handheld computer can promote self-monitoring and use of standard CBT methods for anxiety disorders, thus reducing the requirements for therapist time. For example, Newman and associates16 found that a shortened form of computer-assisted CBT for panic disorder (4 sessions with a therapist) was slightly less effective than a full course of CBT (12 sessions), but there were no significant differences between the 2 forms of therapy at follow-up.
Although currently available, CAT programs have been effective in research studies; they have limitations in clinical practice. CAT programs do not perform full psychiatric assessments, make diagnoses, or develop comprehensive treatment plans; nor do they screen for and manage impulsivity or other potentially dangerous behavior, such as suicidality. And, of course, they cannot display the empathic concern, wisdom, flexibility, and creativity of human therapists. Thus, in clinical applications, CAT programs appear to be best suited as components of an overall treatment strategy that is prescribed and guided by a professional.
CAT is just beginning to take hold in psychiatric practice. Although a vigorous effort is under way to produce and test programs for psychiatric treatment, and the use of computers in society is steadily increasing, most clinicians are either unfamiliar with CAT or have not yet tried to use these programs to augment traditional therapy. The time may be near when clinicians who want to use technology in psychotherapy will have access to useful and effective programs that can enhance learning, make treatment more efficient, and bring a valuable new dimension to the psychotherapeutic process.
Therapists of the future may be able to conduct their daily work with a variety of empirically tested computer tools. These adjuncts could be completed before or after a session, either in waiting rooms or at home, or even in specially designed therapy suites that provide advanced technology (such as virtual reality and fully realized multimedia treatment programs). Further development of portable devices that have better functionality and connectivity, that offer more realistic and engaging programming, and that weave together the human and technological components of treatment could provide a myriad of opportunities for realizing the promise of the computer as a therapeutic “assistant.”
[At the time of writing] Dr. Wright is professor and associate chair for academic affairs in the department of psychiatry and behavioral sciences at the University of Louisville School of Medicine. The author has an agreement to receive a portion of profits from sales of the Good Days Ahead software described in this article.
1. Wright JH, Wright AS. Computer-assisted psychotherapy. J Psychother Pract Res. 1997;6:315-329.
2. Marks IM, Cavanagh K, Gega L. Computer-aided psychotherapy: revolution or bubble? Br J Psychiatry. 2007;191:471-473.
3. Wright JH. Computer-assisted cognitive-behavior therapy. In:Wright JH, ed. Cognitive-Behavior Therapy. Washington, DC:American Psychiatric Publishing Inc; 2004:55-82.
4. Wright JH, Wright AS, Albano AM, et al. Computerassisted cognitive therapy for depression: maintaining efficacy while reducing therapist time. Am J Psychiatry. 2005;162:1158-1164.
5. Carlbring P, Bohman S, Brunt S, et al. Remote treatment of panic disorder: a randomized trial of internet based cognitive behavior therapy supplemented with telephone calls. Am J Psychiatry. 2006;163: 2119-2125.
6. Spek V, Cuijpers P, Nyklícek I, et al. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychol Med. 2007; 37:319-328.
7. Christensen H, Griffiths K, Groves C, Korten A. Free range users and one hit wonders: community users of an Internet-based cognitive behaviour therapy program. Aus N Z J Psychiatry. 2006;40:59-62.
8. Litz BT, Engel CC, Bryant RA, Papa A.A randomized, controlled proof-of-concept trial of an Internet-based, therapist-assisted self-management treatment for post-traumatic stress disorder. Am J Psychiatry. 2007;164:1676-1683.
9. Rothbaum BO, Hodges L, Smith S, et al.A controlled study of virtual reality exposure therapy for the fear of flying. J Consult Clin Psychol. 2000;68:1020-1026.
10. Rothbaum BO, Hodges LF, Ready D, et al. Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder. J Clin Psychiatry. 2001; 62:617-622.
11. Rothbaum BO, Hodges LF, Kooper R, et al. Effectiveness of computer-generated (virtual reality) graded exposure in the treatment of acrophobia. Am J Psychiatry. 1995;152:626-628.
12. Difede J, Cukor J, Jayasinghe N, et al. Virtual reality exposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001. J Clin Psychiatry. 2007;68:1639-1647.
13. Wright JH, Wright AS, Salmon P, et al. Development and initial testing of a multimedia program for computer-assisted cognitive therapy. Am J Psychother. 2002;56:76-86.
14. Proudfoot J, Ryden C, Everitt B, et al. Clinical efficacy of computerized cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial. Br J Psychiatry. 2004;185: 46-54.
15. Kenwright M, Liness S, Marks I. Reducing demands on clinicians by offering computer-aided self-help for phobia/panic: feasibility study. Br J Psychiatry. 2001;179:456-459.
16. Newman MG, Kenardy J, Herman S, Taylor CB. Comparison of palmtop-computer-assisted brief cognitive- behavioral treatment to cognitive-behavioral treatment for panic disorder. J Consult Clin Psychol. 1997;65:178-183.
17. Gruber K, Moran PJ, Roth WT, et al. Computerassisted cognitive behavioral group therapy for socialphobia. Behav Ther. 2001;32:155-165.