COMPUTER AS
THERAPIST
by Joanne Tangorra
Joanne Tangorra is an editor at Publishers Weekly. She has never owned a computer, though she often ends up talking to the terminal at work.
Woody Allen, in a comedy routine from the sixties, would comment on his aversion to automation: "Anything I can't reason with or kiss or fondle I get into trouble with," he would tell the audience. "I have a tape recorder-I paid a hundred and fifty dollars for it-and as I talk into it, it goes, `I know, I know.' "
Sigmund Freud might have laughed at this (though his odd Viennese humor favored jokes like "A wife is like an umbrella ... sooner or later one takes a cab"). Still, the founder of modern psychology, the man who made "transference" a household word, also would have shrunk from the concept of machines replacing human contact in the process of psychological healing.
A False Start
The first suggestion that computers could play a role in the delicate exchange between client and therapist came out of M.I.T. in the mid-sixties, when Prof. Joseph Weizenbaum introduced the software program called Eliza. Considered the first computer "therapist," Eliza interacted with her patients using the "nondirective," clientcentered techniques of Carl Rogers. In Rogerian therapy, patients' feelings are reflected back to them by the therapist, who very often rephrases and repeats what the patient has said.
Appalled that many professionals took Eliza seriously, Dr. Weizenbaum soon rejected his brainchild. His intent was to show the limitations of artificial intelligence, not to spark what has become a serious exploration into the possibilities of computer psychotherapy. In his 1976 book entitled Computer Power and Human Reason, Weizenbaum made his position clear. He stressed that because of significant differences between computers and human beings, the computer should not be used for certain applications-especially not as psychotherapists.
Steve Grumette, president and founder of Artificial Intelligence Inc. in California, issues a similar caveat. Having adapted Eliza to the Apple, IBM PC and Radio Shack personal computers, he warns: "This is an entertainment program and should absolutely not be taken seriously. Eliza provides nothing like the real understanding you would get from a human being."
It might be argued that acceptance by a computer could lead to a lucrative career in the booming computer industry; but a computer's respect would seem less than adequate to improve one's social adjustment. Still, this hasn't stopped exploration into the possibilities of the personal computer as therapist, in one form or another, in homes and schools, in hospitals and doctors' offices-and even at the local 4-H Club. There are those who would even say that in some cases the personal computer may already be more effective in the role of therapist than its human counterparts.
"The computer has an overall advantage in that it's nonthreatening, patient, and has a good memory," says psychologist Dr. David Gustafson, director of the Center for Health Systems Research and Analysis at the University of Wisconsin in Madison. "The computer can take things you say, collect the information and apply it later-it's consistent."
Gustafson, who has developed psychological counseling software for Apple II computers at high schools and 4-H clubs in Wisconsin, designed one program called Barney that deals with stress, smoking, alcohol and drug abuse, diet and human sexuality. "In the stress area, for example, Barney would ask a series of questions to assess the level of mental well-being of the person. If the data indicate he or she is seriously troubled, the program automatically switches over to a listing of referral services, hours the services are open, level of privacy, etc., so that the individual has a sense of what's going to happen to him."
Otherwise, Barney would take the user through situations or scenarios aimed at providing a better understanding of what stress is and what it can do to an individual. A series of coping skills would include, for instance, a discussion on how kidneys fail to discharge sodium in periods of stress, and a list of foods with the amount of sodium they contain would be presented on the screen. The user can also ask for more detailed information: according to Gustafson, the program will try to determine, through a series of questions, what type of aid the user is in need of-"whether or not you need an expert, for example"-and then will list four places to go for support.
Hypnotic Screens
Other professionals, while well aware that a computer is definitely not a human being, are confident in the personal computer's "therapeutic" qualities. Dr. Ron Levy, a psychiatist in Buffalo, has developed programs that perform hypnotherapy much the way he himself would. The computer actually induces a hypnotic state in the patient so that certain anxieties can be dealt with. Levy claims that patients are more comfortable with a computer in hypnosis because they don't feel they're giving up control to a therapist.
Written in BASIC for the Apple II, Levy's programs engage the unconscious mind through a series of on-screen messages. CEPEC (Computerized Emulation of Personality and Environmental Conflicts), for example, starts out by asking the user a series of multiple-choice questions to personalize the program, then pointedly tells the individual: "Your unconscious mind is here and knows how to take what's valuable." The user then chooses from a list of problems that appear on the menu: "I'm worried and afraid"; "I feel that I can't cope"; "I don't know who I am"; "I'm unloved and alone"; or "I need more self-confidence."
The patient is lulled into a hypnotic trance by means of a series of mental "inductions." Through the "alphabet induction," CEPEC might tell you to go back to kindergarten and remember your feelings when you first learned the letters of the alphabet. "CEPEC walks the person through that experience to bring the adult part of the mind and the child part to where integration is possible," says Levy. He stresses that the patient is in control and directs the computer to proceed every step of the way.
Levy has also opened a center in Buffalo that combines computer hypnotherapy and biofeedback. "We're taking the whole thing one step further by interfacing the computer with instruments that can detect the state of the nervous system," he explains. In the Drop-In program, for example, the computer would ask, "Do you feel relaxed?", but it had to rely on the user's subjective report. Now a machine can decide whether or not the user is in a relaxed state, depending on measurements of galvanic skin response, skin temperature, and an electromiograph, which determines the state of muscle tension.
After a twenty-minute protocol (a series of questions and biofeedback exercises that determine what measurements the individual is sensitive to) the appropriate combination of hypnosis and biofeedback instruments is configured to the client's needs. "We need new ways of coping with stress," says Levy. "The computer can be used for stress management-controlling migraine headaches, say-or for more serious emotional problems and phobias such as fear of going out of the house or an anxiety about driving. The computer doesn't try to persuade; it tries to mobilize people to solve their own problems."
Dr. Ron Levy demonstrates his hypnotherapy software.
Cognitive Keyboards
Dr. Bob Reitman, a psychiatrist based in Mountain View, California, has created microcomputer programs for home use that address problems ranging from impotence to jealousy. "In the most classical sense," he observes, "the computer is in a unique position to keep the individual focused."
Reitman is concerned with applying personal computers to cognitive therapy, which deals with underlying assumptions. Computers and cognitive therapy are the "perfect marriage," he says. "Both work on the assumption that there's a problem and that the solution is to get from A to B. These programs can teach the individual about ways to resolve issues and how to make rational choices." An impotence program, for instance, takes the individual through a series of screens of information about impotence and then presents a quiz. Reitman's programs, which number about forty for the Texas Instruments TI 99/4A computer, are not intended to treat psychoses; rather, they are aimed at "behavior that is possible to change," involving such factors as shyness, jealousy and problems related to divorce.
"This type of computer therapy can be used to treat problems such as depression, anxiety and paranoia," says Dr. Albert Ellis, a leading proponent of cognitive therapy and founder of the Institute of Rational Living in New York City. "We can teach the individual rational as opposed to irrational answers-how to think `I prefer to do well,' which is rational, rather than `I must do well,' which is irrational."
For other types of therapy, says Ellis, computer use is "a waste." Psychoanalysis, the so-called "talking cure," is predicated on human interaction, as are other humanist schools of therapy. By definition such approaches to therapy shun the use of "alienating" machines. Yet behavorial approaches to therapy, aimed at altering individuals' behavior without necessarily dredging up their entire life histories, have found that personal computers can bridge a major credibility gap encountered by human therapists.
Computer Confidential
According to Dr. Mark Schwartz, a psychiatrist in New Haven, Connecticut, who founded the Computers in Psychiatry/Psychology newsletter in 1978, "There are studies that suggest people are more honest with computers and more trusting. Very often, people who won't talk to a clinician will answer questions asked by a computer."
Schwartz has chronicled the considerable activity in the mental health community prompted by these kinds of discoveries. "The most activity has been in the area of testing," he explains. "A whole new generation of psychological tests is being created with the computer in mind." Adaptive testing is a new method in which a psychological test adapts itself to the user as it goes along. If the user is female, for instance, the test will automatically alter certain questions. Other tests evaluate intellectual, mental and psychological capabilities that can be effectively tested only by computer-not with paper and pencil, says Schwartz. These include perceptual tests that require graphics.
There is also enormous promise in the area of what Schwartz labels "cognitive rehabilitation," where patients are trying to regain intellectual capabilities. Here the computer offers the patience and repetition that the patient needs. The computer program, which Schwartz likens to an exercise machine, might present a complex series of words or pictures for the patient to interact with at his or her own pace.
Testing has always required one of the most laborious of the professional's tasks: psychological report writing. Yet already the computer can analyze test results at a fairly sophisticated level. "The future for this is tremendous," says Dr. Ralph Smith, a West Virginia psychiatrist who developed a microcomputer system called Psychometer (from CompuPsych in Liberty, Missouri). Smith explains that although computers have been used for testing and report writing since the early seventies, tests had to be sent out for optical scanning. "The turnaround time was awful," he says. "Now I can see the patient's test results immediately, while they're in my office." Smith adds that with today's improved software for report writing and investigative scoring, the computer is able to draw high-level inferences from the test results.
Micro Counselors
The realization that testing and diagnostics appear to be a perfect match for personal computers and psychology has led to the more intimate computer applications of personal interviewing and counseling. A study by psychiatrist John Greist, who in the late seventies developed a computer program to interview suicidal patients, indicated a preference on the part of suicidal patients to be interviewed by a computer rather than by a therapist. Morever, it was found that the computer was more accurate than experienced clinicians in predicting suicide attempts.
Dr. Ken Kerber, a psychologist at Holy Cross College in Worcester, Massachusetts, sees student counseling as another area that lends itself to a computer's assistance. Together with Dr. Morton Wagman of the University of Minnesota, he developed the dilemma counseling system (DCS). "The computer is definitely not as talented as a human being in terms of communication and interaction," Kerber says. "But it is good at remembering and is an excellent aid in helping the student evaluate his or her values, then matching them to an occupation based on the data it has collected. A counselor would have a difficult time doing this." Wagman found in a study of subjects who used the system that they also enjoyed the independence granted by being able to solve personal problems on a computer.
The Dilemma counselling system (DCS) questionaire devised
by Drs. Ken Kerber and Morton Wagmam.
Developed for Control Data Corp.'s centralized PLATO system and originally intended as a tool for college counselors, DCS has come to be used by students independently at universities throughout the world. Its creators plan to adapt the program to personal computers in the near future. "It's a method of dealing with problems in a logical way," Kerber explains. The premise of DCS is that an obstacle faced by the college student-changing a major in junior year, for example-can be phrased in terms of a dilemma. DCS consists of introducing, explaining and practicing "dilemma phrasing" (the student formulates given problems as dilemmas-"If I do this, the result is a negative consequence") and "dilemma matrixing" (the student learns to extricate himself from the problem-"If I do this, the result won't necessarily lead to a negative consequence," followed by "How is it that if I do this it won't necessarily lead to a negative consequence?"). In the final stage, students get to work on their own problems using the DCS technique.
In a study of over two hundred undergraduates to determine the attitudes of college students toward different computer applications, Kerber found that the subjects responded favorably to the use of a computer in quantitative applications (e.g., processing bills) and record keeping (e.g., storing information about criminals) but rejected decision-making applications, especially those involving decisions traditionally made by psychologists.
Survey results indicate that a major fear regarding computers is the belief that they are dehumanizing. Kerber says in his report: "Weizenbaum suggested that computers should not be designed to make psychiatric, judicial and other important decisions about people because these tasks require interpersonal respect, human understanding and love. The respondents in this study seem to agree. . . ." Kerber believes that the use of computers "need not be dehumanizing, even in the case of psychological counseling" and points to the success of the DCS technique. But he does suggest that the humanizing/dehumanizing potential of computerized counseling be further explored.
For all the early successes of the personal computer in psychology, the machine itself has remained an adjunct to human counseling. In the words of Dr. Schwartz, "A computer in place of a human therapist is a long time in the future, if ever . . ."
One reason computers won't ever fully replace human therapists is that the latter will do their best to keep it from happening. Technological obsolescence is something therapists will fight tooth and nail to assure their very survival.
Here, too, Woody Allen was prescient. In his comedy act he spoke of the problems of the technologically unemployed. "My father worked for the same firm for twelve years," he confided. "They fired him and replaced him with a tiny gadget that does everything my father does-only better. The depressing thing is, my mother ran out and bought one, too."
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