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Ethical and professional issues in computer-assisted therapy
Computers in Human Behavior, Vol. 9, pp. 387~400.1993 Printed in the U.S.A. All rights reserved.
Copyright
0747-5632/93 $6.00 + .cxl 0 1993 Pergamon Press Ltd.
Ethical and Professional Issues in Computer-Assisted Therapy B. Douglas Ford York University
Abstract - Ethical and professional issues associated with computer-assisted therapy (CAT) are discussed in this article. Some of these issues are unique to CAT while others have been of concern to psychologists for decades. A succinct overview of CAT is followed by an examination of whether CAT can be considered psychotherapy. Issues associated with CAT self-help software and CAT software in general, such as independent use, validation of effectiveness, and restricted access, are discussed. Clinician resistance to CAT is explored, including Weizenbaum’s (1976, 1977, 1980) oft-quoted objections and Colby’s (1980, 1986) retorts. The issue of client acceptance of CAT is examined, and suggestions for dealing with technoanxious and computerphobic clients are offered. The impact of CAT on ethical standards (American Psychological Association, 1989) is also discussed. It is recommended that guidelines for users, developers, publishers, and distributors of CAT software be developed along the lines of those instituted for computer-assisted assessment (American Psychological Association, 1986).
INTRODUCTION
Researchers began to explore the utility of various clinical applications of computers soon after computers became available. Computer-based test interpretation was developed in the early 196Os, and by the middle of the 1970s many psychological instruments could be administrated, scored, and interpreted by computers; computer-assisted assessments are presently in wide use (Butcher, 1987; Fowler, 1985). Computer-assisted therapy (CAT) was also pioneered in the 1960s (Colby, Watt, & Gilbert, 1966); however, the early attempts to computerize free-form psychotherapy were relatively unsuccessful, and this application received scant attention from clinical researchers until the 1980s. One of two factors which rejuvenated the interest in CAT was the ever decreasing cost of ever more powerful microcomputers and the development of relatively simRequests for reprints should be addressed to the author at Department University, Downsview, Ontario, M3J lP3 Canada. 387
of Psychology,
York
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ple programming languages (Colby, 1980; Levitan, Willis, & Vogelgesang, 1985). Over the past 30 years computer capabilities have increased 1,700 times, while the relative cost has decreased 99% (Simons, 1985b). The second factor was the popularization of behavioral therapy, which had the effect of priming many therapists, not necessarily all of a behavioral bent, to view therapy as a series of steps (Sines, 1980). Hartman (1986a) offered the observation that if psychotherapy was viewed as rational change resulting from education, one would be more apt to envision computers as capable of conducting psychotherapy. “Psychotherapy, in more recent years, is characterized by very specific treatment objectives directed toward the scientific treatment of precisely delineated problems” (Wagman, 1988, p. 6). In combination, these factors led to a renewal of research in CAT. There has been a growing use of CAT in the 1980s and this trend is expected to continue (Lawrence, 1986; Lieff, 1987; Reynolds, McNamara, Marion, & Tobin, 1985; Sampson, 1986; Wagman, 1988). A survey of members of the Ontario Psychological Association revealed that 6% of respondents presently use CAT (Pollock & Maenpaa, 1990). The implications of the proliferation of computers into virtually all facets of contemporary life have been inadequately examined (Danziger, 1985), and the associated ethical issues have been virtually ignored (Johnson & Snapper, 1985; Parker, 1977). It is far beyond the scope of this article to rectify this situation. The purpose of this article is to discuss the ethical and professional issues in psychology which have arisen as the result and promise of CAT. These issues have been relatively neglected by the profession. Continued neglect of these issues will be to the profession’s detriment. Current CAT programs appear relatively primitive; however, computer capabilities are increasing at an ever accelerating rate, and future CAT technology will be much more impressive. The “fifth generation” computer systems under development in the U.S. and Japan will be capable of interactive voice communication and will be able to reprogram themselves on the basis of experience (Sherman, 1985; Simons, 1985a, 1985b). The implications for future CAT applications are simultaneously both horrific and fantastic. This article is divided into six sections. The first section gives an overview of CAT, and this is followed by an examination of whether CAT can be considered psychotherapy. The third section deals with issues associated with CAT self-help software and CAT software in general, such as independent use, validation of effectiveness, and restricted access. Clinician resistance is examined in the fourth section, and Weizenbaum’s (1976, 1977, 1980) objections to CAT are discussed, as well as Colby’s (1980, 1986) retorts. The fifth section deals with client issues such as acceptance of CAT, computerphobia, and computer-dependent clients. The final section focuses on why the advent of CAT necessitates revisions to the American Psychological Association’s (1989) ethical standards. It is hoped that through debate the profession will develop a proactive stance with regard to the ethical and professional issues associated with CAT.
COMPUTER-ASSISTED
THERAPY
CAT is not a singular homogeneous entity, but has at least three main variations with a multitude of combinations. There is direct on-line communication between the therapist and client (Barnett, 1982), programs which function as therapeutic consultants (Goodman, Gingerich, & Shazer, 1989), and therapeutic software
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which can operate independent of the therapist (Lawrence, 1986; Sampson, 1986). This latter variant is the most prevalent form of CAT, and the current article focuses on CAT applications which can function independent of a human therapist, although this is not always the recommended procedure. One example of this genre is MORTON; MORTON is a computer-assisted cognitive behavior therapy program designed to treat mild to moderate depression (Selmi, Klein, Greist, Johnson, & Harris, 1982). MORTON is both didactic and interactive; facets of the program include an explanation of the cognitive theory of depression and subsequent testing of the client’s comprehension of the model, feedback on the Beck Depression Inventory, review of homework assignments, and combatting dysfunctional automatic thoughts. The client interacts with MORTON primarily through choosing from responses offered on the computer screen. MORTON has limited capability for dealing with free-form responses (Selmi et al., 1982). The client interacts in a similar fashion with other CAT programs of this genre, indicating choices from a variety of multiple-choice formats in combination with limited natural language input (Binik, Servan-Schreiber, Freiwald, & Hall, 1988; Carr, Ghosh, Jz Marks, 1988; Colby, Gould, & Aronson, 1989; Wagman, 1988). There is, however, an experimental program which is presently capable of interactive conversation in colloquial natural language, and the developers view the fostering of client self-awareness as one possible use (Colby, Colby, & Stoller, 1990). Many diverse theoretical orientations to therapy have been adapted to CAT, including behavioral, cognitive, educational, and psychodynamic approaches (Lawrence, 1986; Lieff, 1987; Wagman, 1988). Interactive and didactic CAT programs have targeted drug and alcohol abuse (Moncher et al., 1989), AIDS prevention (Schinke & Orlandi, 1990; Schinke et al., 1989), obesity (Burnett, Magel, Harrington, & Taylor, 1989; Burnett, Taylor, & Agras, 1985; Taylor, Agras, Losch, Plante, & Burnett, 1991), personal distress (Wagman, 1980, 1988; Wagman & Kerber, 1980), smoking (Burling et al., 1989; Schneider, 1986; Schneider, Walter, 8z O’Donnell, 1990), stress (Smith, 1987), and sexual dysfunction (Binik et al., 1988; Servan-Schreiber & Binik, 1989). CAT has also been demonstrated to be successful with various clinical populations including mild to moderate depressives (Selmi, Klein, Greist, Sorrell, & Erdman, 1990), phobics (Carr et al., 1988; Chandler, Burck, Sampson, & Wray, 1988; Ghosh, Marks, & Carr, 1984), violent offenders (Ford, 1988; Ford & Vitelli, 1992), and for cognitive retraining with head trauma patients (Larose, Gagnon, Ferland, & Pepin, 1989; Niemann, Ruff, & Baser, 1990). The vast majority of contemporary CAT studies focus on demonstrating treatment effectiveness and making comparisons with human therapists. There are a host of other worthy questions regarding CAT to which researchers could direct their attention. Examining the relative efficacy of combining CAT with humanadministered therapy and determining what aspects of CAT contribute to its effectiveness are two such areas.
IS COMPUTER-ASSISTED
THERAPY
PSYCHOTHERAPY?
Many psychologists question whether CAT can be considered psychotherapy. From questions received after presentations and from discussions with colleagues, it appears as though those who have psychodynamic and humanistic orientations have the most resistance to viewing CAT as psychotherapy. This author contends
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that CAT is a form of psychotherapy; however, in order to debate this contention, the criteria by which one can discern whether an intervention is psychotherapy or not needs to be defined. Zeig (1987), in discussing the proceedings of the Evolution of Psychotherapy Conference, concluded that there was no common definition of psychotherapy that would be agreed upon by the attending acknowledged experts in the field of psycho~erapy such as Whitaker, Ellis, Beck, Rogers, Laing, May, Bettelheim, and Moreno. While there does not appear to be an agreed upon de~nition of psychotherapy, there are identified commonalities amongst the various psychotherapies. In a review, Grencavage and Norcross (1990) identified the following commonalities amongst the psychotherapies: (a) deveiopment of a therapeutic alliance, (b) opportunity for catharsis, (c) acquisition and practice of new behaviors, and (d) clients’ positive expectations. The most frequent superordinate category of convergence was “Change Processes,” and this was defined by Grencavage and Norcross (1990) as ~anstheoretical means by which change can occur in psychotherapy. This superordinate category includes catharsis and new behaviors as well as other commonalities such as provision of rationale, foster insight, emotional and interpersonal learning, feedback, suggestion, and success and mastery experiences. The current generation of CAT programs allow the client to acquire and practice new behaviors and to test these out in simulated situations, to express their feelings and emotions, to receive feedback, to develop insight, and to learn how to interact better with others ~Compsych, 1990; Multi-Health Systems, 1990). If the criteria for determining whether a treatment is considered psychotherapy is sharing a number of commonalities with recognized psychotherapies, then it can be strongly argued that CAT is a form of psychotherapy.
COMPUTER-ASSISTED
THERAPY
SOFTWARE
CAT software is readily available to clinicians and is being marketed to the general public as well. A number of ethical and professional issues such as independent use, validation of effectiveness, and restricted access have become salient as a result.
hdependent Use With regard to clinical populations, most researchers and practitioners stress that CAT should be adjunctive to traditional psychotherapeutic interventions and should not be viewed as a replacement for human therapists (Colby et al., 1989; Davidson, 1985; Ford, 1988; Ford & Vitelli, 1992; Hartman, 1986a; Selmi et al., 1990). Many CAT interventions, however, such as those for smoking, stress, and obesity, at least with moderate functioning clients do not need to be administered by a psychologist (Sampson, 1986; Sampson & Krumboltz, 1991). A demonstration of this point is the apparent therapeutic and economic success of the “Lifesign” method of smoking cessation which is currently being extensively advertised on television. The manufacturer claims an 80% initial success rate and a success rate of 20-25% after one year (Lifesign, 1989). The Lifesign method is a form of CAT similiar in technique to the ambulatory CAT for obesity described by Burnett et al. (1985) and Taylor et al. (1991), and while these programs are designed by psychologists, a psychologist is not necessary for implementation.
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Schneider (1986) and Schneider et al. (1990) have demonstrated that CAT smoking cessation programs offered on-line can also be therapeutically successful. The abstinence rate for subjects who reponded to a 6-month follow-up inquiry and who received the full version of the treatment program was 24% (Schneider et al., 1990). It will not be long before CAT programs are available to the general public for the treatment of such problems as obesity and stress. It appears that for some problems with some clients the human therapist does not necessarily have to be an integral component of CAT administration in order for the treatment to be effective. Therapists are, however, essential for the development and evaluation of effective CAT programs. Self-help therapy programs have been widely available in printed and audio formats for years. Cost, convenience, and privacy are just some of the advantages of self-help programs. “To the extent that it is possible to offer the public sound, effective programs that do not require professional intervention, it would be socially irresponsible to restrict unduly or to discourage psychologists from making such contributions” (Kieth-Spiegel & Koocher, 1985, p. 217). One problem with self-help programs is that there are no support systems if therapy has negative effects for the individual (Kieth-Spiegel & Koocher, 1985). A related situation would be a harried clinician using MORTON (Selmi et al., 1982) and failing to provide proper supervision to a depressed client who subsequently becomes even more depressed and commits suicide. There are legal as well as ethical ramifications for such improper use of CAT. Malpractice is one area in which psychologists might become involved in the courts as a result of CAT. This scenario includes 3 of the most frequent causes of malpractice complaints against therapists: (a) negligent rendering of services, (b) negligence leading to suicide, and (c) not properly supervising a disturbed client (Schwitzgebel & Schwitzgebel, 1980), all of which could be associated with the careless use of CAT by a clinician. Parker (1977) recommends that computer professionals receive adequate training and keep current with regard to their field. This is obviously good advice to be heeded by psychologists conducting and developing CAT, and this would certainly help if one found oneself involved in CAT-related legal proceedings. Validation of Effectiveness
Another problem is that in the course of attempting to market a self-help program authors, publishers, advertisers, and distributors may make unsubstantiated claims for their product (Kieth-Spiegel & Koocher, 1985; Rosen, 1981; Van Hoose & Kottler, 1985). This is also a problem with commercially available CAT self-help software and CAT software in general (Hartman, 1986b; Sampson 8z Krumboltz, 1991). The profession should press CAT software developers and publishers to demonstrate the effectiveness of their products. Until this recommendation is implemented, and even after, it is suggested clinicians rigorously determine the effectiveness of CAT programs which they use and seek out those programs which have been subjected to the peer review process. While proponents of various widely accepted therapies have not always rigorously demonstrated the efficacy of their approaches, this author feels that it is incumbent upon advocates of CAT and all other therapeutic approaches to empirically demonstrate treatment effectiveness. Kieth-Spiegel and Koocher (1985) and Rosen (1981) recommend that self-help programs be empirically evaluated using the target population and the modality in which the program is to be sold to the public. Developers and publishers of CAT self-help software and of CAT software in general should be held to this standard.
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Another problem associated with the marketing of CAT self-help software and CAT software in general is that many laypersons attribute greater veracity to information conveyed by computers (Hartman, 1986b; Sampson, 1986). This author has observed computer-naive clients ascribing “magical” qualities to computer output when the computer displays the client’s name, age, sex, or other personal details even though they personally inputted this information previously. It should be deemed unethical to use this property of computers to market CAT self-help software (Parker, 1977). Restricted Access
One of Matarazzo’s (1983, 1986) concerns regarding computer-assisted assessment was that unqualified individuals such as teachers, nurses, personnel officers, and general practitioners were naively using computerized assessment devices. A recent perusal of mental health software catalogues revealed that there is presently restricted access to most computerized assessment instruments, but that there are few standards for access to CAT software (Compsych, 1990; MultiHealth Systems, 1990). The profession needs to examine whether some CAT software should have restricted access (Hartman, 1986b; Sampson, 1986), particularly for CAT software designed for clients who should receive therapy at least supervised by a clinician. If manufacturers and distributors restricted access of CAT software to qualified professionals, the liability for negligent use of the software would be transferred to the practitioner (Schwitzgebel & Schwitzgebel, 1980). This section has highlighted the need to establish guidelines for CAT software with regard to independent use, validation of effectiveness, and restricted access. The profession needs not only to catch up to current practices, but to take into account probable future CAT software developments.
Brod (1984), in an admitted generalization, dichotomizes the population into those who are technocentred and those who are technoanxious. The technocentred embrace computers, while the technoanxious are fearful and avoid computers if possible. It is obvious from the proliferation of the use of computers in most areas of psychology that some in the field are technocentred. Computerization in psychology has also met some resistance which is at least partially due to technoanxiety on the part of individuals in the profession. Hammer and Hile (1985) and Meier and Geiger (1986) suggest that preservice and inservice training in the basic and clinical use of computers would alleviate some therapists’ technoanxiety and the associated resistance to computerization. Hammer and Hile (1985) argue that all resistance to computerization is not irrational or due to technoanxiety. The computer by its very nature is objective and deals only with information that can be quantified in some manner. Computerization restricts the types of questions which can be asked and subsequently increases the value of quantifiable data in the decision-making process, while other forms of input become devalued (Danziger, 1985; Weizenbaum, 1976). Murphy and Pardeck (1988) warn us that computerized clinical applications can change the very way in which clinicians think about their clients. Clinicians may begin to
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assign greater value to technically based information at the expense of clinical judgement and intuition. Murphy and Pardeck (1988) suggest that there is a danger of dehumanization as the result of the clinical use of computers unless clinicians are concious of the manner in which the computer “microworld” influences our thoughts. One of the most vociferous opponents of CAT is Weizenbaum (1976, 1977, 1980), who contends that CAT is by its very nature dehumanizing. It is indeed ironic that Weizenbaum is at once the biggest opponent of CAT and also one of its pioneers. The famous ELIZA program, a parody of Rogerian therapy, was created by Weizenbaum as an experiment in computerized natural language processing and was not meant to be used as a form of therapy. Weizenbaum (1976) was shocked by the Colby et al. (1966) article, which suggested that programs such as ELIZA could be refined and used as therapeutic devices. Weizenbaum (1976) was also shocked by the manner in which people became deeply involved with and anthropomorphized ELIZA. Weizenbaum (1976) views the ethical issue as not whether computers can adequately conduct therapy, but whether computers ought to conduct therapy. Weizenbaum (1976, 1977) thinks CAT is immoral because of an absence of genuine warmth and empathy in the therapeutic encounter. The assumption being made here is that therapies without warmth and empathy, whether computerized or not, are by definition immoral. While Rogers, Laing, May, and Bettelheim may side with Weizenbaum on this contention, others such as Ellis, Wolpe, Beck, and Lazarus may disagree (Zeig, 1987). Colby (1980, 1986) offers the observation that there is a shortage of human therapists for the current and foreseeable demand, and that traditional psychotherapy is for many too expensive. One of the benefits of CAT is that it is cost effective, and therefore therapy can be offered to more individuals (Colby, 1980, 1986; Davidson, 1985; Ford & Vitelli, 1992; Sampson & Krumboltz, 1991). The major costs associated with CAT are in the areas of software and program design and in purchasing the necessary hardware (Colby, 1980). If effective and economical CAT programs were rejected on the basis of Weizenbaum’s (1976) definition of morality, would this not be unethical? CAT does not happen in a vacuum devoid of human contact, as Weizenbaum (1976) suggests. CAT as described by Colby (1986), Colby et al., (1989), Ford (1988), Ford and Vitelli (1992), and Schinke et al. (1989) is not an individual off on their own working on a terminal; rather, the client works at one of several terminals while other clients are also working on computerized clinical applications with a human therapist supervising. It is more akin to individualized group therapy with constant interaction between the therapist and clients. The relationship component of therapy is provided by the therapist, who also clarifies and discusses much of the material presented by the computer. This verbal interaction between the therapist and clients leads to ethical concerns regarding confidentiality and privacy which are also associated with more traditional forms of group therapy (Lakin, 1988; Meyer & Smith, 1977; Van Hoose & Kottler, 1985). In this section some of the reasons for clinician resistance to CAT have been outlined: technoanxiety, the devaluation of clinical judgement, and the danger of dehumanization. Counterarguments to the latter assertion have also been presented. One factor in clinician resistance to CAT that has been purposefully overlooked is expected client resistance to CAT, and this is discussed in the following section.
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CLIENT ACCEPTANCE
Fowler (1985) and Hammer and Hile (1985) have reported that clinicians often cite probable client resistance to clinical applications of computers as one reason for their resistance to the use of computerized clinical interventions; however, this appears to be a nonissue for the majority of clients. Computerized assessment instruments have been readily accepted by various populations (Erdman, Klein, & Greist, 1985; French & Beaumont, 1987; Harrell, Honaker, Hetu, 8z Oberwager, 1987; Rozensky, Honor, Rasinski, Tovian, & Herz, 1986; Wyndowe, 1987) and have been preferred by some clients (Farrell, Camplair, & McCullough, 1987; Ford & Vitelli, 1992; Lukin, Dowd, Plake, & Kraft, 1985). It is also generally found that CAT clients express positive attitudes with regard to this form of treatment (Binik et al., 1988; Burda, Starkey, & Dominguez, 1991; Clarke & Schoech, 1984; Colby et al., 1989; Ford, 1988; Matthews, De Santi, Callahan, Koblenz-Sulcov, & Werden, 1987; McLemore & Fantuzzo, 1982; Servan-Schreiber & Binik, 1989). Ford and Vitelli (1992), Wagman (1980, 1988) and Wagman and Kerber (1980) have reported that CAT clients express virtually equal preference for CAT and human-conducted therapy sessions when asked to make comparisons; these clients, however, did not receive both treatments. There are going to be some clients who may benefit from CAT that are wary of interacting with computers. This author has found that the majority of reluctant clients become converts after basic computer training and guided positive interaction with the computer. Based on an examination of the etiology of computerphobia, Weil, Rosen, and Wugalter (1990) have recommended that “introducers” be comfortable and skilled with computers and that this introduction occur within a nonevaluative environment. Computer anxiety is reduced and computer attitudes are improved as the result of computer training (Igbaria & Chakrabarti, 1990), and structured computer training programs appear to be best for females (Arch & Cummins, 1989). Rosen, Sears, and Weil (1987) however, have demonstrated that computerphobits do not improve with computer experience alone: Computerphobics working with computers 4 hr per week for 10 weeks did not show improvement on measures of computer anxiety or computer attitudes. Weil, Rosen, and Sears (1987) have developed a treatment program for computerphobia which includes such aspects as thoughtstopping, systematic desensitization, and an information/support group (these treatments were not delivered via CAT). Computerphobic subjects became more comfortable and confident with computers and showed improvement on measures of computer anxiety and computer attitudes after participating in the treatment program (Weil et al., 1987). Gender differences in attitudes towards CAT and the effectiveness of CAT have been reported by Wagman (1988). Male students had more favorable attitudes towards CAT and also improved more in CAT than did females; females showed greater improvement as the result of human-administered counseling sessions (Wagman, 1988). These gender differences should be examined further, as the Wagman (1988) results suggest that sex may be an important selection criterion for CAT. There are also going to be other types of clients for whom CAT may be contraindicated. Brod (1984) thinks the obsessive compulsive qualities of some individuals might be promoted through interaction with computers. Shotton (1989) comprehensively examined individuals who could be considered to be computer
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addicts. Computer dependents are generally male, spend more hours at work and home on the computer, are less interested in physical and social pursuits than others, are introverted and shy, and have poor social relationships. Shotton (1989) postulates that many computer dependents could be considered to be of the “schizoid” personality type. CAT may be contraindicated for computerdependent clients even though these individuals might be very interested in this treatment option. It is clear that in general clients accept CAT. This is not to discount the fact that there are going to be some clients who, due to illiteracy, technoanxiety or computet-phobia, computer dependency, or preference will either be unsuitable for or will resist CAT. For these clients it would be unethical to deny treatment, and in these cases traditional interventions would have to be relied upon.
THE IMPACT ON ETHICAL
STANDARDS
The growing use of CAT is going to necessitate revisions of the American Psychological Association (1989) ethical standards. Even within the Preamble, potential areas of conflict can be identified. Psychologists are supposed to strive for the best interests of the client and society, but what if these interests are in opposition? While it can be argued that CAT may benefit the individual client in the short term, it can also be argued that the continuing computerization of the psychological profession will be detrimental to society and the individual in the long term. In discussing professional societies and ethical codes, Sawyer (1985) stated that it was crucial for professional societies to be aware of the consequences of certain courses of action. The psychological profession needs to debate the ethical issues which arise with the advent of CAT and to develop a proactive agenda for dealing with these issues. Hartman (1986b) identified a CAT program which violated Ethical Principle 2, regarding limits of competence, and Ethical Principle 7a, which involves understanding the competencies of other professions. The treatment package in question failed to advise clients to get a medical examination to rule out physical factors in impotence. If one peruses the American Psychological Association (1989) ethical standards, it is apparent that many additional areas of potential conflict exist between these principles and how some professionals might conduct CAT and or develop CAT software. Certainly Ethical Principle 2: Competence is in danger of violation when those with programming knowledge and limited clinical skill and experience attempt to develop CAT software. This could be rectified by ensuring that programs are developed by qualified individuals, perhaps in collaboration with those skilled in programming. Before CAT software is marketed it should be subjected to an extensive testing process and peer review. Even experienced clinicians could potentially be in violation of Ethical Principle 2: Competence if they begin conducting CAT without proper education and training in this technique. Professional organizations in psychology should begin offering seminars and workshops in this area. Graduate schools should awaken to computerized clinical applications and offer appropriate instruction and supervised experience to graduate students. The increased use of computers in clinical practice, in general as well as in therapy, increases the probability of violations of Ethical Principle 5c, regarding the
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maintenance of confidential records. A basic tenet of all professional societies is that there is an obligation to protect the privacy of clients (Parker, 1977). CAT allows for the direct input of confidential material which could then be accessed relatively easily if psychologists do not take additional security measures to ensure the privacy of clients records. Bongar (1988) and Turn and Ware (1985) recommend physical, software, and communication safeguards such as encryption programs, which can prevent someone from copying information from a hard disk, to protect con~dential records. This author suggests the use of power-on passwords (the computer will not work until the power-on password is typed in) and the use of antiviral software to prevent the possible destruction of files. CAT has the benefit of increasing the clinician’s efficiency and allows more clients to be involved in ~eatment. The following is not meant to paint administrators as ogres, but the fact of the matter is that in general they perceive the world differently from clinicians. Administrators (and even some clinicians) may view CAT as a means of offering ~eatment on an assembly line basis and reducing the need for professional psychology staff. This attitude and accompanying behavior would be in violation of Ethical Principle 6, regarding the welfare of the consumer, and it is the clinician’s responsibility to guard against this possibility. Computerized clinical applications are generally marketed with considerable hyperbole, and most are not adequately evaluated and or subjected to the peer review process. Self-help CAT programs may therefore in some cases violate aspects of Principle 4: Public Statements. The very existence of CAT software necessitates changes in the wording and temper of some articles. Principles 4e and 41, which deal with the promotion and description of products, in particular need to be updated. This article has primarily focussed on CAT programs with didactic and interactive components which do not need to be concurrently attended by a human therapist. There are other possible CAT formats, and the implications of two such possibilities will be briefly examined. Barnett (1982) describes an incident in which circumstances were such that they had no option, but to (successfully~ counsel a suicidal individual via a computer connection. The proliferation of personal computers in conjunction with inexpensive modems and communications software insures that this incident will not be an isolated occurrence. This highlights the need for possible revisions to Principle 4k, which deals with times when a psychologist gives advice out of the context of a professional psychological relationship. What are the implications of conducting psychotherapy when all the information and feedback the therapist and client exchange is exclusively via the computer? BRIEFER is an expert system designed to assist family therapists in developing treatment strategies (Goodman et al., 1989). Programs such as BRIEFER will be useful to psychologists in isolated regions; however, these programs will also undoub~bly result in an overall reduction in professional consultations with peers. Principle 7: Professional Relationships does not deal with issues which arise as the result of CAT consultation programs. Is the use of such programs in the best interest of clients, and under what circumstances? What is the extent of liability for developers of CAT consultation programs (G~dman et al., f989)? Programs such as BRIEFER necessitate the resurrection of the classic actuarial versus clinical prediction debate. “Are clinicians liable for following poor advice which subsequently results in bad outcomes for their clients? Are clinicians liable for not consulting expert systems when having done so would have improved outcomes for their clients?’ (Goodman et al., 1989, p. 66).
Issues in computer-assisted therapy
CONCLUDING
397
REMARKS
CAT, whatever your viewpoint, is going to become more widespread. At the very least, psychologists and their professional organizations need to be cognizant of the ethical and professional issues which have arisen as the result of the development and growing use of CAT. This article has highlighted some areas where there is a necessity for revisions to ethical statutes and professional practices. Numerous authors have called for the development of ethical guidelines for CAT software (Binik et al., 1988; Hartman, 1986b; Reynolds et al., 1985; Sampson, 1986). Ideally, what is needed is a set of ethical and professional guidelines for users, developers, publishers, and distributors of CAT software similar to the American Psychological Association (1986) Guidelines for Computer-Bused Tests and Interpretations. The development of “Guidelines for Computer-Assisted Therapy Software and Procedures” would allow the profession to have a greater degree of influence on the ever-accelerating evolution of CAT. Acknowledgment -
I would like to thank Drs. H. Brooker and W. H. Coons for their comments on earlier drafts of this paper.
REFERENCES
American
Psychological
Association.
(1986).
Guidelines
for computer-based
tests and
interpretations. Washington, DC: Author.
American Psychological Association. (1989). Ethical principles of psychologists. Washington, DC: Author. Arch, E. C., & Cummins, D. E. (1989). Structured and unstructured exposure to computers: Sex differences in attitude and use among college students. Sex Roles, 20,245-254. Bamett, D. C. (1982). A suicide prevention incident involving use of the computer. Professional Psychology, 13,565-569.
Binik, Y. M., Servan-Schrieber, D., Freiwald, S. & Hall, K. S. (1988). Intelligent computer-based assessment and psychotherapy: An expert system for sexual dysfunction. The Journal of Nervous and Mental Disease, 176,387-m.
microcomputers, and confidentiality. Professional Psychology: Research and Practice, 19.286-289. Brod, C. (1984). Technostress: The human cost of the computer revolution. Don Mills, Ontario, Bongar, B. (1988). Clinicians,
Canada: Addison-Wesley. Burda, P. C., Starkey, T. W., & Dominguez, F. (1991). Computer-administered treatment of psychiatric inpatients. Computers in Human Behavior, 7, l-5. Burling, T. A., Marotta, J., Gonzalez, R., Moltzen, J. O., Eng, A. M., Schmidt, G. A., Welch, R. L., Ziff, D. C., & Reilly, P. M. (1989). Computerized smoking cessation program for the worksite: Treatment outcome and feasibility. Journal of Consulting and Clinical Psychology, 57,619-622. Burnett, K. F., Magel. P M., Harrington, S., & Taylor, C. B. (1989). Computer-assisted behavioral health counselling for high school students. Journal of Counseling Psychology, 36, 63-67. Burnett, K. F., Taylor, C. B., 8z Agras, W. S. (1985). Ambulatory computer-assisted therapy for obesity: A new frontier for behavior therapy. Journal of Consulting and Clinical Psychology, 53, 698-703.
Butcher, J. N. (1987). The use of computers in psychological assessment: An overview of practices and issues. In J. N. Butcher (Ed.), Computerized psychological assessment (pp. 3-14) New York: Basic Books. Carr, A. C., Ghosh, A., & Marks, I. M. (1988). Computer-supervised exposure treatment for phobias. Canadian Journal of Psychiatry, 33, 112-l 17. Chandler, G. M., Burck, H., Sampson, J. P., & Wray, R. (1988). The effectiveness of a generic computer program for systematic desensitization. Computers in Human Behavior, 4,339-346.
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Clarke, B., & Schoech, D. (1984). A computer-assisted game for adolescents: Initial development and comments. In M. D. Schwartz (Ed.), Using computers in clinical practice: Psychotherapy and mental health applications (pp. 335-353). New York: Haworth. Colby, K. M. (1980). Computer psychotherapists. In J. B. Sidorski, J. H. Johnson, & T. A. Williams (Eds.), Technology in mental health care delivery systems (pp. 109-117). Norwood, NJ: Ablex. Colby, K. M. (1986). Ethics of computer-assisted psychotherapy. Psychiatric Annals, 16,414-415. Colby, K. M., Colby, P. M. & Stoller, R. J. (1990). Dialogues in natural language with GURU, a psychologic inference engine. Philosophical Psychology, 3.171-186. Colby, K. M., Gould, R. L., & Aronson, G. (1989). Some pros and cons of computer-assisted psychotherapy. l%e Journal of Nervous and Mental Disease, 177, 105-108. Colby, K. M., Watt, J. B., & Gilbert, J. P. (1966). A computer method of psychotherapy: Preliminary communication. The Journal of Nervous and Mental Disease, 142, 148-152. Compsych. (1990). Compsych mental health software directory: Counseling, clinical and testing. Computer Use in Social Services Network, 10,6-34. Danziger, J. N. (1985). Social science and the social impacts of computer technology. Social Science Quarterly, 66, 3-21. Davidson, R. S. (1985). Applications of computer technology to learning therapy. Journal of Organizational Behavior Management, 6, 155-168. Erdman, H. P., Klein, M. H., & Greist, J. H. (1985). Direct patient computer interviewing. Journal of Consulting and Clinical Psychology, 53,760-773. Farrell, A. D., Camplair, P. S., & McCullough, L. (1987). Identification of target complaints by computer interview: Evaluation of the computerized assessment system for psychotherapy evaluation and research. Journal of Consulting and Clinical Psychology, 55,691-700. Ford, B. D. (1988). An ongoing computerized adjunct to psychotherapy program: Two years plus in a two years minus correctional center. Paper presented at Counselling as Education Conference, Lakehead University. Thunder Bay, Ontario, Canada. Ford, B. D., & Vitelli, R. (1992). Inmate attitudes towards computerized clinical interventions. Computers in Human Behavior, 8, 223-230. Fowler, R. D. (1985). Landmarks in computer-assisted psychological assessment. Journal of Consulting and Clinical Psychology, 53,748-759. French, C. C., & Beaumont, J. G. (1987). The reaction of psychiatric patients to computerized assessment. British Journal of Clinical Psychology, X,267-278. Ghosh, A., Marks, I. M., & Carr, A. C. (1984). Controlled study of self-exposure treatment for phobits: A preliminary communication. Journal of the Royal Society of Medicine, 77,483-487. Goodman, H., Gingerich, W. J., & Shazer, S. (1989). BRIEFER: An expert system for clinical practice. Computers in Human Services, 5, 53-68. Grencavage, L. M., & Norcross, J. C. (1990). Where are the commonalities among the therapeutic common factors?. Professional Psychology: Research and Practice, 21, 372-378. Hammer, A. L., & Hile, M. G. (1985). Factors in clinicians’ resistance to automation in mental health Computers in Human Services, 1, l-23. Harrell, T. H., Honaker, L. M., Hetu, M., & Oberwager, J. (1987). Computerized versus traditional administration of the multidimensional aptitude battery-verbal scale: An examination of reliability and validity. Computers in Human Behavior, 3, 129-137. Hartman, D. E. (1986a). Artificial intelligence or artificial psychologist? Conceptual issues in clinical microcomputer use. Professional Psychology: Research and Practice, 17,528-534. Hartman, D. E. (1986b). On the use of clinical psychology software: Practical, legal, and ethical concerns. Professional Psychology: Research and Practice, 17,462-465. Igbaria, M., & Chakrabarti, A. (1990). Computer anxiety and attitudes towards microcomputer use. Behaviour & Information Technology, 9, 229-241. Johnson, D. G., & Snapper, J. W. (Eds.). (1985). Ethical issues in the use of computers. Belmont, CA: Wadsworth. K&h-Spiegel, I?, & Koocher, G. P. (1985). Ethics in psychology. New York: Random House. L&in, M. (1988). Ethical issues in the psychotherapies. New York: Oxford University Press. Larose, S., Gagnon, S., Ferland, C., & Pepin, M. (1989). Psychology of computers: XIV. Cognitive rehabilitation through computer games. Perceptual and Motor Skills, 69,851-858. Lawrence, G. H. (1986). Using computers for the treatment of psychological problems. Computers in Human Behavior, 2.43-62. Levitan, K. B., Willis, E. A., & Vogelgesang, J. (1985). Microcomputers and the individual practioner: A review of the literature in psychology and psychiatry. Computers in Human Services, 1, 65-84. Lieff, J. D. (1987). Computer applications in psychiatry. Washington, DC: American Psychiatric Press.
Issues in computer-~sisted therapy
399
Lifesign. (1989). How Lifesign makes it easy. Reston, VA: Author. Lukin, M. E., Dowd, T., Plake, B. S., & Kraft, R. G. (1985). Comparing computerized versus traditional psychological assessment. Computers in Human Behavior, 1,49-58. Matarazzo, J. D. (1983). Computerized psychological testing. Science, 221,323. Matarazzo, J. D. (1986). Computerized clinical psychological test interpretations. American Psychologist, 4X14-24.
Matthews, T. J., De Santi, S. M., Caliahan, D., Koblenz-Sulcov, C. J., & Werden, J. L. (1987). The ~crocomputer as an agent of intervention with psychiatric patients: Preliminary studies. Computers in Human Behavior, 3,37-47.
McLemore, C. W., & Fantuzzo, J. W. (1982). CARE: Bridging the gap between clinicians and computers. Professional Psychology, 13, 501-5 10. Meier, S. T., & Geiger, S. M. (1986). Implications of computer-assisted testing and assessment for professional practice and training. Measurement and Evaluation in Counselling and Development, 19,29-34. Meyer, R. G., & Smith, S. R. (1977). A crisis in group therapy. American Psychologist, 32,638-643. Moncher, M. S., Parms, C. A., Orlandi. M. A., Schinke, S. P, Miller, S. O., Palleja, J., & Schinke, M. B. (1985). Mi~~omputer-based approaches for p~venting drug and alcohol abuse among adolescents from ethnic-racial minority backgrounds. Computers in Human Behavior, 5,79-93. Multi-Health Systems. (1990). Multi-Health Systems Inc. 1990/1991 catalogue. Toronto: Author. Murphy, J. W., & Pardeck, J. T. (1988). Dehumanization, computers and clinical practice. Journal of Social Behavior and Personality, 3, 107-l 16.
Niemann, H., Ruff, R. M., & Baser, C. A. (1990). Computer-assisted attention retraining in headinjured individuals: A controlled efficacy study of an outpatient program. Journal of Consulting and Clinical Psychology, 58,81 I-817.
Parker, D. B. (1977). ethical ~on~icts in compz~ter science and tec~ology, Menlo Park, CA: SRI Intemational. Pollock, N. L.. & Maenpaa, M. (1990). How are psychologists using computers?. Canadian Psychology, 31.167-171.
Reynolds, R. V. C., McNamara, J. R., Marion, R. J., & Tobin, D. L. (1985). Computerized service delivery in clinical psychology. Professional Psychology: Research and Practice, 16.339-353. Rosen, L. D., Sears, D. C., & Weil, M. M. (1987). Computerphobia. Behavior Research Methods, Instruments, & Computers, 19, 167-179.
Rosen, G. M. (1981). Guidelines for the review of do-it-yourself treatment books. Contemporary Psychology, 26,189-l
91.
Rozensky, R. H., Honor, L. F., Rasinski, K., Tovian, S. M., & Herz, G. I. (1986). Paper-pencil versus computer-administered MMPI’s: A comparison of patient’s attitudes. Computers in Human Behavior, 2, 11l-116. Sampson, J. P (1986). The use of computer-assisted instmction in support of psychotherapeutic processes. Computers in Human Behavior, 2, 1-19. Sampson, J. I?, & Krumboltz, J. D. (1991). Computer-assisted instruction: A missing link in counseling. Journal of Counseling & Development, 69,395-397. Sawyer, F. H. (1985). What should professional societies do about ethics?. In D. G. Johnson & J. W. Snapper (Eds.), Ethical issues in the use of computers (pp. 43-49). Belmont, CA: Wadswo~. Schinke, S. P., & Odandi, M. A. (1990). Skills-based, interactive computer inte~entions to prevent HIV infection among African-American and Hispanic adolescents. Computers in Human Behavior, 6,235-246.
Schinke, S. P., Orlandi, M. A., Gordon, A. N., Weston, R. E., Moncher, M. S., & Parms, C. A. (1989). AIDS prevention via computer-based intervention, Computers in Human Services, 5, 147-156. Schneider, S. J. (1986). Trial of an on-line behavioral smoking cessation program. Computers in Human Behavior, 2.277-286.
Schneider, S. J., Walter, R., & O’Donnell, R. (1990). Computerized communication as a medium for behavioral smoking cessation treatment: Controlled evaluation. Computers in Hug behavior, 6, 141-151. Schwitzgebel, R. L., & Schwitzgebel, R. K. (1980). Law and p~chological practice. Toronto: Wiley. Sehni, P. M., Klein, M. H., Greist, J. H., Johnson, J. H., & Harris, W. G. (1982). An investigation of computer-assisted cognitive-behavior therapy in the treatment of depression. Behavior Research Methods and Instrumentation, 14, 181-185. Selmi, P M., Klein, M. H., Greist, J. H., Sorell, S. P., & Erdman, H. P (1990). Computer-administered cognitive-behavioral therapy for depression. American Journal of Psychiatry, 147, 51-56. Servan-Schreiber, D., & Binik, Y. M. (1989). Extending the intelligent tutoring system paradigm: Sex therapy as intelligent tutoring. ~ompurers in Human Behavior, 5,241-259.
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Ford
Sherman, B. (1985). 77re new revolution. Toronto: Wiley. Shotton, M. A. (1989). Computer addiction?. New York: Taylor & Francis. Simons, G. (1985a). i‘7re biology of computer life. Sussex, England: The Harvester Press. Simons, G. (1985b). Silicon shock. New York: Basil Blackwell. Sines, J. 0. (1980). The use of computers in the delivery of mental health health care: The necessary background conditions. In J. B. Sidowski, J. H. Johnson, & T. A. Williams (Eds.), Technology in mental health care delivery systems (pp. 3-16). Norwood, NJ: Ablex. Smith, J. J. (1987). The effectiveness of a computerized self-help stress coping program with adult males. Computers in Human Services, 2, 37-49. Taylor, C. B., Agras, W. S., Losch, M., Plante, T. G., & Burnett, K. (1991). Improving the effectiveness of computer-assisted weight loss. Behavior Therapy, 22,229-236. Turn, R., & Ware, W. H. (1985). Privacy and security issues in information systems. In D. G. Johnson & J. W. Snapper (Eds.), Ethical issues in the use of computers (pp. 133-147). Belmont, CA: Wadsworth. Van Hoose, W. H., & Kottler, J. A. (1985). Ethical and legal issues in counseling and psychotherapy. San Francisco: Jossey-Bass. Wagman, M. (1980). PLATO DCS: An interactive computer system for personal counseling. Journal of Counseling Psychology, 27, 16-30. Wagman, M. (1988). Computer psychotherapy systems. New York: Gordon and Breach Science Publishers. Wagman, M., & Kerber, K. W. (1980). PLATO DCS, an interactive computer system for personal counseling: Further development and evaluation. Journal of Counseling Psychology, 27, 3 l-39. Weil, M. M., Rosen, L. D., & Sears, D. C. (1987). The Computerphobia Reduction Program: Year 1. Program development and preliminary results. Behavior Research Methods, Instruments, & Computers, 19, 180-184. Weil, M. M., Rosen, L. D., & Wugalter, S. E. (1990). The etiology of computerphobia. Computers in Human Behavior, ii, 361-379. Weizenbaum, J. (1976). Computer power and hunzan reason. San Francisco: W.H. Freeman. Weizenbaum, J. (1977). Computers as “therapists”. Science, 198, 354. Weizenbaum, J. (1980). Once mom, the computer revolution. In T. Forester (Ed.), Tlze microelectronics revolution (pp. 550-570). Oxford, England: Basil Blackwell. Wyndowe, J. (1987). The Microcomputerized Diagnostic Interview Schedule: Clinical use in an outpatient setting. Canadian Journal of Psychiatry, 32,93-99. Zeig, J. K. (1987). The evolution of psychotherapy. New York: BrunnerhIazel.
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0747-5632/93 $6.00 + .cxl 0 1993 Pergamon Press Ltd.
Ethical and Professional Issues in Computer-Assisted Therapy B. Douglas Ford York University
Abstract - Ethical and professional issues associated with computer-assisted therapy (CAT) are discussed in this article. Some of these issues are unique to CAT while others have been of concern to psychologists for decades. A succinct overview of CAT is followed by an examination of whether CAT can be considered psychotherapy. Issues associated with CAT self-help software and CAT software in general, such as independent use, validation of effectiveness, and restricted access, are discussed. Clinician resistance to CAT is explored, including Weizenbaum’s (1976, 1977, 1980) oft-quoted objections and Colby’s (1980, 1986) retorts. The issue of client acceptance of CAT is examined, and suggestions for dealing with technoanxious and computerphobic clients are offered. The impact of CAT on ethical standards (American Psychological Association, 1989) is also discussed. It is recommended that guidelines for users, developers, publishers, and distributors of CAT software be developed along the lines of those instituted for computer-assisted assessment (American Psychological Association, 1986).
INTRODUCTION
Researchers began to explore the utility of various clinical applications of computers soon after computers became available. Computer-based test interpretation was developed in the early 196Os, and by the middle of the 1970s many psychological instruments could be administrated, scored, and interpreted by computers; computer-assisted assessments are presently in wide use (Butcher, 1987; Fowler, 1985). Computer-assisted therapy (CAT) was also pioneered in the 1960s (Colby, Watt, & Gilbert, 1966); however, the early attempts to computerize free-form psychotherapy were relatively unsuccessful, and this application received scant attention from clinical researchers until the 1980s. One of two factors which rejuvenated the interest in CAT was the ever decreasing cost of ever more powerful microcomputers and the development of relatively simRequests for reprints should be addressed to the author at Department University, Downsview, Ontario, M3J lP3 Canada. 387
of Psychology,
York
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ple programming languages (Colby, 1980; Levitan, Willis, & Vogelgesang, 1985). Over the past 30 years computer capabilities have increased 1,700 times, while the relative cost has decreased 99% (Simons, 1985b). The second factor was the popularization of behavioral therapy, which had the effect of priming many therapists, not necessarily all of a behavioral bent, to view therapy as a series of steps (Sines, 1980). Hartman (1986a) offered the observation that if psychotherapy was viewed as rational change resulting from education, one would be more apt to envision computers as capable of conducting psychotherapy. “Psychotherapy, in more recent years, is characterized by very specific treatment objectives directed toward the scientific treatment of precisely delineated problems” (Wagman, 1988, p. 6). In combination, these factors led to a renewal of research in CAT. There has been a growing use of CAT in the 1980s and this trend is expected to continue (Lawrence, 1986; Lieff, 1987; Reynolds, McNamara, Marion, & Tobin, 1985; Sampson, 1986; Wagman, 1988). A survey of members of the Ontario Psychological Association revealed that 6% of respondents presently use CAT (Pollock & Maenpaa, 1990). The implications of the proliferation of computers into virtually all facets of contemporary life have been inadequately examined (Danziger, 1985), and the associated ethical issues have been virtually ignored (Johnson & Snapper, 1985; Parker, 1977). It is far beyond the scope of this article to rectify this situation. The purpose of this article is to discuss the ethical and professional issues in psychology which have arisen as the result and promise of CAT. These issues have been relatively neglected by the profession. Continued neglect of these issues will be to the profession’s detriment. Current CAT programs appear relatively primitive; however, computer capabilities are increasing at an ever accelerating rate, and future CAT technology will be much more impressive. The “fifth generation” computer systems under development in the U.S. and Japan will be capable of interactive voice communication and will be able to reprogram themselves on the basis of experience (Sherman, 1985; Simons, 1985a, 1985b). The implications for future CAT applications are simultaneously both horrific and fantastic. This article is divided into six sections. The first section gives an overview of CAT, and this is followed by an examination of whether CAT can be considered psychotherapy. The third section deals with issues associated with CAT self-help software and CAT software in general, such as independent use, validation of effectiveness, and restricted access. Clinician resistance is examined in the fourth section, and Weizenbaum’s (1976, 1977, 1980) objections to CAT are discussed, as well as Colby’s (1980, 1986) retorts. The fifth section deals with client issues such as acceptance of CAT, computerphobia, and computer-dependent clients. The final section focuses on why the advent of CAT necessitates revisions to the American Psychological Association’s (1989) ethical standards. It is hoped that through debate the profession will develop a proactive stance with regard to the ethical and professional issues associated with CAT.
COMPUTER-ASSISTED
THERAPY
CAT is not a singular homogeneous entity, but has at least three main variations with a multitude of combinations. There is direct on-line communication between the therapist and client (Barnett, 1982), programs which function as therapeutic consultants (Goodman, Gingerich, & Shazer, 1989), and therapeutic software
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which can operate independent of the therapist (Lawrence, 1986; Sampson, 1986). This latter variant is the most prevalent form of CAT, and the current article focuses on CAT applications which can function independent of a human therapist, although this is not always the recommended procedure. One example of this genre is MORTON; MORTON is a computer-assisted cognitive behavior therapy program designed to treat mild to moderate depression (Selmi, Klein, Greist, Johnson, & Harris, 1982). MORTON is both didactic and interactive; facets of the program include an explanation of the cognitive theory of depression and subsequent testing of the client’s comprehension of the model, feedback on the Beck Depression Inventory, review of homework assignments, and combatting dysfunctional automatic thoughts. The client interacts with MORTON primarily through choosing from responses offered on the computer screen. MORTON has limited capability for dealing with free-form responses (Selmi et al., 1982). The client interacts in a similar fashion with other CAT programs of this genre, indicating choices from a variety of multiple-choice formats in combination with limited natural language input (Binik, Servan-Schreiber, Freiwald, & Hall, 1988; Carr, Ghosh, Jz Marks, 1988; Colby, Gould, & Aronson, 1989; Wagman, 1988). There is, however, an experimental program which is presently capable of interactive conversation in colloquial natural language, and the developers view the fostering of client self-awareness as one possible use (Colby, Colby, & Stoller, 1990). Many diverse theoretical orientations to therapy have been adapted to CAT, including behavioral, cognitive, educational, and psychodynamic approaches (Lawrence, 1986; Lieff, 1987; Wagman, 1988). Interactive and didactic CAT programs have targeted drug and alcohol abuse (Moncher et al., 1989), AIDS prevention (Schinke & Orlandi, 1990; Schinke et al., 1989), obesity (Burnett, Magel, Harrington, & Taylor, 1989; Burnett, Taylor, & Agras, 1985; Taylor, Agras, Losch, Plante, & Burnett, 1991), personal distress (Wagman, 1980, 1988; Wagman & Kerber, 1980), smoking (Burling et al., 1989; Schneider, 1986; Schneider, Walter, 8z O’Donnell, 1990), stress (Smith, 1987), and sexual dysfunction (Binik et al., 1988; Servan-Schreiber & Binik, 1989). CAT has also been demonstrated to be successful with various clinical populations including mild to moderate depressives (Selmi, Klein, Greist, Sorrell, & Erdman, 1990), phobics (Carr et al., 1988; Chandler, Burck, Sampson, & Wray, 1988; Ghosh, Marks, & Carr, 1984), violent offenders (Ford, 1988; Ford & Vitelli, 1992), and for cognitive retraining with head trauma patients (Larose, Gagnon, Ferland, & Pepin, 1989; Niemann, Ruff, & Baser, 1990). The vast majority of contemporary CAT studies focus on demonstrating treatment effectiveness and making comparisons with human therapists. There are a host of other worthy questions regarding CAT to which researchers could direct their attention. Examining the relative efficacy of combining CAT with humanadministered therapy and determining what aspects of CAT contribute to its effectiveness are two such areas.
IS COMPUTER-ASSISTED
THERAPY
PSYCHOTHERAPY?
Many psychologists question whether CAT can be considered psychotherapy. From questions received after presentations and from discussions with colleagues, it appears as though those who have psychodynamic and humanistic orientations have the most resistance to viewing CAT as psychotherapy. This author contends
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that CAT is a form of psychotherapy; however, in order to debate this contention, the criteria by which one can discern whether an intervention is psychotherapy or not needs to be defined. Zeig (1987), in discussing the proceedings of the Evolution of Psychotherapy Conference, concluded that there was no common definition of psychotherapy that would be agreed upon by the attending acknowledged experts in the field of psycho~erapy such as Whitaker, Ellis, Beck, Rogers, Laing, May, Bettelheim, and Moreno. While there does not appear to be an agreed upon de~nition of psychotherapy, there are identified commonalities amongst the various psychotherapies. In a review, Grencavage and Norcross (1990) identified the following commonalities amongst the psychotherapies: (a) deveiopment of a therapeutic alliance, (b) opportunity for catharsis, (c) acquisition and practice of new behaviors, and (d) clients’ positive expectations. The most frequent superordinate category of convergence was “Change Processes,” and this was defined by Grencavage and Norcross (1990) as ~anstheoretical means by which change can occur in psychotherapy. This superordinate category includes catharsis and new behaviors as well as other commonalities such as provision of rationale, foster insight, emotional and interpersonal learning, feedback, suggestion, and success and mastery experiences. The current generation of CAT programs allow the client to acquire and practice new behaviors and to test these out in simulated situations, to express their feelings and emotions, to receive feedback, to develop insight, and to learn how to interact better with others ~Compsych, 1990; Multi-Health Systems, 1990). If the criteria for determining whether a treatment is considered psychotherapy is sharing a number of commonalities with recognized psychotherapies, then it can be strongly argued that CAT is a form of psychotherapy.
COMPUTER-ASSISTED
THERAPY
SOFTWARE
CAT software is readily available to clinicians and is being marketed to the general public as well. A number of ethical and professional issues such as independent use, validation of effectiveness, and restricted access have become salient as a result.
hdependent Use With regard to clinical populations, most researchers and practitioners stress that CAT should be adjunctive to traditional psychotherapeutic interventions and should not be viewed as a replacement for human therapists (Colby et al., 1989; Davidson, 1985; Ford, 1988; Ford & Vitelli, 1992; Hartman, 1986a; Selmi et al., 1990). Many CAT interventions, however, such as those for smoking, stress, and obesity, at least with moderate functioning clients do not need to be administered by a psychologist (Sampson, 1986; Sampson & Krumboltz, 1991). A demonstration of this point is the apparent therapeutic and economic success of the “Lifesign” method of smoking cessation which is currently being extensively advertised on television. The manufacturer claims an 80% initial success rate and a success rate of 20-25% after one year (Lifesign, 1989). The Lifesign method is a form of CAT similiar in technique to the ambulatory CAT for obesity described by Burnett et al. (1985) and Taylor et al. (1991), and while these programs are designed by psychologists, a psychologist is not necessary for implementation.
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Schneider (1986) and Schneider et al. (1990) have demonstrated that CAT smoking cessation programs offered on-line can also be therapeutically successful. The abstinence rate for subjects who reponded to a 6-month follow-up inquiry and who received the full version of the treatment program was 24% (Schneider et al., 1990). It will not be long before CAT programs are available to the general public for the treatment of such problems as obesity and stress. It appears that for some problems with some clients the human therapist does not necessarily have to be an integral component of CAT administration in order for the treatment to be effective. Therapists are, however, essential for the development and evaluation of effective CAT programs. Self-help therapy programs have been widely available in printed and audio formats for years. Cost, convenience, and privacy are just some of the advantages of self-help programs. “To the extent that it is possible to offer the public sound, effective programs that do not require professional intervention, it would be socially irresponsible to restrict unduly or to discourage psychologists from making such contributions” (Kieth-Spiegel & Koocher, 1985, p. 217). One problem with self-help programs is that there are no support systems if therapy has negative effects for the individual (Kieth-Spiegel & Koocher, 1985). A related situation would be a harried clinician using MORTON (Selmi et al., 1982) and failing to provide proper supervision to a depressed client who subsequently becomes even more depressed and commits suicide. There are legal as well as ethical ramifications for such improper use of CAT. Malpractice is one area in which psychologists might become involved in the courts as a result of CAT. This scenario includes 3 of the most frequent causes of malpractice complaints against therapists: (a) negligent rendering of services, (b) negligence leading to suicide, and (c) not properly supervising a disturbed client (Schwitzgebel & Schwitzgebel, 1980), all of which could be associated with the careless use of CAT by a clinician. Parker (1977) recommends that computer professionals receive adequate training and keep current with regard to their field. This is obviously good advice to be heeded by psychologists conducting and developing CAT, and this would certainly help if one found oneself involved in CAT-related legal proceedings. Validation of Effectiveness
Another problem is that in the course of attempting to market a self-help program authors, publishers, advertisers, and distributors may make unsubstantiated claims for their product (Kieth-Spiegel & Koocher, 1985; Rosen, 1981; Van Hoose & Kottler, 1985). This is also a problem with commercially available CAT self-help software and CAT software in general (Hartman, 1986b; Sampson 8z Krumboltz, 1991). The profession should press CAT software developers and publishers to demonstrate the effectiveness of their products. Until this recommendation is implemented, and even after, it is suggested clinicians rigorously determine the effectiveness of CAT programs which they use and seek out those programs which have been subjected to the peer review process. While proponents of various widely accepted therapies have not always rigorously demonstrated the efficacy of their approaches, this author feels that it is incumbent upon advocates of CAT and all other therapeutic approaches to empirically demonstrate treatment effectiveness. Kieth-Spiegel and Koocher (1985) and Rosen (1981) recommend that self-help programs be empirically evaluated using the target population and the modality in which the program is to be sold to the public. Developers and publishers of CAT self-help software and of CAT software in general should be held to this standard.
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Another problem associated with the marketing of CAT self-help software and CAT software in general is that many laypersons attribute greater veracity to information conveyed by computers (Hartman, 1986b; Sampson, 1986). This author has observed computer-naive clients ascribing “magical” qualities to computer output when the computer displays the client’s name, age, sex, or other personal details even though they personally inputted this information previously. It should be deemed unethical to use this property of computers to market CAT self-help software (Parker, 1977). Restricted Access
One of Matarazzo’s (1983, 1986) concerns regarding computer-assisted assessment was that unqualified individuals such as teachers, nurses, personnel officers, and general practitioners were naively using computerized assessment devices. A recent perusal of mental health software catalogues revealed that there is presently restricted access to most computerized assessment instruments, but that there are few standards for access to CAT software (Compsych, 1990; MultiHealth Systems, 1990). The profession needs to examine whether some CAT software should have restricted access (Hartman, 1986b; Sampson, 1986), particularly for CAT software designed for clients who should receive therapy at least supervised by a clinician. If manufacturers and distributors restricted access of CAT software to qualified professionals, the liability for negligent use of the software would be transferred to the practitioner (Schwitzgebel & Schwitzgebel, 1980). This section has highlighted the need to establish guidelines for CAT software with regard to independent use, validation of effectiveness, and restricted access. The profession needs not only to catch up to current practices, but to take into account probable future CAT software developments.
Brod (1984), in an admitted generalization, dichotomizes the population into those who are technocentred and those who are technoanxious. The technocentred embrace computers, while the technoanxious are fearful and avoid computers if possible. It is obvious from the proliferation of the use of computers in most areas of psychology that some in the field are technocentred. Computerization in psychology has also met some resistance which is at least partially due to technoanxiety on the part of individuals in the profession. Hammer and Hile (1985) and Meier and Geiger (1986) suggest that preservice and inservice training in the basic and clinical use of computers would alleviate some therapists’ technoanxiety and the associated resistance to computerization. Hammer and Hile (1985) argue that all resistance to computerization is not irrational or due to technoanxiety. The computer by its very nature is objective and deals only with information that can be quantified in some manner. Computerization restricts the types of questions which can be asked and subsequently increases the value of quantifiable data in the decision-making process, while other forms of input become devalued (Danziger, 1985; Weizenbaum, 1976). Murphy and Pardeck (1988) warn us that computerized clinical applications can change the very way in which clinicians think about their clients. Clinicians may begin to
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assign greater value to technically based information at the expense of clinical judgement and intuition. Murphy and Pardeck (1988) suggest that there is a danger of dehumanization as the result of the clinical use of computers unless clinicians are concious of the manner in which the computer “microworld” influences our thoughts. One of the most vociferous opponents of CAT is Weizenbaum (1976, 1977, 1980), who contends that CAT is by its very nature dehumanizing. It is indeed ironic that Weizenbaum is at once the biggest opponent of CAT and also one of its pioneers. The famous ELIZA program, a parody of Rogerian therapy, was created by Weizenbaum as an experiment in computerized natural language processing and was not meant to be used as a form of therapy. Weizenbaum (1976) was shocked by the Colby et al. (1966) article, which suggested that programs such as ELIZA could be refined and used as therapeutic devices. Weizenbaum (1976) was also shocked by the manner in which people became deeply involved with and anthropomorphized ELIZA. Weizenbaum (1976) views the ethical issue as not whether computers can adequately conduct therapy, but whether computers ought to conduct therapy. Weizenbaum (1976, 1977) thinks CAT is immoral because of an absence of genuine warmth and empathy in the therapeutic encounter. The assumption being made here is that therapies without warmth and empathy, whether computerized or not, are by definition immoral. While Rogers, Laing, May, and Bettelheim may side with Weizenbaum on this contention, others such as Ellis, Wolpe, Beck, and Lazarus may disagree (Zeig, 1987). Colby (1980, 1986) offers the observation that there is a shortage of human therapists for the current and foreseeable demand, and that traditional psychotherapy is for many too expensive. One of the benefits of CAT is that it is cost effective, and therefore therapy can be offered to more individuals (Colby, 1980, 1986; Davidson, 1985; Ford & Vitelli, 1992; Sampson & Krumboltz, 1991). The major costs associated with CAT are in the areas of software and program design and in purchasing the necessary hardware (Colby, 1980). If effective and economical CAT programs were rejected on the basis of Weizenbaum’s (1976) definition of morality, would this not be unethical? CAT does not happen in a vacuum devoid of human contact, as Weizenbaum (1976) suggests. CAT as described by Colby (1986), Colby et al., (1989), Ford (1988), Ford and Vitelli (1992), and Schinke et al. (1989) is not an individual off on their own working on a terminal; rather, the client works at one of several terminals while other clients are also working on computerized clinical applications with a human therapist supervising. It is more akin to individualized group therapy with constant interaction between the therapist and clients. The relationship component of therapy is provided by the therapist, who also clarifies and discusses much of the material presented by the computer. This verbal interaction between the therapist and clients leads to ethical concerns regarding confidentiality and privacy which are also associated with more traditional forms of group therapy (Lakin, 1988; Meyer & Smith, 1977; Van Hoose & Kottler, 1985). In this section some of the reasons for clinician resistance to CAT have been outlined: technoanxiety, the devaluation of clinical judgement, and the danger of dehumanization. Counterarguments to the latter assertion have also been presented. One factor in clinician resistance to CAT that has been purposefully overlooked is expected client resistance to CAT, and this is discussed in the following section.
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CLIENT ACCEPTANCE
Fowler (1985) and Hammer and Hile (1985) have reported that clinicians often cite probable client resistance to clinical applications of computers as one reason for their resistance to the use of computerized clinical interventions; however, this appears to be a nonissue for the majority of clients. Computerized assessment instruments have been readily accepted by various populations (Erdman, Klein, & Greist, 1985; French & Beaumont, 1987; Harrell, Honaker, Hetu, 8z Oberwager, 1987; Rozensky, Honor, Rasinski, Tovian, & Herz, 1986; Wyndowe, 1987) and have been preferred by some clients (Farrell, Camplair, & McCullough, 1987; Ford & Vitelli, 1992; Lukin, Dowd, Plake, & Kraft, 1985). It is also generally found that CAT clients express positive attitudes with regard to this form of treatment (Binik et al., 1988; Burda, Starkey, & Dominguez, 1991; Clarke & Schoech, 1984; Colby et al., 1989; Ford, 1988; Matthews, De Santi, Callahan, Koblenz-Sulcov, & Werden, 1987; McLemore & Fantuzzo, 1982; Servan-Schreiber & Binik, 1989). Ford and Vitelli (1992), Wagman (1980, 1988) and Wagman and Kerber (1980) have reported that CAT clients express virtually equal preference for CAT and human-conducted therapy sessions when asked to make comparisons; these clients, however, did not receive both treatments. There are going to be some clients who may benefit from CAT that are wary of interacting with computers. This author has found that the majority of reluctant clients become converts after basic computer training and guided positive interaction with the computer. Based on an examination of the etiology of computerphobia, Weil, Rosen, and Wugalter (1990) have recommended that “introducers” be comfortable and skilled with computers and that this introduction occur within a nonevaluative environment. Computer anxiety is reduced and computer attitudes are improved as the result of computer training (Igbaria & Chakrabarti, 1990), and structured computer training programs appear to be best for females (Arch & Cummins, 1989). Rosen, Sears, and Weil (1987) however, have demonstrated that computerphobits do not improve with computer experience alone: Computerphobics working with computers 4 hr per week for 10 weeks did not show improvement on measures of computer anxiety or computer attitudes. Weil, Rosen, and Sears (1987) have developed a treatment program for computerphobia which includes such aspects as thoughtstopping, systematic desensitization, and an information/support group (these treatments were not delivered via CAT). Computerphobic subjects became more comfortable and confident with computers and showed improvement on measures of computer anxiety and computer attitudes after participating in the treatment program (Weil et al., 1987). Gender differences in attitudes towards CAT and the effectiveness of CAT have been reported by Wagman (1988). Male students had more favorable attitudes towards CAT and also improved more in CAT than did females; females showed greater improvement as the result of human-administered counseling sessions (Wagman, 1988). These gender differences should be examined further, as the Wagman (1988) results suggest that sex may be an important selection criterion for CAT. There are also going to be other types of clients for whom CAT may be contraindicated. Brod (1984) thinks the obsessive compulsive qualities of some individuals might be promoted through interaction with computers. Shotton (1989) comprehensively examined individuals who could be considered to be computer
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addicts. Computer dependents are generally male, spend more hours at work and home on the computer, are less interested in physical and social pursuits than others, are introverted and shy, and have poor social relationships. Shotton (1989) postulates that many computer dependents could be considered to be of the “schizoid” personality type. CAT may be contraindicated for computerdependent clients even though these individuals might be very interested in this treatment option. It is clear that in general clients accept CAT. This is not to discount the fact that there are going to be some clients who, due to illiteracy, technoanxiety or computet-phobia, computer dependency, or preference will either be unsuitable for or will resist CAT. For these clients it would be unethical to deny treatment, and in these cases traditional interventions would have to be relied upon.
THE IMPACT ON ETHICAL
STANDARDS
The growing use of CAT is going to necessitate revisions of the American Psychological Association (1989) ethical standards. Even within the Preamble, potential areas of conflict can be identified. Psychologists are supposed to strive for the best interests of the client and society, but what if these interests are in opposition? While it can be argued that CAT may benefit the individual client in the short term, it can also be argued that the continuing computerization of the psychological profession will be detrimental to society and the individual in the long term. In discussing professional societies and ethical codes, Sawyer (1985) stated that it was crucial for professional societies to be aware of the consequences of certain courses of action. The psychological profession needs to debate the ethical issues which arise with the advent of CAT and to develop a proactive agenda for dealing with these issues. Hartman (1986b) identified a CAT program which violated Ethical Principle 2, regarding limits of competence, and Ethical Principle 7a, which involves understanding the competencies of other professions. The treatment package in question failed to advise clients to get a medical examination to rule out physical factors in impotence. If one peruses the American Psychological Association (1989) ethical standards, it is apparent that many additional areas of potential conflict exist between these principles and how some professionals might conduct CAT and or develop CAT software. Certainly Ethical Principle 2: Competence is in danger of violation when those with programming knowledge and limited clinical skill and experience attempt to develop CAT software. This could be rectified by ensuring that programs are developed by qualified individuals, perhaps in collaboration with those skilled in programming. Before CAT software is marketed it should be subjected to an extensive testing process and peer review. Even experienced clinicians could potentially be in violation of Ethical Principle 2: Competence if they begin conducting CAT without proper education and training in this technique. Professional organizations in psychology should begin offering seminars and workshops in this area. Graduate schools should awaken to computerized clinical applications and offer appropriate instruction and supervised experience to graduate students. The increased use of computers in clinical practice, in general as well as in therapy, increases the probability of violations of Ethical Principle 5c, regarding the
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maintenance of confidential records. A basic tenet of all professional societies is that there is an obligation to protect the privacy of clients (Parker, 1977). CAT allows for the direct input of confidential material which could then be accessed relatively easily if psychologists do not take additional security measures to ensure the privacy of clients records. Bongar (1988) and Turn and Ware (1985) recommend physical, software, and communication safeguards such as encryption programs, which can prevent someone from copying information from a hard disk, to protect con~dential records. This author suggests the use of power-on passwords (the computer will not work until the power-on password is typed in) and the use of antiviral software to prevent the possible destruction of files. CAT has the benefit of increasing the clinician’s efficiency and allows more clients to be involved in ~eatment. The following is not meant to paint administrators as ogres, but the fact of the matter is that in general they perceive the world differently from clinicians. Administrators (and even some clinicians) may view CAT as a means of offering ~eatment on an assembly line basis and reducing the need for professional psychology staff. This attitude and accompanying behavior would be in violation of Ethical Principle 6, regarding the welfare of the consumer, and it is the clinician’s responsibility to guard against this possibility. Computerized clinical applications are generally marketed with considerable hyperbole, and most are not adequately evaluated and or subjected to the peer review process. Self-help CAT programs may therefore in some cases violate aspects of Principle 4: Public Statements. The very existence of CAT software necessitates changes in the wording and temper of some articles. Principles 4e and 41, which deal with the promotion and description of products, in particular need to be updated. This article has primarily focussed on CAT programs with didactic and interactive components which do not need to be concurrently attended by a human therapist. There are other possible CAT formats, and the implications of two such possibilities will be briefly examined. Barnett (1982) describes an incident in which circumstances were such that they had no option, but to (successfully~ counsel a suicidal individual via a computer connection. The proliferation of personal computers in conjunction with inexpensive modems and communications software insures that this incident will not be an isolated occurrence. This highlights the need for possible revisions to Principle 4k, which deals with times when a psychologist gives advice out of the context of a professional psychological relationship. What are the implications of conducting psychotherapy when all the information and feedback the therapist and client exchange is exclusively via the computer? BRIEFER is an expert system designed to assist family therapists in developing treatment strategies (Goodman et al., 1989). Programs such as BRIEFER will be useful to psychologists in isolated regions; however, these programs will also undoub~bly result in an overall reduction in professional consultations with peers. Principle 7: Professional Relationships does not deal with issues which arise as the result of CAT consultation programs. Is the use of such programs in the best interest of clients, and under what circumstances? What is the extent of liability for developers of CAT consultation programs (G~dman et al., f989)? Programs such as BRIEFER necessitate the resurrection of the classic actuarial versus clinical prediction debate. “Are clinicians liable for following poor advice which subsequently results in bad outcomes for their clients? Are clinicians liable for not consulting expert systems when having done so would have improved outcomes for their clients?’ (Goodman et al., 1989, p. 66).
Issues in computer-assisted therapy
CONCLUDING
397
REMARKS
CAT, whatever your viewpoint, is going to become more widespread. At the very least, psychologists and their professional organizations need to be cognizant of the ethical and professional issues which have arisen as the result of the development and growing use of CAT. This article has highlighted some areas where there is a necessity for revisions to ethical statutes and professional practices. Numerous authors have called for the development of ethical guidelines for CAT software (Binik et al., 1988; Hartman, 1986b; Reynolds et al., 1985; Sampson, 1986). Ideally, what is needed is a set of ethical and professional guidelines for users, developers, publishers, and distributors of CAT software similar to the American Psychological Association (1986) Guidelines for Computer-Bused Tests and Interpretations. The development of “Guidelines for Computer-Assisted Therapy Software and Procedures” would allow the profession to have a greater degree of influence on the ever-accelerating evolution of CAT. Acknowledgment -
I would like to thank Drs. H. Brooker and W. H. Coons for their comments on earlier drafts of this paper.
REFERENCES
American
Psychological
Association.
(1986).
Guidelines
for computer-based
tests and
interpretations. Washington, DC: Author.
American Psychological Association. (1989). Ethical principles of psychologists. Washington, DC: Author. Arch, E. C., & Cummins, D. E. (1989). Structured and unstructured exposure to computers: Sex differences in attitude and use among college students. Sex Roles, 20,245-254. Bamett, D. C. (1982). A suicide prevention incident involving use of the computer. Professional Psychology, 13,565-569.
Binik, Y. M., Servan-Schrieber, D., Freiwald, S. & Hall, K. S. (1988). Intelligent computer-based assessment and psychotherapy: An expert system for sexual dysfunction. The Journal of Nervous and Mental Disease, 176,387-m.
microcomputers, and confidentiality. Professional Psychology: Research and Practice, 19.286-289. Brod, C. (1984). Technostress: The human cost of the computer revolution. Don Mills, Ontario, Bongar, B. (1988). Clinicians,
Canada: Addison-Wesley. Burda, P. C., Starkey, T. W., & Dominguez, F. (1991). Computer-administered treatment of psychiatric inpatients. Computers in Human Behavior, 7, l-5. Burling, T. A., Marotta, J., Gonzalez, R., Moltzen, J. O., Eng, A. M., Schmidt, G. A., Welch, R. L., Ziff, D. C., & Reilly, P. M. (1989). Computerized smoking cessation program for the worksite: Treatment outcome and feasibility. Journal of Consulting and Clinical Psychology, 57,619-622. Burnett, K. F., Magel. P M., Harrington, S., & Taylor, C. B. (1989). Computer-assisted behavioral health counselling for high school students. Journal of Counseling Psychology, 36, 63-67. Burnett, K. F., Taylor, C. B., 8z Agras, W. S. (1985). Ambulatory computer-assisted therapy for obesity: A new frontier for behavior therapy. Journal of Consulting and Clinical Psychology, 53, 698-703.
Butcher, J. N. (1987). The use of computers in psychological assessment: An overview of practices and issues. In J. N. Butcher (Ed.), Computerized psychological assessment (pp. 3-14) New York: Basic Books. Carr, A. C., Ghosh, A., & Marks, I. M. (1988). Computer-supervised exposure treatment for phobias. Canadian Journal of Psychiatry, 33, 112-l 17. Chandler, G. M., Burck, H., Sampson, J. P., & Wray, R. (1988). The effectiveness of a generic computer program for systematic desensitization. Computers in Human Behavior, 4,339-346.
398
Ford
Clarke, B., & Schoech, D. (1984). A computer-assisted game for adolescents: Initial development and comments. In M. D. Schwartz (Ed.), Using computers in clinical practice: Psychotherapy and mental health applications (pp. 335-353). New York: Haworth. Colby, K. M. (1980). Computer psychotherapists. In J. B. Sidorski, J. H. Johnson, & T. A. Williams (Eds.), Technology in mental health care delivery systems (pp. 109-117). Norwood, NJ: Ablex. Colby, K. M. (1986). Ethics of computer-assisted psychotherapy. Psychiatric Annals, 16,414-415. Colby, K. M., Colby, P. M. & Stoller, R. J. (1990). Dialogues in natural language with GURU, a psychologic inference engine. Philosophical Psychology, 3.171-186. Colby, K. M., Gould, R. L., & Aronson, G. (1989). Some pros and cons of computer-assisted psychotherapy. l%e Journal of Nervous and Mental Disease, 177, 105-108. Colby, K. M., Watt, J. B., & Gilbert, J. P. (1966). A computer method of psychotherapy: Preliminary communication. The Journal of Nervous and Mental Disease, 142, 148-152. Compsych. (1990). Compsych mental health software directory: Counseling, clinical and testing. Computer Use in Social Services Network, 10,6-34. Danziger, J. N. (1985). Social science and the social impacts of computer technology. Social Science Quarterly, 66, 3-21. Davidson, R. S. (1985). Applications of computer technology to learning therapy. Journal of Organizational Behavior Management, 6, 155-168. Erdman, H. P., Klein, M. H., & Greist, J. H. (1985). Direct patient computer interviewing. Journal of Consulting and Clinical Psychology, 53,760-773. Farrell, A. D., Camplair, P. S., & McCullough, L. (1987). Identification of target complaints by computer interview: Evaluation of the computerized assessment system for psychotherapy evaluation and research. Journal of Consulting and Clinical Psychology, 55,691-700. Ford, B. D. (1988). An ongoing computerized adjunct to psychotherapy program: Two years plus in a two years minus correctional center. Paper presented at Counselling as Education Conference, Lakehead University. Thunder Bay, Ontario, Canada. Ford, B. D., & Vitelli, R. (1992). Inmate attitudes towards computerized clinical interventions. Computers in Human Behavior, 8, 223-230. Fowler, R. D. (1985). Landmarks in computer-assisted psychological assessment. Journal of Consulting and Clinical Psychology, 53,748-759. French, C. C., & Beaumont, J. G. (1987). The reaction of psychiatric patients to computerized assessment. British Journal of Clinical Psychology, X,267-278. Ghosh, A., Marks, I. M., & Carr, A. C. (1984). Controlled study of self-exposure treatment for phobits: A preliminary communication. Journal of the Royal Society of Medicine, 77,483-487. Goodman, H., Gingerich, W. J., & Shazer, S. (1989). BRIEFER: An expert system for clinical practice. Computers in Human Services, 5, 53-68. Grencavage, L. M., & Norcross, J. C. (1990). Where are the commonalities among the therapeutic common factors?. Professional Psychology: Research and Practice, 21, 372-378. Hammer, A. L., & Hile, M. G. (1985). Factors in clinicians’ resistance to automation in mental health Computers in Human Services, 1, l-23. Harrell, T. H., Honaker, L. M., Hetu, M., & Oberwager, J. (1987). Computerized versus traditional administration of the multidimensional aptitude battery-verbal scale: An examination of reliability and validity. Computers in Human Behavior, 3, 129-137. Hartman, D. E. (1986a). Artificial intelligence or artificial psychologist? Conceptual issues in clinical microcomputer use. Professional Psychology: Research and Practice, 17,528-534. Hartman, D. E. (1986b). On the use of clinical psychology software: Practical, legal, and ethical concerns. Professional Psychology: Research and Practice, 17,462-465. Igbaria, M., & Chakrabarti, A. (1990). Computer anxiety and attitudes towards microcomputer use. Behaviour & Information Technology, 9, 229-241. Johnson, D. G., & Snapper, J. W. (Eds.). (1985). Ethical issues in the use of computers. Belmont, CA: Wadsworth. K&h-Spiegel, I?, & Koocher, G. P. (1985). Ethics in psychology. New York: Random House. L&in, M. (1988). Ethical issues in the psychotherapies. New York: Oxford University Press. Larose, S., Gagnon, S., Ferland, C., & Pepin, M. (1989). Psychology of computers: XIV. Cognitive rehabilitation through computer games. Perceptual and Motor Skills, 69,851-858. Lawrence, G. H. (1986). Using computers for the treatment of psychological problems. Computers in Human Behavior, 2.43-62. Levitan, K. B., Willis, E. A., & Vogelgesang, J. (1985). Microcomputers and the individual practioner: A review of the literature in psychology and psychiatry. Computers in Human Services, 1, 65-84. Lieff, J. D. (1987). Computer applications in psychiatry. Washington, DC: American Psychiatric Press.
Issues in computer-~sisted therapy
399
Lifesign. (1989). How Lifesign makes it easy. Reston, VA: Author. Lukin, M. E., Dowd, T., Plake, B. S., & Kraft, R. G. (1985). Comparing computerized versus traditional psychological assessment. Computers in Human Behavior, 1,49-58. Matarazzo, J. D. (1983). Computerized psychological testing. Science, 221,323. Matarazzo, J. D. (1986). Computerized clinical psychological test interpretations. American Psychologist, 4X14-24.
Matthews, T. J., De Santi, S. M., Caliahan, D., Koblenz-Sulcov, C. J., & Werden, J. L. (1987). The ~crocomputer as an agent of intervention with psychiatric patients: Preliminary studies. Computers in Human Behavior, 3,37-47.
McLemore, C. W., & Fantuzzo, J. W. (1982). CARE: Bridging the gap between clinicians and computers. Professional Psychology, 13, 501-5 10. Meier, S. T., & Geiger, S. M. (1986). Implications of computer-assisted testing and assessment for professional practice and training. Measurement and Evaluation in Counselling and Development, 19,29-34. Meyer, R. G., & Smith, S. R. (1977). A crisis in group therapy. American Psychologist, 32,638-643. Moncher, M. S., Parms, C. A., Orlandi. M. A., Schinke, S. P, Miller, S. O., Palleja, J., & Schinke, M. B. (1985). Mi~~omputer-based approaches for p~venting drug and alcohol abuse among adolescents from ethnic-racial minority backgrounds. Computers in Human Behavior, 5,79-93. Multi-Health Systems. (1990). Multi-Health Systems Inc. 1990/1991 catalogue. Toronto: Author. Murphy, J. W., & Pardeck, J. T. (1988). Dehumanization, computers and clinical practice. Journal of Social Behavior and Personality, 3, 107-l 16.
Niemann, H., Ruff, R. M., & Baser, C. A. (1990). Computer-assisted attention retraining in headinjured individuals: A controlled efficacy study of an outpatient program. Journal of Consulting and Clinical Psychology, 58,81 I-817.
Parker, D. B. (1977). ethical ~on~icts in compz~ter science and tec~ology, Menlo Park, CA: SRI Intemational. Pollock, N. L.. & Maenpaa, M. (1990). How are psychologists using computers?. Canadian Psychology, 31.167-171.
Reynolds, R. V. C., McNamara, J. R., Marion, R. J., & Tobin, D. L. (1985). Computerized service delivery in clinical psychology. Professional Psychology: Research and Practice, 16.339-353. Rosen, L. D., Sears, D. C., & Weil, M. M. (1987). Computerphobia. Behavior Research Methods, Instruments, & Computers, 19, 167-179.
Rosen, G. M. (1981). Guidelines for the review of do-it-yourself treatment books. Contemporary Psychology, 26,189-l
91.
Rozensky, R. H., Honor, L. F., Rasinski, K., Tovian, S. M., & Herz, G. I. (1986). Paper-pencil versus computer-administered MMPI’s: A comparison of patient’s attitudes. Computers in Human Behavior, 2, 11l-116. Sampson, J. P (1986). The use of computer-assisted instmction in support of psychotherapeutic processes. Computers in Human Behavior, 2, 1-19. Sampson, J. I?, & Krumboltz, J. D. (1991). Computer-assisted instruction: A missing link in counseling. Journal of Counseling & Development, 69,395-397. Sawyer, F. H. (1985). What should professional societies do about ethics?. In D. G. Johnson & J. W. Snapper (Eds.), Ethical issues in the use of computers (pp. 43-49). Belmont, CA: Wadswo~. Schinke, S. P., & Odandi, M. A. (1990). Skills-based, interactive computer inte~entions to prevent HIV infection among African-American and Hispanic adolescents. Computers in Human Behavior, 6,235-246.
Schinke, S. P., Orlandi, M. A., Gordon, A. N., Weston, R. E., Moncher, M. S., & Parms, C. A. (1989). AIDS prevention via computer-based intervention, Computers in Human Services, 5, 147-156. Schneider, S. J. (1986). Trial of an on-line behavioral smoking cessation program. Computers in Human Behavior, 2.277-286.
Schneider, S. J., Walter, R., & O’Donnell, R. (1990). Computerized communication as a medium for behavioral smoking cessation treatment: Controlled evaluation. Computers in Hug behavior, 6, 141-151. Schwitzgebel, R. L., & Schwitzgebel, R. K. (1980). Law and p~chological practice. Toronto: Wiley. Sehni, P. M., Klein, M. H., Greist, J. H., Johnson, J. H., & Harris, W. G. (1982). An investigation of computer-assisted cognitive-behavior therapy in the treatment of depression. Behavior Research Methods and Instrumentation, 14, 181-185. Selmi, P M., Klein, M. H., Greist, J. H., Sorell, S. P., & Erdman, H. P (1990). Computer-administered cognitive-behavioral therapy for depression. American Journal of Psychiatry, 147, 51-56. Servan-Schreiber, D., & Binik, Y. M. (1989). Extending the intelligent tutoring system paradigm: Sex therapy as intelligent tutoring. ~ompurers in Human Behavior, 5,241-259.
400
Ford
Sherman, B. (1985). 77re new revolution. Toronto: Wiley. Shotton, M. A. (1989). Computer addiction?. New York: Taylor & Francis. Simons, G. (1985a). i‘7re biology of computer life. Sussex, England: The Harvester Press. Simons, G. (1985b). Silicon shock. New York: Basil Blackwell. Sines, J. 0. (1980). The use of computers in the delivery of mental health health care: The necessary background conditions. In J. B. Sidowski, J. H. Johnson, & T. A. Williams (Eds.), Technology in mental health care delivery systems (pp. 3-16). Norwood, NJ: Ablex. Smith, J. J. (1987). The effectiveness of a computerized self-help stress coping program with adult males. Computers in Human Services, 2, 37-49. Taylor, C. B., Agras, W. S., Losch, M., Plante, T. G., & Burnett, K. (1991). Improving the effectiveness of computer-assisted weight loss. Behavior Therapy, 22,229-236. Turn, R., & Ware, W. H. (1985). Privacy and security issues in information systems. In D. G. Johnson & J. W. Snapper (Eds.), Ethical issues in the use of computers (pp. 133-147). Belmont, CA: Wadsworth. Van Hoose, W. H., & Kottler, J. A. (1985). Ethical and legal issues in counseling and psychotherapy. San Francisco: Jossey-Bass. Wagman, M. (1980). PLATO DCS: An interactive computer system for personal counseling. Journal of Counseling Psychology, 27, 16-30. Wagman, M. (1988). Computer psychotherapy systems. New York: Gordon and Breach Science Publishers. Wagman, M., & Kerber, K. W. (1980). PLATO DCS, an interactive computer system for personal counseling: Further development and evaluation. Journal of Counseling Psychology, 27, 3 l-39. Weil, M. M., Rosen, L. D., & Sears, D. C. (1987). The Computerphobia Reduction Program: Year 1. Program development and preliminary results. Behavior Research Methods, Instruments, & Computers, 19, 180-184. Weil, M. M., Rosen, L. D., & Wugalter, S. E. (1990). The etiology of computerphobia. Computers in Human Behavior, ii, 361-379. Weizenbaum, J. (1976). Computer power and hunzan reason. San Francisco: W.H. Freeman. Weizenbaum, J. (1977). Computers as “therapists”. Science, 198, 354. Weizenbaum, J. (1980). Once mom, the computer revolution. In T. Forester (Ed.), Tlze microelectronics revolution (pp. 550-570). Oxford, England: Basil Blackwell. Wyndowe, J. (1987). The Microcomputerized Diagnostic Interview Schedule: Clinical use in an outpatient setting. Canadian Journal of Psychiatry, 32,93-99. Zeig, J. K. (1987). The evolution of psychotherapy. New York: BrunnerhIazel.