Computers in Assessment and Cognitive Behavioral ... - Science Direct

BEHAVIORTHERAPY28, 211-235, 1997

Computers in Assessment and Cognitive Behavioral Treatment of Clinical Disorders: Anxiety as a Case in Point MICHELLE G. NEWMAN

Penn State University ANDRI~S CONSOLI

San Francisco State University Co BARR TAYLOR

Stanford University Computers have the potential to provide effective assessment and to assist in the provision of therapy at relatively low cost. This article reviews the research on computer programs for the assessment and cognitive behavioral treatment of anxiety disorders. Empirical findings on the use of computers for clinical diagnoses, as substitutes for paper and pencil assessment measures, as the sole providers of behavior therapy, and as an adjunct to clinician guidance are presented. In addition to being the first critical review of the methodology of this research, this paper describes desktop and ambulatory computer technology and programs, discusses their advantages and disadvantages, and provides suggestions for future research. Although this review focuses on anxiety disorder research, most of the basic points that are made with respect to the computer technology and research apply to computer assessment and therapy as it relates to other disorders.

According to the Epidemiological Catchment Area Survey, 27.3 million individuals in the U.S. will experience an anxiety disorder at some time in their lives (National Institute of Mental Health, cited in Dupont et al., 1993). As anxiety disorders occur with greater frequency than other disorders, second only to mood disorders, there is a large cost associated with them. Within the current climate of cost-containment, such high cost has made the develWe would like to thank Louis G. Castonguay, Ph.D., and Beth Sherman for their comments on earlier drafts of this manuscript. Correspondence concerning this article should be addressed to Michelle G. Newman, Ph.D., Department of Psychology, Penn State University, 310 Moore Bldg., University Park, PA 16802-3103. Electronic mail may be sent to [email protected]. 211 0005-7894/97/021t-02355 1.00/0 Copyright 1997 by Associationfor Advancementof BehaviorTherapy All rights of reproduction in any form reserved.

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opment of cost-effective anxiety treatments an increasingly important issue in the field. One of the most well-researched treatments for anxiety disorders is cognitive behavioral therapy (CBT). CBT has demonstrated efficacy in the treatment of panic disorder, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, and simple phobias (Barlow, 1988; Chainbless & Gillis, 1993; Zinbarg, Barlow, Brown, & Hertz, 1992). Though CBT is considered a short-term approach, techniques that further reduce therapist contact time may be as efficacious and less costly. Moreover, there are research findings suggesting that CBT techniques may be underutilized by mental health care providers (Breier, Charney, & Heninger, 1986; Taylor et al., 1989). Thus, methods that increase cost-effectiveness and dissemination of CBT would make it accessible to a wider range of clients. Computer-assisted therapy programs have the potential to increase the costeffectiveness of CBT by reducing therapist contact time (e.g., Newman, Kenardy, Herman, & Taylor, 1997). Such programs can also be used to standardize treatment, thus facilitating dissemination. They have been shown to be viable media for such CBT techniques as relaxation (e.g., Baer & Surman, 1985; Buglione, DeVito, & Mulloy, 1990), systematic desensitization (e.g., Buglione et al., 1990; Chandler, Burck, Sampson, & Wray, 1988), selfexposure (e.g., Carr, Ghosh, & Marks, 1988; Ghosh, Marks, & Carr, 1988), and cognitive restructuring (Selmi, Klein, Greist, Johnson, & Harris, 1982; Selmi, Klein, Greist, Sorrell, & Erdman, 1990). However, a systematic critical review of this research is lacking. The present article reviews research to date on the use of computers as diagnostic assessment devices, as alternatives to paper and pencil measures, as sole providers of CBT, and as an adjunct to therapy for anxiety. The advantages and disadvantages of the computer programs are reviewed and directions for future research are discussed. Although this review focuses on anxiety disorder research, most of the basic points that are made with respect to computer technology and research apply to computer assessment and therapy as it relates to other disorders. The Computer as a Diagnostic Assessment Device

The first step in therapy is assessment, including a diagnostic evaluation. Such an evaluation is usually conducted by clinician-administered unstructured, semistructured, or structured interviews. Whereas structured interviews are the most reliable assessment method, these interviews are costly and require more detailed and consistent assessment than is often performed in many clinical settings (Climent, Plutchik, & Estrada, 1975; Kiernan, McCreadie, & Flanagan, 1976). Moreover, even structured interviews are subject to unreliable administration. One study found that clinicians accidentally omit as much as 5% of required questions (Fairbairn, Woods, & Fletcher, 1959). An advantage of computer interviews over clinician-administered interviews is that each client is asked the same set of questions in the same manner

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and context (e.g., certain follow-up questions will always follow the same response), a feat difficult for a human interviewer (Stillman, Roth, Colby, & Rosenbaum, 1969). Whereas the expectations of a human interviewer may influence the client, a computer has no expectations. In addition, the same program can be written in different languages facilitating access to services in areas where bilingual providers are scarce. For low reliability diagnoses, the interview can be readministered at little additional cost. The economical advantage of computerized screening is increased in the case of research studies for which hundreds of clients are often screened to select a subgroup meeting very specific inclusion and exclusion criteria. Furthermore, lengthy, detailed interviews tend to be monotonous for clinicians, and the computer frees therapist time for more rewarding tasks. A variety of computerized interviews have been developed and tested, including computer versions of the revised clinical interview schedule (Lewis, 1994), Hamilton Anxiety and Depression scales (Kobak, Reynolds, & Greist, 1993, 1994), and the Diagnostic Interview Schedule (Erdman et al., 1992; Greist et al., 1987). Additional programs assess psychiatric history (Carr, Ghosh, & Ancill, 1983; Ferriter, 1993), target complaints (Farrell, Camplair, & McCullough, 1987), intake information (Barton, Daniels, & O'Toole, 1987), suicide risk (Erdman et al., 1987), mental status (Erdman, Klein, & Greist, 1985), and conduct a behavioral assessment (Angle, Ellinwood, Hay, Johnson, & Hay, 1977; Carr & Ghosh, 1983). Studies have shown high rates of reliability when comparing the computer to trained human interviewers administering structured assessments (Ancill, Rogers, & Carr, 1985; Carr & Ghosh, 1983; Greist et al., 1987; Lewis, 1994). Research also supports high test-retest reliability and high internal consistency of some computer interviews (Kobak et al., 1993; McCullough, 1982). Reliability superior to clinician assessments has been demonstrated by several studies showing that computers tend to collect important information that had been missed by human interviewers in settings where the interviews were typically unstructured (Carr et al., 1983; Gr~ist, Van Cura, & Kneppreth, 1973; Simmons & Miller, 1971; Weitzel, Morgan, & Guyden, 1973). For example, Carr and colleagues (1983) found that the computer elicited an average of 5.5 new facts that had been previously unrecorded during several prior extensive interviews in an inpatient psychiatric hospital. Computer interviews have also been shown to be valid. For example, studies assessing criterion validity have compared agreement between computer and clinician and found it to be comparable to comparisons of two expert clinicians or two trained interviewers administering structured interviews (e.g., Carr & Ghosh, 1983; Erdman et al., 1985; Erdman et al., 1992; Greist et al., 1987; Kobak et al., 1993). Additional research has supported high convergent and discriminant validity compared to self-report measures (Farrell et al., 1987) or comparable sensitivity and specificity to a clinicianadministered structured interview (Kobak, Reynolds, Rosenfeld, & Greist, 1990). There is also evidence that computer assessments yield superior data

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in terms of quantity and quality when compared to clinician-administered assessments (e.g., Angle, Ellinwood, & Carrol, 1978; Angle et al., 1977; Erdman et al., 1985; Ferriter, 1993; Fowler, 1985; Greist & Klein, 1980; Lucas, Mullin, Lunar, & McInroy, 1977) and that in sensitive areas (e.g., criminal record, blackouts from drinking, sexual disorders, repeatedly being fired from jobs, attempting suicide) clients tend to reveal more information to a computer than to a clinician (e.g., Angle et al., 1977, 1978; Carr et al., 1983; Erdman et al., 1985; Fowler, 1985; Greist & Klein, 1980; Lucas et al., 1977). In addition, a series of studies showed that a computer interview that assessed suicide risk was more accurate at predicting clients who subsequently attempted suicide than clinicians who knew the clients (Erdman, Greist, Gustafson, Taves, & Klein, 1987; Erdman et al., 1985; Greist et al., 1973). This suggests that in some cases, computer interviews may be more valid than clinician-administered interviews. Despite demonstrations of reliability and validity, there is some resistance from clinicians to the use of computer administered interviews. Clinicians fear that clients will react negatively to an iimpersonal computer interview. However, studies consistently find the computer interview to be as acceptable (Carr et al., 1983; Erdman et al., 1985, 1992; Greist et al., 1987; Millstein, 1987) or preferable to a human interviewer (Angle et al., 1977; Carr & Ghosh, 1983; Erdman, Klein, & Greist, 1983; Greist et al., 1973, 1987; Millstein; Petrie & Abell, 1994; Skinner & Allen, 1983). Evidence shows that clients may prefer the computer interview because they feel freer to take the time to think about their responses (Greist et al., 1987) and feel less embarrassed providing sensitive information (Erdman et al., 1992; Greist et al., 1987; Kobak et al., 1994). Acceptance does not seem to be contingent on use with a computer-literate (Farrell et al., 1987; Kobak et al.) or high functioning population (Carr et al., 1983; Greist et al., 1987; Stillman et al., 1969). Although a computer diagnosis may provide benefits, there are also some potential disadvantages. First, a computer interview is only economical if it is used often enough to offset the initial start-up cost. Moreover, when a clinician conducts an assessment, he or she uses clinical intuition to make various judgments. The clinician may also evaluate aspects of client behavior during the interview. A computer, on the other hand, has neither clinical intuition nor the ability to evaluate overt behavior. Therefore, it must take a client's response at face value. Another weakness is that a computer interview cannot tailor its language to the needs of a particular client. Thus, it is possible that a computer assessment program will never be able to account for the more subtle aspects of individual differences in psychopathology. Computer interviews will probably prove most useful in conjunction with clinical interviews, which could be briefer and focused on more ambiguous issues. Although a number of studies have assessed the reliability and validity of computer interviews, additional research is needed before definitive conclusions can be reached about their psychometric properties. Attempts should be made to replicate previous findings using the same computer program in dif-

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ferent settings and with a variety of populations, including clients with comorbid diagnoses. Additional studies should examine the sensitivity and specificity with which computers can capture subtle variations in psychopathology. Moreover, researchers can create computer programs from interviews for the American Psychiatric Association's (APA) fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; 1994) such as the Structured Clinical Interview for DSM-IVAxis I Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 1995) and Anxiety Disorders Interview Schedule-IV (Brown, Di Nardo, & Barlow, 1994). Agreement between two clinicians should also be compared to agreement between two computer administrations. The Computer as an Alternative to Paper-and-Pencil Measures Studies have begun to test the use of computers in place of paper-andpencil self-report measures for anxiety (e.g., Lukin, Dowd, Plake, & Kraft, 1985; Klepsch, 1990; Wilson, Genco, & Yager, 1985). The use of computers in this capacity may provide some unique advantages. Whereas questionnaires can seem impersonal, a computer can create a more personal impression. For example, computers can be programmed to refer to individuals by their first names and to mention previously given information in follow-up questions (e.g., "John, you mentioned that you have been feeling.. "). Moreover, a computer can reduce the potential intimidation of lengthy questionnaires by presenting questions one at a time. This method of administration also insures that the client's response cannot be influenced by glancing at subsequent questions, prior questions, or prior responses. In addition, responses can be selected from a menu, and the computer allows for branching of questions dependent on the response, so irrelevant items can be skipped. As a result, one study showed that computer administered assessment can be less time-consuming to complete than a paper-and-pencil form and may gather more information in greater depth than is possible in a questionnaire format (Hart & Goldstein, 1985). Research also suggests that computer assessment is preferred to a paper-and-pencil assessment (Klepsch; Lukin,et al., 1985). Further, though paper-and-pencil questionnaires are often returned partially completed, a computer can be programmed to ensure no missed questions. In addition, computer administration is more economical than paper-andpencil measures insofar as it eliminates photocopying and paper expenses as well as the need for hand scoring. Research on the use of computer-administered assessment instruments has found them to be comparable to self-report measures in reliability and validity (e.g., Klepsch, 1990; Lukin et al., 1985; Wilson et al., 1985) on such instruments as the State Trait Anxiety Inventory (Spielberger, Gorsuch, Lushene, & Vagg, 1983), the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the Therapeutic Reactance Scale (Dowd, Milne, & Wise, 1991), and measures of test anxiety (Wilson et al.). One study showed that respondents were more open with a computer (Hart & Goldstein, 1985), suggesting enhanced validity.

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Recent advances have allowed researchers to make use of the highly portable palmtop computer to aid in naturalistic self-monitoring (Kenardy, Fried, Kraemer, & Taylor, 1992; Taylor, Fried, & Kenardy, 1990). Palmtop computers weigh only a few ounces, making them much more portable than laptops. Similar to paper-and-pencil measures, self-monitoring can be conducted in the environment the person typically inhabits, so external validity is built in. The assessment of events as they are happening also avoids retrospective recall biases. The palmtop computer provides unique advantages. With paper-and-pencil diary methods, respondents must be relied on to consistently record events at specified times, and there is no way to insure that collected data was not retrospectively entered at some later date. On the other hand, palmtops automatically date- and time-stamp each entry so that clients cannot enter missing information at some later date and pass it off as prospective. In addition, palmtops can be programmed to beep clients at fixed or variable intervals to prompt them to enter momentary assessment information within a specified time period (e.g., within 1 minute). This feature provides clients with a structured reminder and the researcher with more precise data than paper-andpencil measures. These features might also motivate clients to comply more carefully with prospective monitoring. Moreover, whereas paper-and-pencil measures create a paper trail of sensitive information, palmtops can be programrned to download data to a separate file where recorded information cannot be accessed or understood (e.g., appears only as a string of numbers) by anyone but a clinician. The ability of palmtops to collect, store, and download large amounts of data to a desktop computer eliminates costly hand scoring as well as data transposition that is required of paper-and-pencil measures. Moreover, this feature avoids any possibility of scoring or data transposition errors. The benefits of palmtop computers to collect information on the natural course of anxiety disorders has been suggested by two studies (Kenardy et al., 1992; Taylor et al., 1990). In the first study, Kenardy and associates showed that naturally occurring panic attacks were preceded by significantly higher ratings of the expectancy of panic when compared to matched nonpanic times. By using the palmtop computer, these authors were able to extend findings from laboratory studies demonstrating that panic was mediated by manipulated expectancy during carbon dioxide (CO2) inhalation (e.g., Rapee, Mattick, & Murrell, 1987) or lactate induction (Van der Molen & Van den Hout, 1988; Van der Molen et al., 1986). Similarly, Taylor et al. showed that laboratory heart rate studies of panic disordered subjects could be extended to the real world through ambulatory computer selfreports synchronized with heart rate recordings. Although a portable computer reduces retrospective biases and increases privacy, as with all self-report measures there is no guarantee that a person will answer any question accurately. Moreover, someone can still forget to carry the computer with them. Individuals may also resist using the computer


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in public because they want to avoid calling attention to themselves. However, fewer than 5% of participants in two studies reported that a computer that beeped them once every hour was intrusive (Kenardy et al., 1992; Taylor et al., 1990). Despite the promise of computer assessment devices, additional research is needed. Future research should computerize a series of standard paper-andpencil anxiety measures for particular disorders and assess their psychometric properties and acceptability. Internet Web pages on college campuses could be programmed to include standardized assessment batteries for research purposes. Moreover, only a handful of studies have employed palmtop computers as momentary assessment tools and much more research is needed to assess the psychometric properties, acceptability, and drawbacks of these devices. Research could also compare compliance, validity, and reliability of paper-and-pencil self-monitoring measures to an ambulatory computer.

The Computer as the Sole Provider of CBT for Anxiety A number of computer programs have been developed to be used as the sole provider of CBT. CBT is particularly well suited to interactive computer programs because it is highly structured with well-delineated procedures, targets specific behaviors and symptoms, and proceeds in a systematic fashion (Selmi et al., 1990). Computer-based CBT offers many unique advantages. Because clients decide how often, when, and how long to use the computer, they are largely responsible for their own treatment. This responsibility encourages a greater sense of mastery and control. Moreover, failure of some techniques may be due to therapist rather than client pacing, whereas the computer allows clients to proceed at their own pace. In addition, the accessibility and privacy of computerized interventions may enhance comfort, acceptability, and treatment response in some clients. The computer also offers the advantage of exact reproducibility of therapy. Moreover, techniques from leading therapists can be included in a program or added on an ongoing basis and the resultant expertise made widely available. Treatment elements can then be added or withdrawn to assess their importance. Furthermore, in situations where therapists are unwilling or unable to treat clients outside of their office, an ambulatory computer can be used to help clients who might otherwise remain untreated (e.g., agoraphobic clients who are unwilling/unable to drive to the therapist's office) and can be made available anytime and anyplace to suit the most handicapped client. Directly related to cost-benefit issues, computer-based therapy may be implemented when the demand for treatment outweighs what can be provided by human resources in a specific treatment setting. The use of computers as the sole provider of therapy has some potential disadvantages. Many clinicians are concerned that computers will supplant therapists, will compromise the therapeutic relationship, will increase the rate of client dropouts, and will not be accepted by clients. However, studies that have compared standard therapies to computer-administered therapies

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for anxiety consistently find equal dropout rates (Buglione et al., 1990; Carr et al., 1988; Ghosh & Marks, 1987; Ghosh et al., 1988) and equal rates of satisfaction (Ghosh et al.) between the two conditions. Interestingly, Ghosh and Marks found that compliance to treatment was highest in the computerinstructed condition. In addition, Ghosh et al. ended up with unequal sample sizes because more people in the therapist-instructed condition refused treatment than book-instructed and computer-instructed conditions. Thus, empirical evidence has not confirmed the fear of clinicians. A variety of computer programs have been developed to implement behavior therapy as the sole provider of treatment for anxiety problems. These programs train clients in the application of systematic desensitization, in-vivo exposure, relaxation techniques, and coping skills. Computer-Administered Systematic Desensitization. Systematic desensitization (SD) programs have been used with desktop computers to treat test anxiety (Biglan, Villwock, & Wick, 1979; Buglione et al., 1990; Wilson, Omeltschenko, & Yager, 1991) or generic anxiety (Chandler, Burck, & Sampson, 1986; Chandler et al., 1988). Three studies examined computeradministered SD for test anxiety. Biglan and associates (1979) studied the effect of computer-administered SD plus audiotaped relaxation instructions on 15 undergraduates who scored high on a test anxiety measure. The 9 participants who completed the treatment showed significant improvement on a self-report measure of test anxiety as well as on subjective ratings of discomfort with two exam situations. In a subsequent study, Buglione and associates (1990) compared computeradministered SD to group therapy for test anxiety. Both treatments were applied over a 6-week period and both used audiotaped relaxation. Although each treatment contained the central component of SD, there were also differences. Whereas the group treatment contained rational emotive therapy, the computer treatment contained what the authors labeled as concentration training and success rehearsal. Despite differences in modalities and treatment components, no differences in impact were found. Both treatments resulted in reductions of scores on a measure of test anxiety and neither treatment resulted in grade point average improvements. Another group of researchers developed a computer program for test anxiety treatment that incorporated instruction on its use, information on the learning theory view of test anxiety, and several self-report assessment devices (Wilson et al:, 1991). The program also administered relaxation training and SD. Pre-relaxation and postdesensitization anxiety were assessed. These authors have not published any controlled outcome studies using this computer program, but do present two successful case studies. In addition to programs for test anxiety, an SD program for generic anxiety has been developed and preliminarily tested (Chandler et al., 1986, 1988). This program requires the client to construct a personalized hierarchy that is integrated into the computer program. These authors published a successful case study (Chandler et al., 1986) as well as a pre-post study using


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seven community volunteers with a variety of phobias (Chandler et al., 1988). Although two clients dropped out of the latter study, the remaining five demonstrated significantly reduced scores on the Fear Questionnaire (Marks & Mathews, 1979) and were able to meet their behavioral goals which were maintained at an 8-month follow-up. One additional study examined the impact of computer-administered relaxation instructions without SD on a nonclinical sample to treat stress reduction (Baer & Surman, 1985). This program delivered written instructions for progressive muscle relaxation, guided imagery, eye fixation, and controlled breathing. Components could be accessed individually or consecutively. Twenty subjects participated in two 30-minute sessions within 1 week. Results showed significant decreases in state anxiety after each relaxation session. Computer-administered in-vivo exposure. Ghosh and colleagues (Cart et al., 1988; Ghosh & Marks, 1987; Ghosh et al., 1988) developed a program that trained clients to use in-vivo exposure via desktop computer. In one study, Carr et al. used a sample of mostly agoraphobic individuals and compared self-directed exposure instructions administered by computer to instructions delivered by a nurse-therapist. These authors found that both treatments were effective and there were no differences between the two conditions. In another study, Ghosh et al. examined self-directed exposure instructions administered by their computer program (N = 28), therapist (N = 19), or self-help workbook (N = 24). Each condition included participants with either agoraphobia, social phobia, or simple phobia. As with Carr et al., this study found no differences between the compared conditions. A subset of this data that represented only agoraphobic clients was published by Ghosh and Marks demonstrating the same results. While there is preliminary support for the use of computers as the sole treatment provider, only a few controlled outcome studies have been done (see Table 1). The uncontrolled studies contain either no control group at all (Baer & Surman, 1985; Biglan et al., 1979; Chandler et al., 1988) or only case study data (Chandler et al., 1986; Wilson et al., 1991). Only one program has been tested in more than one controlled outcome study using different subject samples (Carr et al., 1988; Ghosh et al., 1988). Additional weaknesses of this research include: (a) no follow-up assessment (Baer & Surman; Biglan et al.; Buglione et al., 1990; Wilson et al.), (b) small sample sizes (Biglan et al.; Chandler et al., 1988), (c) no objective measures of improvement (Baer & Surman; Biglan et al.; Wilson et al.), (d) or nonclinical samples (Baer & Surman). Clearly, more controlled outcome studies need to be conducted on computers as the sole provider of therapy before definitive conclusions can be reached. Future research should test the same computer program across a variety of studies and use standardized therapy and therapist contact. Moreover, studies on the use of ambulatory computers as the sole therapy provider need to be conducted. Determinations should also be made about which disorders and which types of clients are inappropriate for sole computer interventions.

Desktop

Desktop

Desktop

Desktop

Desktop

Desktop

Desktop

Carr et al. (1988)

Ghosh et al. (1988)

Biglan et al. (1979)

Baer & Surman (1985)

Wilson et al. (1991)

Buglione et al. (1990)

Comp

Ghosh & Marks (1987)

Author

Alone

Alone

Alone

Alone

Alone

Alone

Alone

How Comp Used

Test anxiety

Test anxiety

Non-clinical

Test anxiety

Mixed phobia

Mixed phobia

PD w/agor.

Disorder

16 (comp) 20 (CBGT)

2

20

9

28 (CABT) 19 (BT) 24 (SH)

20 (BT) 20 (CABT)

15 (CABT) 12 (BT) 13 (SH)

Sample Size Per Cell

RET (CBGT)

+ PMR +

In vitro SD + PMR + CNT & SR (CABT) vs. In vitro SD

SD + PMR

PMR, EF, BRT, PI

In vitro SD + PMR

Exposure

Exposure

Exposure

Therapy Components

CBGT

None

None

None

BT & SH

BT

BT & SH

None

None

None

None

6 mo.

6 mo.

6 mo.

Comparison FollowConditions up

6 for CBGT vs. as needed up to 10 for CABT

3 2 & 19

2

Varied M = 4

3 - 1 0 BT M = 3.2 & CABT M = 6.2

3 - 1 0 BT M = 7.9 & CABT M = 6.4

3 - 1 0 for BT & CABT

Number Therapy Sessions

TABLE 1 SUMMARY OF COMPUTER THERAPY STUDIES

CBGT = CABT

No control group, no follow-up, small sample

Case study, no follow-up

Improvement in treated participants

No control group, no follow-up, nonclinical sample

No control group, no follow-up, small sample

Uncontrolled therapist contact time (BT M = 4.6 hrs. vs. 4.7 for CABT)

Uncontrolled therapist contact time (BT M = 4.6 hrs. vs. 2.7 for CABT), BT group more severely disturbed at baseline

Uncontrolled therapist contact time

Main Weaknesses



CABT = BT = SH

BT - CABT

CABT = BT = SH

Outcome

Laptop & palmtop

Palmtop

Palmtop

Palmtop

Palmtop

Virtual reality

Virtual reality

Baer et al. (1987; 1988)

Newman et al. (1996)

Newman et al. (1997)

Newman et al. (in press)

Gruber et al. (1996)

Rothbaum et al. (1995b)

Rothbaum et al. (1995a)

Adjunct

Adjunct

Adjunct

Adjunct

Adjunct

Adjunct

After standard therapy failed

Alone

Alone

Acrophobia

Acrophobia

Social phobia

GAD

PD

PD

OCD checkers

Mixed phobia

PD agor.

10 (VR) 7 (wait-list)

1 (VR)

15

3

9

1

1/study

5

1

Exposure

Exposure

CT + exposure

CT + PMR + BRT + PI

CT + exposure + BRT + IE

CT + exposure + BRT + IE

Response prevention

SD + PMR

PMR, EF, BRT, PI

Wait=list

None

CBGT-12 CBGT-8 wait-list

None

CBT-12

None

None

None

None

None

None

6 rno.

6 too.

6 mo.

6 mo.

91 week

8 too.

8 too.

7

5

8 for CACBGT-8 + computer as needed for 12 weeks, 8 for CBGT-8, 12 for CBGT-12

6

4 + computer as needed for 12 wks (CACBT) vs. 12 (CBT)

4 + computer as needed for 12 weeks

As needed

As needed

13

VR > wait-list

Improvement in treated participant

CACBGT-8 = CBGT12 at follow-up


C A C B T = CBT

Improvement in treated participant

Relapse when computers were taken away


Improvement i.n treated participant

Small sample, no follow-up, no exposure comparison

Case study, no follow-up

No follow-up conducted on CBGT8 and Wait-list conditions

Small sample no comparison group

No 4 session therapy noncomputer comparison group, small sample

Case study

Case study

Case study, no follow -up

No eorttro~ group, no follow-up, nonclinical sample

Desktop = nonambulatory computer; Comp = computer; ther. = therapist admini.stered; SH = self-help treatment; too. = month; PD = panic disorder; O C D = obsessive compulsive disorder; agor. = agoraphobia; CBT = cognitive behavioral therapy; BT = behavior therapy; CABT = computer administered behavior therapy; CACBT = computer assisted CBT; CBGT = cognitive behavioral group therapy; CACBGT = computer assisted CBGT; SD = systematic desensitization; CNT = concentration training; SR = success rehearsal; RET = rational emotive therapy; EF = eye fixation; BRT = breathing retraining; PI = pleasant imagery; PMR = progressive muscle relaxation: CT = cognitive therapy; IE = interoceptive exposure; VR = virtual reality.

Desktop

Chandler et al. ( 1988)

Note.

Desktop

Chandler et al. (1986)

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The Use of a Computer as an Adjunct to Therapy

In addition to examining the impact of a computer as the sole provider of therapy, studies have examined the use of a computer as an adjunct to CBT. This treatment modality can extend therapy beyond the therapy hour, which is especially helpful to CBT approaches since most therapy is assumed to take place between sessions. Moreover, since CBT often requires systematic repetition of instructions and skills demonstration, a computer program can reduce the amount of time the therapist must spend on such repetition. In addition, computers can effectuate therapeutic tasks that therapists may find monotonous or uninteresting (e.g., relaxation training). Thus, the computer may free clinicians to spend extra time on more complex aspects of any one case. Using the computer in conjunction with therapy may also increase its efficiency and reduce required contact time, thus increasing its costeffectiveness (e.g., Newman et al., 1997). There is some evidence that computer therapy programs have a greater impact when used in conjunction with concurrent therapy than when used as the sole treatment provider. When computers are used in conjunction with therapy, some studies have shown higher compliance rates and lower dropout rates than when used alone (see Agras, Taylor, Feldman, Losch, & Burnett, 1990; Baer, Minichiello, Jenike, & Holland, 1988; Burnett, Taylor, & Agras, 1992). Studies demonstrating incremental compliance and reduced dropout rates have made use of ambulatory computer programs (see Agras et al., 1990; Baer et al., 1988; Burnett et al., 1992). The ambulatory programs can incorporate goal setting and practice prompts as applied to cognitive and behavioral tasks. Moreover, when a client is anticipating, experiencing, or recovering from an anxiety-provoking situation, he or she can use the computer at that moment to lead them through anxiety-reduction techniques. Prompting practice in the client's natural environment helps reinforce systematic use of therapy skills and helps generalize the impact of therapy. If lack of adherence is due to a problem with the client's ability to self-structure, the computer program can provide structure through timed programmed practice as well as immediate accessible guidance. The computer can also provide immediate feedback (e.g., timing of a breathing retraining exercise with feedback on breathing rate). The ability to carry the computer in anxietyprovoking situations and to make use of skills application instructions may also help avoidant patients feel better equipped to approach feared situations. Kenardy and Adams (1993) found that agoraphobic women reported feeling safer with the palmtop computer and viewed it as mode of support. Ambulatory computers can be used during the course of therapy as an aid to self-monitoring, which is an integral component of CBT for anxiety. As stated earlier, using the palmtop computer in place of paper-and-pencil measures insures that all collected diary data is prospective in nature. This may improve the therapist's ability to conduct CBT functional analyses and to determine which techniques are helpful for a particular client in a particular


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situation. In addition, a program can be written that summarizes client information in a way that is particularly useful to the therapist. For example, in Newman and colleagues (1996, 1997) a subprogram summarized data entries from the previous week and this information was automatically printed out each time the therapist transferred the palmtop data to a PC. Although there are many potential advantages to adjunctive computer use, there are also some potential disadvantages. One disadvantage is that phobic clients may be fearful of carrying a device that may call attention to them. This fear can be viewed as a therapeutic issue and directly addressed by their clinician. A second potential problem is that clients may forget to carry the computer or might not use it. However, because of its internal clock, the ambulatory computer does not allow clients to complete self-monitoring entries minutes before each session, and this feature may serve to motivate client adherence. Moreover, it is possible that for some disorders, the computer may function as a safety signal. An additional disadvantage that applies to all computer therapy programs is the amount of effort required to develop and debug them. Computer programs that are used as an adjunct to therapy have only been developed recently (Baer, Minichiello, & Jenike, 1987; Baer et al., 1988; Gruber, Taylor, & Roth, 1996; Newman, Consoli, & Taylor, in press; Newman, Kenardy, Herman, & Taylor, 1996; Newman et al., 1997; Rothbaum et al., 1995a, 1995b). All but one of the existing programs were tested on ambulatory computers and each program was developed for a specific anxiety disorder. These disorders include obsessive-compulsive disorder (Baer et al., 1987), social phobia (Gruber et al., 1996), panic disorder (Newman et al., 1996; Newman et al., 1997), GAD (Newman et al., in press), and acrophobia (Rothbaum et al., 1995a, 1995b). Baer and associates (1987, 1988) conducted the first published study to use ambulatory computer technology in the treatment of an anxiety disorder. Clients with obsessive-compulsive disorder used a laptop computer at home and palmtop computer outside the home. This procedure was tested in two case studies using clients who had not responded to behavibr therapy from a therapist. Clients consulted the program each time they had an urge to engage in a ritual. The program instructed them to resist the urge for 3 minutes (which was timed by the computer) and reminded them that no negative consequences would result from resisting the urge. The program also stored information on the date, time, intensity, and frequency of all urges and gave clients feedback on the number of daily times they had failed to resist an urge. Results of the two case studies suggested that clients made substantial improvement in the reduction of rituals and in compliance to response prevention exercises when they used the computers. However, when both computers were taken away from one client, and when the other client stopped using the palmtop computer outside the home, rituals in the associated environment returned to baseline levels. Thus, it is possible that the computers served as safety signals.

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TABLE 2 FEATURES OF A COMPUTER PROGRAM TO ASSIST IN THE TREATMENT OF PATIENTS SUFFERING FROM GENERALIZED ANXIETY DISORDER

Modules Structured Assessment

Components Ongoing evaluation of user's signs and symptoms of the disorder.

Implemented at 3 phases: Four times a day, users are prompted to enter data indicating • baseline % of time spent worrying (0-100), # of acute anxiety episodes • treatment (>50 on a 100-point scale), and the highest level of anxiety, all for the last hour, as well as the present level of anxiety (0-10). • follow-ups For users who have begun treatment, those entering 3 or higher are offered the therapy modules (listed below). If participants are in baseline stage, they do not have access to any therapy components. At the end of the day, users are prompted to rate their level of anxiety for the day (0-10), % of time spent worrying, and highest level of anxiety. Users who have begun treatment are also queried about the outcome of the events they worried about, the strength of their coping, and are offered more appropriate self-coping statements. Cognitive Therapy

Program facilitates the recognition of triggers (first cues for anxiety such as worry, behavioral changes, or physiological sensations) and the content of anxiety-inducing thoughts. It encourages users to see their thoughts as hypotheses, and to put them into perspective (e.g., quantify the probability of feared outcome coming true). It helps users identify and redress logical errors (e.g., filtering, black-and-white thinking, etc.) by providing definitions and examples of coping statements. An evaluative component assesses levels of anxiety before and after the application of cognitive therapy.

(Continued) A c o m p u t e r p r o g r a m for p a n i c d i s o r d e r was tested in a recent controlled study by N e w m a n and associates (1997). A t t e m p t i n g to d e c r e a s e the cost of CBT, these researchers r e d u c e d the therapist contact time o f clients who c a r r i e d the computer. They c o m p a r e d 4 sessions of CBT with c o m p u t e r assistance to 12 sessions o f standard CBT. Both treatments contained cognitive, behavioral, and relaxation c o m p o n e n t s . At the end of 12 weeks the c o m p u t e r was taken a~vay. Results showed no differences b e t w e e n the c o m p a r e d treatments in c l i n i c a l l y significant change at 6 - m o n t h follow-up. Participants in both conditions b e g a n with an average o f six p a n i c attacks p e r w e e k and d r o p p e d to zero. Moreover, unlike Baer and associates (1987), these researchers found that clients m a i n t a i n e d their gains o r continued to improve even after the c o m p u t e r was taken away. Thus the c o m p u t e r did not a p p e a r to serve as a safety signal. A c o m p u t e r therapy p r o g r a m for g e n e r a l i z e d anxiety d i s o r d e r ( G A D ) was

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TABLE 2 (Continued) Modules

Components

Relaxation Training

Program instructs users on diaphragmatic breathing (a built-in timer assesses breathing rate and provides immediate feedback to the user), progressive muscle relaxation (16, 7, or 4 muscle group tense and release, 4 muscle group relaxation by recall, or relaxation by counting alone), and pleasant imagery. An evaluative component assesses levels of anxiety before and after the application of each relaxation technique.

Exposure Paradigm

Program prompts users to imagine themselves exposed to upcoming situations that make them anxious. It encourages them to remain in the situation long enough for the anxiety to subside while deploying coping strategies. An evaluative component assesses level of anxiety pre- and post-intervention.

Modules

Structure

Computer Initiated Interactions

At four prearranged prompts/day (e.g., 8 A.M., noon, 4 P.M., t~ 8 P.M.) and at the end of the day (e.g., 10 P.M.) computer beeps to signal user to respond to questions outlined in the Structured Assessment (see above). Depending on users' level of anxiety (>3 in a 0-10 range) they will be offered the opportunity to implement any of the therapy techniques (see above).

User Initiated Interactions

Users start the program whenever they choose and interact with modules that they deem most appropriate vis-h-vis present symptoms or mastery interest.

Data structure

Data from each computer interaction is recorded with an ID number and a date and time stamp and saved to a database that is accessible (via password) and understandable only to the therapist. If someone other than the therapist is able to access the database, it will appear only as a series of numbers.

also recently d e v e l o p e d ( N e w m a n et al., in press) with the ~im o f increasing the cost-effectiveness o f therapy. It is the m o s t extensive c o m p u t e r p r o g r a m to date i n c o r p o r a t i n g structured assessment, cognitive therapy, breathing retraining, progressive m u s c l e relaxation, p l e a s a n t imagery, and imaginal exposure (Table 2). F i g u r e 1 provides an overview o f the d i a p h r a g m a t i c breathing algorithm used in this p r o g r a m . T h r e e pilot clients w h o met D S M - I V G A D criteria were treated with the c o m p u t e r in c o n j u n c t i o n with six sessions o f group CBT. Clients used the c o m p u t e r for 12 weeks and then it was taken away. At 6 - m o n t h follow-up, the three clients m a i n t a i n e d treatment gains and no l o n g e r m e t G A D criteria, providing evidence that the c o m p u t e r did not serve as a safety signal in this study. These researchers are currently conducting a controlled trial to d e t e r m i n e w h e t h e r c o m p u t e r - a s s i s t e d b r i e f g r o u p therapy improves u p o n b r i e f g r o u p therapy without the computer. A n o t h e r recently d e v e l o p e d a m b u l a t o r y c o m p u t e r p r o g r a m for social p h o b i a

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(Gruber et al., 1996) was tested in a controlled trial. The computer.program included cognitive restructuring and exposure instructions. These researchers compared cognitive-behavioral group therapy (CBGT; 12 sessions), brief CBGT with the computer (8 sessions), brief CBGT without the computer (8 sessions), and a waiting-list control group. Results showed that CBGT was superior to computer-assisted brief CBGT at post-test but these differences disappeared at 6-month follow-up. Similar to Newman et al. (1997), participants in the computer-assisted condition continued to improve after the computer was taken away. However, the brief noncomputer CBGT was equivalent to brief computerassisted CBGT at post-test and no follow-up measures were taken for this group. Therefore, it is unclear whether the computer incremented the impact of this brief group therapy. Making use of virtual reality (VR) technology, Rothbaum and associates (1995a) applied therapist-guided in-vivo exposure to acrophobic clients without leaving the therapist's office. This technology integrated visual displays, body tracking, and other sensory input devices to engage the participant in a computergenerated virtual environment. Although this study contained small sample sizes, preliminary results were encouraging. Participants treated with seven weekly sessions of VR showed greater improvement than a waiting-list control group. Moreover, 7 of the 10 clients who received the VR treatment exposed themselves to heights between treatment sessions even though they were never specifically instructed to do so. These authors point out that there are several advantages to using VR instead of standard therapist-guided in-vivo exposure. VR can be used for situations that are difficult to arrange and control (e.g., combat exposure), and can be made as mild or extreme as necessary. This technology can also be cost-effective when repeated exposure to the feared situation is expensive to create in real life (e.g., air travel with repeated takeoffs and landings). Although there have been some promising results, research on the use of the computer in conjunction with CBT is still quite preliminary. As with research on the computer as the sole treatment provider, published studies on the computer as an adjunct to therapy have many limitations (Table 1). These limitations include no more than one study testing any one computer program (Baer et al., 1987, 1988; Gruber et al., 1996; Newman et al., in press), small sample sizes (Baer et al., 1987, 1988; Newman et al., 1996; Newman et al., 1997; Newman et al., in press; Rothbaum et al., 1995a, 1995b), no therapy comparison group (Baer, Minichiello, & Jenike, 1987; Baer et al., 1988; Newman et al., 1996; Newman et al., in press; Rothbaum et al., 1995a, 1995b), and no follow-up assessment (Rothbaum et al., 1995a, 1995b). In addition, Newman et al. (1997) did not include a brief therapy group without the computer, and Gruber et al. did not conduct a follow-up assessment on their brief noncomputer group. Thus, the lack of differences found in these studies between brief and standard-length therapies may not have been due to the addition of the computer.


RTItaa~ation

AMn°di:tl yte

DiscomlMo ~x I

;3

If

if~ ¢ Good relaxation Maintaining this relaxation'level will be

I

ters

--(

/

Would you like to lower your anxiety ] ~ , ~ . level now? "~ ] ' 1. Do Cognitive Therapy 2. Do relaxation Therapy 3. Neither Winch relaxation exercises will you I) 16 muscle group tension-release 2) 7 muscle group tension release 3) 4 muscle group tension-release 4) 4 muscle group recall 5) 4 muscle group recall & counting 6) Counting alone 7) Diaphragmatic Breathing 8) Imagery Traimnz

It may be helpful to slow your breathing down. Would you like to time 5 breaths again? I) Yes

2) No

~

veryusoful

. ~ . ~ . , ~ ~~ r e r ~ ~

~

"~

e

227

I __[ Begin by giving y. . . . . If pernlission I to relax. '1

P r your abdomen above your belly [ button. As you breathe only the band on

- -

,/ Breathe in count 1, breathe out, and say calm. Breathe in count 2, breathe out, and say calm. Count to 10. Focus only on your breathing and clear your mind of all other thoughts. If your mind starts wanderingjust focus back on your breathing. Breathe slowly and not too deeply. After you get to 10. count 5 normal breaths. Touch the space bar when you start and end.

Breathing rate is fairly good. Would you like slow your breathing rate even further?

} I Breatlfingrate is triceand slow.

1) Yes

What is your post-relaxationanxiety level? ,.--,...,-..,...,--,---,-.,__-,.._,--_,, Total Moderate Max Relaxation Anxiety Discomfort

FIo. 1. An example of an algorithm for Palmtop Computer Administered Diaphragmatic Breathing.

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Future research on adjunctive computer use should include more controlled trials employing the same computer program. Further, studies should compare computer-assisted, computer-only, and standard interventions in the same trial. This comparison could also assess compliance and dropout rate differences. Research should also continue to examine the extent to which computers may serve as a safety signal.

Cost-Effectiveness As mentioned, by maximizing efficient use of therapist's time, computers have the potential to provide outcomes similar to established techniques at reduced costs. Such cost-effectiveness depends largely upon the manner in which computers are used (e.g., as an adjunct to brief therapy, as the sole provider with 10-minute check-ins, for a time-limited period vs. as needed), the specific hardware required (palmtop, PC, VR equipment), overhead fees, equipment maintenance fees, and training costs. Moreover, cost must be contrasted with costs of standard therapies. Two studies included cost estimates in their findings (Newman et al., 1997; Newman et al., in press). The first study estimated costs per individual therapy client based on an average fee for service of $80.00 per therapist contact hour, palmtop computer hardware costs, base station costs, and miscellaneous costs. Accounting for these factors, brief computer-assisted treatment had an estimated cost of $900.00 compared to $1,440.00 for standard CBT for panic disorder and saved $540.00. Brief treatment without the computer was $800.00 per person, about $100.00 less than brief computer-assisted treatment. Therefore, the palmtop did not excessively increment the cost of brief therapy. In Newman et al. (in press), the computer was used in a group therapy format and was estimated to save $1,057.50 per person when compared to 14 sessions of individual therapy for GAD. However, costs for software development were not included in either of these studies. It is likely that development and start-up costs for any program will add significantly to its basic cost and that programs will be most cost-effective when they have already been developed, debugged, and are widely available. Future studies need to include these and other "hidden" costs. In addition, VR studies should examine costeffectiveness in light of hardware and software costs. Thus, it remains to be proven that computers are truly cost-effective. Additional Issues and Future Research Applications and availability of computer technologies are changing at lightning speed. Moreover, assessment and therapy applications are a fairly new domain. As a result, there is a wide open field for additional research possibilities as well as issues that need to be addressed. Among the most pressing topics are: (a) the place for multimedia software and Internet access, (b) the comparative effectiveness of computers to self-help therapy, (c) the identification of individuals who may not be responsive to this treatment, and (d) ethical issues in computer usage. Each of these issues is briefly addressed below.


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Multimedia software and Internet access. Advances in interactive computer software and hardware are likely to improve the availability, acceptability, and perhaps even effectiveness of computer-based programs. In addition, multimedia programs on Websites with "chat rooms" have the potential to serve, at low cost, a large number of individuals. Already many anxiety disorder support groups exist on the Internet. However, the effectiveness of such groups is unknown. One study did examine a multimedia program combined with an electronic support group to increase body satisfaction and decrease frequency of disordered eating behavior in college women at risk for eating disorders (Winzelberg, 1996). In this study, 57 students were randomized to a 3-month intervention or to a control group. The intervention demonstrated a statistically significant effect on improved body image at 3-month follow-up. To date, no comparable study has been conducted with anxiety disordered clients and this is a research area that deserves more attention. Comparison between computer-assisted and self-help therapy. In addition to exploring Internet research options, future research should examine whether computer programs improve on self-help treatments. Such research would also address the potential cost-efficiency of computer therapies. Similar to self-help workbooks and videos, computer technology may develop to the point where therapy programs are available for individual purchase and use on any PC. There are many ways that a computer might improve on selfhelp therapy. First, the interactive nature of the computer has the advantage of re-creating therapist patter in a way that a workbook cannot (e.g., branching off dependent on client responses). Second, if clients have trouble with self-structure, they may forget to follow a practice schedule whereas computer prompts can provide structure and motivation. Third, studies demonstrating that a self-help workbook was as effective as therapistadministered treatment incorporated "adherence phone calls" (e.g., Gould & Clum, 1995; Lidren, Watkins, Gould, & Clum, 1994), which might be eliminated when using an ambulatory computer that beeps participants to remind them to practice techniques or to respond to diary assessments. Fourth, a palmtop computer can provide guidance to clients as they begin to learn CBT techniques in a manner less likely to call attention to them in public situations than a workbook. Only one study compared computer-administered therapy to self-help therapy in the treatment of anxiety (Ghosh et al., 1988). Thus, much more research is needed before a determination can be made regarding the superiority or lack of superiority of computer-assisted therapy to selfhelp therapy. This study did not find computer-administered therapy to be superior; however, these researchers used a stationary computer located in their office and the therapy was composed of in-vivo exposure only. Therefore, it is possible that a computer program that incorporates multiple therapy techniques, and/or an ambulatory computer, may be superior to self-help therapy. Future research should examine this issue. Individuals who may not benefit from computer therapy. Computers will

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never be able to serve as a blanket substitute for the human therapist. For individuals with certain disorders (e.g., personality disorders) or symptoms (e.g., suicidality), a computer intervention may be counter-therapeutic or more helpful when used as an adjunct to therapy rather than the sole provider. Similarly, some clients may benefit more from one type of computer hardware than another (e.g., VR, desktop, or palmtop computers). For example, the reviewed research suggested that for obsessive-compulsive disorder (Baer et al., 1987, 1988) there may be a risk for an ambulatory computer to become a safety signal whereas for GAD (Newman et al., in press), panic disorder (Newman et al., 1997), or social phobia (Gruber et al., 1996), removal of the computer did not interfere with recovery. Future research should begin to determine for whom the computer is and is not helpful by investigating relevant client and symptom dimensions. For each disorder, different amounts of therapist contact and different types of hardware should be explored.

Ethical Issues in Computer-Based Assessment and Therapy The use of computers for assessment and therapy provision raises a number of important clinical (e.g., risk management) and ethical (e.g., confidentiality) issues. Most of the computer usage described within this article was supervised enough to create the opportunity for appropriate monitoring and intervention if needed. For example, users interactions are monitored at the time of uploading or downloading of information (assessment), discussed with patients at the end of treatment or in periodical built-in checks (computer-based therapy), or reviewed at the time of patients' therapy appointment (computer-assisted therapy). The American Psychological Association (1996) Ethics Committee noted on July 16, 1995, that "Many of the enforceable ethical standards are, in fact, relevant to such services (telephone, teleconferencing, and Internet), and based on these standards it could be difficult for a psychologist to demonstrate that it is ethical to conduct therapy solely by telephone, teleconferencing, Internet, or similar methods." The APA Committee was concerned that such interventions alone may not allow the therapist to adequately assess the patient or develop a relationship, or in other ways may limit care. Such concerns are reasonable and need to be considered in computer therapy. The committee also noted that these interventions raise important issues of confidentiality. Indeed, computer bulletin boards or chat rooms are hard to keep confidential. Free-standing computers or computer programs stored on a hard disk are less of a problem and may be more confidential than paperand-pencil records. However, even free-standing programs face potential loss of confidentiality, and certainly, this is the case if such programs are blended with Internet-based programs and communications. All of these concerns point to the need for more research into this area, and the exponential growth of the Internet makes the need for such research urgent. If computers do prove useful and cost-effective, particularly as aides to faceto-face therapy, their implementation and dissemination presents another set

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of problems, including resistance to using the technology, lack of familiarity with the technology or unavailability of the needed hardware, and software or training in such hybrid models of therapy. While it seems premature to address such issues of dissemination, hybrid case-management systems using computers and telephone have been demonstrated to be effective for managing such problems as congestive heart failure and cardiovascular risk factors (DeBusk et al., 1994) and are being widely used in many health care settings.

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