________________________________________________________________ VOLUME 1, ISSUE 4 PSYCHNEWS INTERNATIONAL July 1996 ________________________________________________________________ SECTION A: REPORT SELF-HELP SOFTWARE ON THE WEB Fred Cutter, Ph.D. (email@example.com) 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- firstname.lastname@example.org) 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- tory/ai/html/air.html). 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 charge. 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- mation. 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 email@example.com. _________________________________________________________________ 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 groups. 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. CONCLUSIONS 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 clients. 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- cess. 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. REFERENCES 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/ Studies 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. html Eliza implementations http://www.cs.cmu.edu/afs/cs/ project/ai-respository/ai/areas/ classics/eliza/0.html 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. html Stockley List http://www.freenet.msp.mn.us/ip/ (Internet Mental Health health/stockley/mental_health.htm Resources) TABLE 2. Array of Eliza Implementations From CMU Artificial Intelligence Repository (AI.Repository@cs.cmu.edu) 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. Origin: Many Eliza implementations can be found on eecs.nwu.edu:/pub/eliza/ This directory contains a variety of implementations of Eliza.