Fred Cutter, Ph.D. 

 Self-help   software has been around since 1966  when  Weizenbaum
 (1966)  created the Eliza program. In this survey I found  a  few
 different  mental  health web pages that include a list  of  psy-
 chological software for downloading.  Some of these invite  users
 to upload programs they have written. A list is given in table 1.
 The  opportunity to interact with one of these while on line  was
 not found in this or previous surveys (Cutter,1996 b&c). Instead,
 individual psychologists offer web page surfers an opportunity to
 try  on-line psychotherapy. If a potential client accepts a  com-
 puter  approach  to self help, is it better to  seek  a  prepared
 computer program or to accept on-line professional help through a
 web page?
 In a  previous article on  on-line psychotherapy  (Cutter, 1996c)
 I described the current status. This article focuses more on  the
 available  software, purchasable or downloadable, approaches  the
 issues of which is optimal.
 Over the years of trying to use computer programs with clients in
 a self help context,  I searched the major publishers' catalogues
 of psychological tests, and books to find appropriate software. I
 also  searched the electronic bulletin boards like 'Shrink  Tank'
 'suicide prevention resources', 'testing station' and others  too
 numerous to mention.  Gradually, I accumulated a list of programs
 I could invite my clients to use for growth or  psychotherapeutic
 goals.   I  wondered if these  programs,  or  new  ones, would be
 available for download or access on the web?
 Virtual  psychotherapy whether on line or through a desktop  pro-
 gram  seems to have started with "Eliza", George  Bernard  Shaw's
 fictitious heroine, a cockney flower seller, who is converted  to
 a  Victorian lady speaking perfect English by "Henry Higgins",  a
 speech professor.  Yuppies may recognize this theme as the  story
 line in "My fair lady". Joseph Weizenbaum (1966), wrote the first
 program  to provide client interaction, while at Mass.  Institute
 of  Technology  in Boston, MA.  He dubbed it  "Eliza".  The  user
 received  a preprogrammed response  from the computer,  and  when
 continued,  the  dialogue begins to approximate  a  non-directive
 counseling session.
 This  program  has survived more than 30 years as a  parlor  game
 since neither programmers nor psychologists were able to do  very
 much with it.  Their is now a web page listing all the variations
 on this first and venerable way to approach psychotherapy through
 a  computer program. Indeed there are many web pages  (AI.Reposi-
 tory@cs.cmu.edu)  spun  off  from  variations  on  the   original
 "Eliza".  Table 2 gives a list of these modified eliza  programs,
 available  on  this web  page  (afs/cs.cmu.edu/project/ai.reposi-
 The  subsequent generation of interventions by means of  computer
 programs  focused on more specific goals such as  stress  manage-
 ment,  assertive  training, self esteem,  overcoming  depression,
 dealing  with  suicide, and various psychotherapy  approaches  or
 cognitive behavior modification. These are different in intention
 from  diagnostic types of programs to achieve  assessment  goals.
 However,  the two missions get combined in  classifications  like
 "clinical".   Some of the testing programs are  self-administered
 and  the  results are available for self evaluation  and  growth,
 i.e. self help software.  This convergence between assessment and
 therapy makes it more difficult to identify how many exist.
 The third edition of Stolaff & Couch (1992) describes 94 separate
 items  in a merged list.  A June 1996 visit to Sibyl: The  Social
 Science  Software  Information Bank yields a list  of  82  items,
 under    clinical    psychology,   which   are    also    blurred
 (http://www.gamma.rug.nl/sibyl.htm).  However,  they  do  provide
 various kinds of searches; keywords, categories or user  defined.
 An additional advantage that Sibyl provides  is a description  of
 each  item with some minimal assurances that the programs are  at
 least  functional.  Sybil may become the software  equivalent  of
 the  Buros book because they provide on-line descriptions by  the
 authors, and independent reviews of psychological software.  They
 invite software authors to submit their programs for review at no
 Buros book users will be pleased to find its continuation on  the
 web    through    The   Buros    Institute    (http://www.unl.edu
 /buros/home.html)  which offers test locators and  test  reviews,
 just like the original book.
 The evolution of psychological software is both fast and  arcane.
 Using  my own experience in the area of suicide I  identified  15
 different programs addressing various aspects of suicide, assess-
 ment and prevention, in 1991 (Cutter,1992). This article included
 a  proposal and outline for linking to various resources in  sui-
 cide  prevention.  In 1995 (Cutter, 1995) I described the  status
 of  virtual suicide on the Internet and reported a wide range  of
 psychological activities oriented towards suicide and its preven-
 tion. This would include all behavior short of self injury  while
 on-line;i.e. parasuicide. The issues of suicidal death on the web
 emerged suddenly with Tim Leary's threat to overdose live on  his
 web  page when his metastatic prostate cancer got to "bad"  (Cut-
 ter, 1996a).
 A  1996  survey of the net using archie and the  keyword  suicide
 yielded a long list of the same seven programs. These were suici-
 dal methods originating from the Newsgroup   Alt.Suicide.Holiday,
 references to the same group (ASH) itself, a reference to suicide
 chicken-wings   presumably   a  recipe,  suicide   is   painless,
 suicide.c.gz,  (a condensed version),  suicide.j.pg. (an  image).
 These  seven programs had spread to 30 different hosts,  or main-
 frames. Many of them contained multiple directories with the same
 seven files listed there.
 Aside  from  the above, I was pleasantly surprised to  find  'the
 suicide  prevention triangle (Cutter, 1992) software  on  several
 web  pages:  Shrink Tank (http://www.shrinktank.com)  and  Global
 Psych  Software  Repository  (http://rdz.stjohns.edu/gp/software.
 htm). These represent earlier versions (1992).  The current  ones
 are  programmed  in Foxpro and run faster. They  also  have  some
 upgradable  aspects such as revising the annual suicide rates  by
 country or year. Many of the interpretations and  recommendations
 are  predicated on the suicide rate of the cohort for the  person
 being  evaluated.  The  current version is  available  through  a
 distributor (ALS, 1995) or contacting the author for more  infor-
 In clinical practice there continues to be a resistance to client
 use of computer programs, as provided in an office setting with a
 resident  therapist  available for consultation.  An  example  of
 resistance is the invitation I posted to a local web page to come
 into  a laboratory  to try  one or more  of the listed  programs.
 The potential consumers were students at  a  technical university
 in my area.  I did this in 1994, and have not  received a  single
 inquiry to date.  In my office practice  I was able to persuade a
 dozen patients to try one or more of the same programs, but main-
 ly 'overcoming depression.' The responses  ranged from  rejection
 to enthusiasm,   with  the more  intellectually  oriented clients
 getting  lost in  the reflections of  their  own  reification  of
 terms. The latter was potentially constructive in  that  examples
 were then available for discussion.
 The web pages  reviewed  here did not offer nor    provide oppor-
 tunities  for a user to seek self help through computer  programs
 while on-line.  The more likely alternative seems to be a greater
 willingness  to interact with a live therapist through e-mail  or
 mediated by web pages. These contacts provide initial and  primi-
 tive  opportunities for psychotherapy that have all  the  limita-
 tions of computer programs, without the advantages of a carefully
 thought  out sequence with support emphasized.  The best  of  the
 web pages in my recent review (Cutter, 1996c) was given by  David
 Sommers, Ph.D.   (http:// nicom.com/~davids/pageone.htm).
 In  contrast, a colleague in Madras India has created  a  virtual
 clinic  in  his offices, where a dozen or more clients  work  the
 computers  daily.   These  are probably  middle  class,  computer
 literate individuals. He reports much success in providing needed
 services by using computer program support in effectively extend-
 ing his ability to care for a larger population (VJ, 1991).
 The  burgeoning  number of web pages oriented to  psychology  and
 psychiatry  are  quite  spectacular when compared  to  hard  copy
 journals or newsletters. They are even more interesting when they
 focus  on  the  psychology  of  the  web  (http://www1.rider.edu/
 ~suler/psycyber/psycyber.html).   When  I searched  for  software
 oriented towards self-help tasks, the going got rougher. Not that
 there  are no examples, but they are less prominent  and  require
 more  effort  to locate. Table 1 provides  the  uniform  resource
 locator (URL) for each.  One minor impediment is the great varie-
 ty  of  search engines found on different web pages.  While  they
 tend  to  work the same way the different formats  requires  more
 attention to the details specifying optimal terms.
 Currently, any client can participate in an interactive self-help
 program  gratis, or for very modest charges. A fundamental  ques-
 tion  would be, do these web pages offer something not  otherwise
 available?  And  does this choice do any good?   Since  very  few
 practitioners of psychotherapy offer web page  opportunities,  an
 answer is not immediately available. A published example of self-
 help  counseling  by computer program in a research  setting  was
 reported  recently (Mestal,1995). A full copy is  available  from

   Jacobs (1995) reported at a meeting of the Western  Psychologi-
 cal Association  last month, results   from a study of 90  people
 at  the University of California, Los Angeles, all with  mild  to
 moderate  psychological problems. Half of the group were given  a
 weekly  50-minute  session with a therapist for  ten  weeks.  The
 others had 10 sessions with a computer program called Therapeutic
 Learning Program, followed by 10 minutes with the therapist.
     TLP was developed by Roger Gould, a psychiatrist at UCLA.  It
 is designed to help patients explore and confront their problems.
 They work their way through a series of menus, first to  identify
 sources  of stress and then to explore their feelings  about  the
 stress,  how their behavior and life history contributes  to  it,
 and what they might do to improve matters.
     At  the end of the study, patients from both groups  reported
 equal  improvement  and satisfaction with  their  treatment.  Six
 months  later,  there  was still no difference  between  the  two
     The  same computer program can partially replace a  therapist
 in more serious cases. In another study, at Kaiser Permanente,  a
 private  health  care organization in Los Angeles,  109  patients
 with  clinical depression and anxiety were given either  an  hour
 and a half of group therapy a week, or a shorter session preceded
 by a session with TLP. Depression and anxiety ratings fell by the
 same degree in both groups (Dolezal, 1994).
 The general conclusion was that the therapeutic learning  program
 was helpful but did not replace the live psychologist which seems
 to answer the question of do they help.  A reverse question would
 be  "Do  these self-help programs do or permit harm?"    As  with
 support  groups, the danger may be delay in seeking  professional
 help.   However,  the greater danger  in support  groups  is  the
 perpetration of wrong advice reinforced by a consensus, such that
 the  victim  comes to a wrong and very negative  conclusion.  The
 real damage is the loss of hope and the acceptance of self  deni-
 gration. This danger while real and possible, is usually prevent-
 ed by the leadership of an effective group therapist. 
 With  computer  programs written by  knowledgeable  professionals
 there  is  always an emphasis on the reassuring, and  self  image
 building  elements.  Wrong advice is not  very  likely,  although
 misperceptions  are  always possible.  The antidote  is  to  have
 adequate support and supervision when offering these programs  so
 that the client can be debriefed following significant sessions.

 This optimal safeguard does not prevail now, since there seems to
 be so little use of computers in office practice, and a  tendency
 to try spontaneous "live" therapists on-line.
 Again,  the question. Can software replace  professionals?  Since
 many potential clients will not seek help from available resourc-
 es,   programs  may become an alternative source  of  assistance.
 Self-help software, especially  when it is effective,  encourages
 the  individual  to  seek a  professional  consultation,  because
 programming  itself contains a built in ceiling. The  effects  of
 repeated  use  of the same software  assistance  is  increasingly
 limited when it does not become boring.
 1.  Software  providing  self-help  interactions  are  available.
 Stolaff and Couch, 1992) list 94 clinical items. All of these are
 available from conventional distributors of psychological  tests,
 and  books.  They offer the advantages of  a  carefully  planned,
 tested  program with reassurance and efforts to build in  preven-
 tion of client misperceptions.
 2.  A  lesser number of software are downloadable from  at  least
 thirteen mental health WEB pages (table 1), many of them  differ-
 ent than those listed in Stolaff and Couch (1992).
 3.  There  were no examples of computer programs  accessible  for
 interaction  while  on-line,  although 30-40  programs  could  be
 downloaded and used on a personal desktop. 
 4.  There  continues to be a lag in mental  health  professionals
 adopting the available programs for office practice, even  though
 this represents the safest approach to the use of computers  with
 5.  The net is more likely to see an expansion of interaction  on
 web  pages  provided by live licensed  psychotherapists  than  by
 reliance  upon  computer programs on one's  personal  desktop  or
 accessing these while on-line.
 6.  "Live"  psychotherapy on-line is  occurring,  but  primitive.
 Impediments due to the current state of the medium create  deliv-
 ery problems not encountered in office practice.  Aside from  the
 obvious  lack of visual clues, and voice inflections;  continuity
 obstacles  abound as one runs into firewalls, interrupted  calls,
 overloaded circuits, bandwidth, or readability of messages creat-
 ed by some on-line service providers. 
 7.  The  professional therapies offered through  web  pages,  are
 attempts  to  extend  current office practices  to  the  Internet
 medium.  Mental Health Professionals try to offer their  services
 through web pages which lacks visual and aural cues. CU-SEEME and
 VOCAL  technology  will reduce some of these  obstacles  as  they
 improve.  E-mail or web delivered messages are fast and  conveni-
 ent.   Relative to office practice the availability is  "instant"
 and  from  a live licensed therapist to the statements of  an on-
 line  client.  It  is cost effective for  all  participants,  and
 extends availability to many who would otherwise not seek face to
 face  office contacts.
 It  is  very likely that this approach will evolve  in  terms  of
 better  continuity  of care, more feedback of  consequences,  and
 perhaps even less unconscious resistance to direct statements  by
 professionals  due to the influence of the computer on  the  pro-
 8.  These advantages of current on-line "live" psychotherapy  are
 offset  by  the availability of computer software  that  is  more
 carefully  prepared and safer, but by definition more  restricted
 in scope. Using the existing computer programs, in a web context,
 may be a more effective choice for the serious client willing  to
 try self help. This is especially so when supplemented by a human
 resource available through the web page, or near a residence.

ALS PO Box 1366, Shawinigan-Sud, Quebec G9P 4E2 -Fax 819.536.0262
(source for the manual and the software).

Cutter, F.  Potential Advantages of Computer Programs in  Suicide 
Prevention. Paper presented at 1992 AAS Meeting (copies available 
from the author).

Cutter,  F. Virtual Suicide. InterPsych Newsletter,  2(6), Sect  D. 
Research, 1995. (virtual=parasuicidal behavior).

a) Cutter, F. Suicide on Leary's Web Page Perspectives, July, 96.

b) Cutter,  F. The Internet and the Pursuit of Happiness. Perspec-
tives, In press, 96.

c) Cutter, F. Virtual Psychotherapy. PsychNews International, 1(3), 
July, 96.

Mestel, R. Tell me, what seems to be the problem? New  Scientist, 
IPC Publications 22 April 1995.

Stolaff,M.L. & Couch,J.V. Computer use in psychology, a directory 
of software. APA, Washington DC, 1992.

S.Vijayakumar,MD  Computer use in psychiatric practice.  Personal 
communication, 1991.

Weizenbaum,J.  "ELIZA  --  A computer program for  the  study  of 
natural language communication between man and machine", Communi-
cations of the ACM 9(1):36-45, 1966.

TABLE 1. List of Web Sites with Downloadable Clinical Programs 

WEB PAGE NAME:                URL:

Center for Psychotherapeutic  http://www.shef.ac.uk/~psysc/

Clinical Psychol.Resources    http://www.psychologie.uni-bonn.de
for psychotherapy             /kap/links/li_pt.htm

Compsych  software inf for    http://www.plattsburgh.edu/
psychology                    compsych/

Computer Use in Social        http://www.uta.edu/cussn/cussn.htm 
Services Networks(cussn)           or cussnet.htm
c/o dick schoech              http://www.uta.edu/cussn/diskcopy.
email=Schoech@uta.edu         htm

CTI:directory of psychology   http://www.york.ac.uk/inst/
software (every topic)        ctipsych/web/CTI/DirTxt/abnormal.

Eliza implementations         http://www.cs.cmu.edu/afs/cs/
                         or  (ftp://eecs.nwu.edu/pub/eliza/)

Global  Psych Software          http://www.rdz.stjohns.edu/
repository                    gp/software.htm or /gsr.htm

Medweb:Biomed. Internet       http://www.cc.emory.edu/WHSCL/
Resources                     biomed.html

Mental Health Newsletter      http://www.cmhc.com

Psycsite                      http://unipissing.ca/psyc/soft.htm

Shrinktank                    http://www.shrinktank.com/

Sibyl (alphabetic search      http://www.gamma.rug.nl/alfa
Home Page)                    http://www.gamma.rug.nl/sibhome.

Stockley List                 http://www.freenet.msp.mn.us/ip/
(Internet Mental Health       health/stockley/mental_health.htm

TABLE 2. Array of Eliza Implementations

From CMU Artificial Intelligence Repository 

   azile/     AZILE: The evil version of Eliza
   basic/     Implementations of Eliza in BASIC
   bender/    Eliza for the Macintosh
   bg/        Eliza in Lisp
   dbase/     Eliza in dBase III
   emacs/     DOCTOR: Implementations of Eliza in Emacs Lisp
   honey/     Honey: Eliza in Lisp
   mac/       Eliza for the Macintosh
   pascal/    Eliza in Pascal
   pc/        Implementation of Eliza for PCs
   prolog/    Prolog implementation of Eliza
   splotch/   Splotch: Eliza-like program implemented in C.

   Many Eliza implementations can be found on

This directory contains a variety of implementations of Eliza.