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VOLUME 1, ISSUE 4 PSYCHNEWS INTERNATIONAL July 1996
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SECTION A: REPORT
SELF-HELP SOFTWARE ON THE WEB
Fred Cutter, Ph.D.
(fcutter@ix.netcom.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-
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-
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
depression-l@netcom.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.