- Email: [email protected]
Self-help computer conferencing
COMPUTERS
AND
BIOMEDICAL
RESEARCH
19,
274-281 (1986)
Self-Help Computer
Conferencing
SID J. SCHNEIDER' ANDJAYTOOLEY Behavioral Health Systems. Inc.. 44 Belleview Averme. Ossining, NeHI York 10562 Received December 9, 1985
Computer conferencing has become popular as an alternative to face-to-face conferencing in many kinds of organizations. Since users can participate at any time, from any terminal, computer conferencing makes communication very convenient, though many find the medium to be impersonal. This paper discusses the potential of computer conferencing to increase the number of people who participate in self-help groups, such as groups to help people lose weight or stop smoking. The kinds of interactions that make for successful selfhelp groups might be encouraged by a computer-conferencing format, even though there is no direct, face-to-face contact. The results of a trial smoking-cessation program which employed computer conferencing suggest that computer conferencing could play a useful rote in health promotion. o 1986 Academic press. IK
Computer conferencing allows any number of individuals to take part in a discussion, even though they may be far apart from each other and unable to all be present at the same moment. Participants in a computer conference call a central computer and read and enter conference comments at any time, from any terminal. The technique has become increasingly popular in business and professional organizations. Unlike business meetings or telephone conferences, computer conferences can accommodate lengthy discussions without the need for time and travel, or even for all the participants to be present simultaneously. Computer conferencing has not been widely used for health promotion groups. However, there may be a useful application among the peopie who form groups to help themselves give up smoking, lose weight, grapple with an alcohol or cocaine problem, and so on. Self-help groups which used computer conferencing would be available to the participants at all times, and remain as near as a terminal and modem. Participants who wished to remain anonymous could enter their conference comments under a pseudonym. The present paper is to discuss the potential uses and problems of computerized conferencing in
I To whom requests for reprints should be addressed. 274 0010~4809/86 $3.00 Copyright AU rights
0 1986 by Academic Press, Inc. of reproduction in any form reserved.
SELF-HELP
COMPUTER
275
CONFERENCING
self-help groups and to report on a recent trial of a stop-smoking computer-conferencing network. COMPUTER
CONFERENCING
AND SELF-HELP
group on a
GROUPS
One of the basic findings of communications research has been that the nature of the medium used for a message affects the content of the message itself. As electronic mail and computer bulletin boards and conferences have proliferated, it has become clear that they have a special impact on the way their users communicate. Messages which were usually exchanged orally must be typed out in acomputer-mediated conversation. All visual cues and nonverbal feedback such as smiles, nods, and shifting tones of voice are absent. There is no way to detect hesitations or the speed with which a message is presented. In a computer conference, there is no one at the head of a table, no one speaking more loudly or assuredly than the rest, no one whose dress conveys status or power. There is no impressive letterhead stationery, no conspicuous secretaries and staffs. All aspects of communication are stripped away from the messages, except for the words themselves. Hiltz and Turoff (4) felt that the removal of the social cues from communication could actually enhance the communication. They pointed out that in a computer conference, participants can read comments over, while in face-toface communication, participants receive only the information that they hear the first time. Also, participants are more likely to stick to the topic and not be distracted by social cues when written comments are exchanged. Hiltz and Turoff (4) concluded that computer-mediated discussions could reach their goals and come to consensus at least as quickly as face-to-face discussions. At the same time, electronic communication can be impersonal specifically because there is no way to immediately acknowledge a message or provide even minimal immediate feedback (7). Without rapid feedback and nonverbal cues, messages can become strong and uninhibited. “Flaming,” or impassioned communications, might occur more frequently in computer-mediated communication than in face-to-face communication because of the lack of cues that speakers use to regulate their exchanges. Speakers cannot know rapidly whether their messages were correctly comprehended, and the norms that usually control a conversation can occasionally break down. Computer-mediated communication is relatively new and the rules for etiquette have not yet been firmly established (6). A self-help group that met via computer would certainly conduct itself differently than one that met face-to-face. First, it is likely that a computer-mediated group would attract a different group of participants. Only those who owned or worked at terminals and modems could participate, of course. Many individuals might participate who would not want to take part in face-to-face meetings. For example, a self-help smoking-cessation group that ran via computer conferencing need not require the participants to make a public commitment to quit
276
SCHNEIDER
AND
TOOLEY
smoking. The impersonal aspects of computerized communication might lead some people to fear failure less, because participants need never meet each other or risk being personally identified as a participant who failed. Moreover, people who lived in remote or rural areas, or whose schedules precluded participation in self-help groups, might prefer one that is available at any time, from any terminal. The goals of a self-help group are to provide mutual advice, and sharing of experience and perceptions about a single topic. Some, like Alcoholics Anonymous, begin with their own philosophies, but more often, self-help groups are leaderless and the direction of the groups is determined by the participants. Self-help groups often provide peer support, as in self-help groups for handicapped people or for people who live with Alzheimer victims. They can also provide peer pressure to conform to certain behaviors, as in weight loss or alcoholic groups. Self-help groups have helped people adopt more healthful lifestyles (13) by increasing the motivation to stop smoking, lose weight, and the like, and by providing the structure to accomplish these goals. The groups offer role models, the opportunity to discuss problems, and concerned others who can monitor behavior and prevent setbacks. Several reviews (22, 17) have concluded that successful self-help groups share several characteristics. First, the contact among members occurs frequently. Secondly, the group adheres to structure and rules. For example, group members might always report their cigarette intake or eating behavior since the last meeting. Third, self-help groups should encourage active participation. Passive lecture-oriented groups may be of less value. A self-help group that used a computer-conferencing format would not have to sacrifice any of these qualities. If computer conferences do minimize differences in status among the participants, and bring about goal-directed, uninhibited discussions, these features might enhance the active participation, role modeling, and adherence to group rules which are the qualities of successful self-help groups. However, computer conferencing might sacrifice the personal, immediate contact that face-to-face groups provide. Face-to-face contact is important in establishing attraction between individuals (I). Face-to-face contact does appear to permit positive feelings to develop among individuals faster than computer contact does. As a result, greater self-disclosure usually take place in face-to-face than in computer communications (7). A self-help group using computer conferencing might not develop mutual rapport and trust, and therefore mutual influence, as quickly as a face-to-face self-help group might. On the other hand, some studies have suggested that interpersonal contact is not a crucial factor in bringing about lifestyle changes (3). Self-monitoring, that is, the ability to detect urges to smoke, overeat, or deviate from the desired lifestyle, and the motivation to change to that desired lifestyle, might be more critical than the nature of any therapeutic interactions in predicting a person’s success in a health-promotion program (10). Stop-smoking programs offered
SELF-HELP
COMPUTER
CONFERENCING
277
over the television or in book form allow for no interpersonal contact. Even so, the programs are relatively successful (2). Work by Janis (5) suggests that participants in lifestyle change programs are most successful when they feel that they are viewed positively by those helping them, so that participation in the program enhances their self-esteem. Computer conferencing lacks the immediate face-to-face feedback that can create a climate of warmth and concern. However, this lack of direct contact might also make it easier for participants to discuss their problems and setbacks, because there is also less opportunity for immediate negative feedback. Also, since computer conferences are available at all hours, participants can share their views at those particular times that they are most ready to do so. Anonymous participation, which is impossible in face-to-face groups, could help eliminate the excuses and embarrassment that some people associate with lifestylechange groups. In this way, people who fear that participation in a self-help group might diminish their self-esteem might be drawn into groups run via computer conferencing. There has been little research on whether the qualities of computer conferencing have a generally positive or negative effect on selfhelp groups. To explore that issue, we established a smoking-cessation selfhelp group on EIES, a computer-conferencing network. A COMPUTERIZED
SELF-HELPPROGRAM
EIES, the Electronic Information Exchange System, is a computer messaging, conferencing, and notebook system administered from the New Jersey Institute of Technology. The entire system is programmed in the language Interact. Users who wish to add special-purpose routines to EIES simply add their Interact code to the system. For this on-line smoking-cessation program Interact routines were developed which permitted 1. Access to a conference of smokers who were trying to quit their habit. A psychologist also participated as the conference coordinator. 2. Interactive, personalized stop-smoking instruction. A 4-week program, aimed at total abstinence, was provided. There were seven sets of stop-smoking instructions available weekly. The program offered behavior modification treatment, tailored to each particular participant on the basis of his or her responses to questions that were posed by the system, and progress thus far. 3. Record keeping. The participants recorded on the system a “diary” of daily smoking behavior. 4. Help with immediate urges. Participants could choose to read messages designed to eliminate an immediate urge to light up. 5. Group progress report. The participants could see how well they were doing as a group. Sixteen smokers took part in the pilot run of the program. The content of the conferencing part of the system reveals how a computer-mediated self-help group might proceed.
278
SCHNEIDER
AND
TOOLEY
THE TRIAL
CONFERENCE
The subjects entered a total of 55 comments over the 3-month life of the conference. In the first comment, the psychologist explained and set the tone of the conference: “ . . . all participants in this conference are people who are trying to quit smoking, or who have already gone through the program. I hope that the conference becomes the place where people share . . . their opinions about the steps that they have taken to quit smoking . . . and the pitfalls that they have encountered. I hope that when people reach a point where they are struggling with their smoking . . . they can turn to the others in the conference . . .” The next day, one participant joined in under the pseudonym “Sir Walter Raleigh” : “This is my nth attempt to stop smoking. . . . For a long time 1 haven’t smoked at the office. Officially. If I go out to lunch and am sure I won’t be seen by anyone from the office, I may light up. It would kill me if my secretary found out; she would be very disappointed in me. . . . I . . . believe I can really quit this time.” This initial bit of self-disclosure was not matched by any other participant. Only two participated in the conference for the first 2 weeks. They conversed at an intellectual level about the physiology of smoking cessation. Then, one user wrote under her real name: “I’m here and reading, but not participating. And wondering why: it’s surely not ‘lurking’ or casual observation; putting a good amount of energy and anguish into trying to stop smoking for good this time, this conference is indeed very important to me. Guess part of it is the reluctance to bare my sour, even though I know I can use a pen name or anonymity if I want to. . . . The instructions tell us to reward ourselves for not smoking. What kinds of rewards are you people using, I’m having trouble thinking of any other than food and I Will Not Gain Weight!” The comment was the first of several emotive ones: “Irritable? Grrr! Argh! What do you mean irritable you son of a bitch?” “I’m not yet irritable . . . maybe it’ll get worse . . .” “Not only am I irritable, but my concentration and memory are affected. . _ . What do I do, take vitamin E?” “Here is what I did for the tremendous urge to eat. 1 bought all this fresh vegetable and fruit stuff. . . and ate. _ . . I still wanted to stuff things in my mouth but there was no more room in my stomach . . .” “I find that exercise is somewhat effective both as a reward . . . and also compensates for eating (sometimes). . . . I wish I could go to the equivalent of a ‘drying out’ facility, preferably a posh one, for the next few weeks . . .” “The biggest challenge will be right after my quit date . . . I think my chances of holding out will be increased if I advance my quit date . _ . what do you think?” “ . . . I feel as if I sort of have two people within me. My dark side says,
SELF-HELP
COMPUTER
CONFERENCING
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‘Forget it! You love smoking and can’t live without it!‘. . . . Do I still qualify for this program?” ‘Can’t seem to get to sleep without a cigarette. There I lay, even though I was tired, and smelled my husband’s G-- d--- pipe.” “Until recently, I thought that I smoked only 20 cigarettes a day. Now that I am counting, I have noticed that I smoke double or even triple that amount. . . . As my failure in my two previous attempts to quit illustrate, my ability to avoid any of my many vices drops after a drink or two . . .” “ . . . I am dragging out old yoga books . . .” “ . . . I am taking Nicorette gum and no cigarettes on my trip . . .” “I haven’t bitten off any heads in the last few days. I do chew a lot of gum . . .” “It seems that for every situation I master I find myself in another one where I smoke . . . ” “ . . . I quit. . . . I look forward to being able to tell the diary that I’m at ZERO again. . . . I have painted myself into a corner now so that it would be too humiliating to report I was off the wagon . . .” The conference comments contained very little “small talk” or conversation away from the topic of smoking, once the conversation began. At many points, the conversation did become uninhibited, with participants cursing about their husband’s pipe, or the inability of the smoking-cessation instructions to eliminate the urge to smoke. Many participants did disclose personal information, some using pen names. There was no instance of participants attacking another participant; there were a number of very supportive comments. In sum, the conference had the characteristics of a good self-help group: active participation, a clear set of goals and rules, and frequent contact. The lack of direct face-to-face contact may have helped keep the comments relevant to the task of quitting smoking, and responsive to each other as Hiltz and Turoff (4) might have predicted. RESULTS
The outcome
of the trial was as follows:
5 quit smoking for at least 3 months. 2 quit smoking, but resumed smoking within 3 months. 9 dropped out or did not quit smoking. This success rate appears superior to those of many televised stop-smoking programs (2), and is similar to that of many face-to-face programs (9). The success rate appears superior to that of computerized stop-smoking programs that lacked computer conferencing (14, 15). However, the smokers who succeeded in this pilot trial were relatively light smokers (14.6 cigarettes per day, compared with 31.7 for the non-quitters). Those who quit had been smoking for 24.6 years (22.6 for the non-quitters). The successful subjects had relatively low scores on on-line tests which measure the strength or the urge to smoke.
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AND TOOLEY
The actual power of the computerized smoking-cessation program can be evaluated only with a much larger sample. That work is under way, and should reveal whether the program can be helpful even to heavy smokers. CONCLUSIONS
Some 90% of smokers wish that they did not smoke (11). Yet, only 30% have any interest in face-to-face smoking-cessation sessions and only one-tenth of that number actually attend (16). Weight-loss, tension-reduction, and other health-promotion programs are also underused by those who could benefit. Computer conferencing may provide a way to bring selfihelp interventions to the substantial number of individuals who seek to change their lifestyles, feel unable to do so alone, and yet do not wish to go to face-to-face meetings. Computer conferencing does sacrifice the immediate, interpersonal contact of face-to-face meetings. Most computer users would not associate computers with self-disclosure. However, computer conferencing also has characteristics which could encourage the kinds of interactions that are appropriate for selfhelp groups. Computer conferencing can supplement, though not replace, existing health promotion campaigns, reaching large numbers in their homes and workplaces. ACKNOWLEDGMENTS The authors thank Anthony DeVito, Murray Turoff, Starr Roxanne Hiltz, and Hugh Lafave. This work was supported by Small Business Innovation Research Grant lR43 HL33053-01 from the National Heart, Lung, and Blood Institute, and Contract SBIR 85-24 from the New York State Science and Technology Foundation. This paper is dedicated to the memory of Jay Tooley, Ed.D. (1936-1985). REFERENCES 2. BERSCHEID, E., AND WALSTER, E. H. “Interpersonal Attraction.” Addison-Wesley, Reading. Mass., 1969. 2. BEST, J. A. Mass media, self management, and smoking modification. In “Behavioral Medicine: Changing Health Lifestyles” (P. 0. Davidson and S. M. Davidson, Eds.), pp. 371-390. Brunner-Mazel, New York, 1980. 3. GLASGOW, R. E. Effects of a self-control manual, rapid smoking, and amount of therapist contact on smoking reduction. J. Consult. Clin. Psychol. 44, 1439 (1978). 4. HILTZ, S. R., AND TUROFF, M. “The Network Nation: Human Communication via Computer.” Addison-Wesley, Reading, Mass., 1978. 5. JANIS, I. The role of social support in adherence to stressful decisions. Amer. Psycho/. 38, 143 (1983). 6. KERR, E. B., AND HILTZ, S. R. “Computer-Mediated Communication Systems.” Academic Press, New York, 1982. 7. KIESLER, S., SIEGEL, J., AND MCGUIRE, T. W. Social psychological aspects of computermediated communication. Amer. Psycho/. 39, 1123 (1984). 8. KIESLER, S., ZUBROW, D., MOSES, A. M., AND GELLER, V. Affect in computer-mediated communication: An experiment in synchronous terminal to terminal discussion. Hum. Comput. Interact. 1, 77 (1985).
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9. LICHTENSTEIN, E., AND DANAHER, B. G. Modification of smoking behavior: A critical analysis of theory, research and practice. In “Progress in Behavior Modification” (M. Hersen, R. M. Eisler, and P. M. Miller, Eds.), Vol. 3, pp. 70-132. Academic Press, New York, 1976. IO. MCFALL, R. M., AND HAMMEN, C. L. Motivation, structure, and self-monitoring: Role of nonspecific factors in smoking reduction. J. Consult. Clin. Psychol. 37, 80 (1971). II. National Clearinghouse on Smoking and Health. “Adult Use of Tobacco.” U.S. Government Printing Office, Washington, D.C., 1975. 12. PERRI, M. G. Unpublished manuscript. University of Indiana, 1984. 13. PERRI, M. G., MCADOO, W. G., SPEVAK, P. A., AND NEWLAN, D. B. Effect of a multicomponent maintenance program on long-term weight loss. J. Consult. Clin. Psychol. 52,480 (1984). 14. SCHNEIDER, S. J. Who quits smoking in a behavioral treatment program? Addict. Behau. 9,373 (1984). 15. SCHNEIDER, S. J., BENYA, A., AND SINGER, H. Computerized direct mail to treat smokers who avoid treatment. Compuf. Biomed. Res. 17, 409 (1984). 16. SCHWARTZ, J. S., AND DUBITZKY, M. Requisites for success in smoking withdrawal. In “Smoking, Health. and Behavior” (E. F. Borgatta and R. R. Evans, Eds.), pp. 231-242. Aldine, Chicago, 1968. 17. STUART, R. B. Self-help group approach to self-management. In “Behavioral Self-Management” (R. B. Stuart, Ed.). Brunner-Mazel, New York, 1979.
AND
BIOMEDICAL
RESEARCH
19,
274-281 (1986)
Self-Help Computer
Conferencing
SID J. SCHNEIDER' ANDJAYTOOLEY Behavioral Health Systems. Inc.. 44 Belleview Averme. Ossining, NeHI York 10562 Received December 9, 1985
Computer conferencing has become popular as an alternative to face-to-face conferencing in many kinds of organizations. Since users can participate at any time, from any terminal, computer conferencing makes communication very convenient, though many find the medium to be impersonal. This paper discusses the potential of computer conferencing to increase the number of people who participate in self-help groups, such as groups to help people lose weight or stop smoking. The kinds of interactions that make for successful selfhelp groups might be encouraged by a computer-conferencing format, even though there is no direct, face-to-face contact. The results of a trial smoking-cessation program which employed computer conferencing suggest that computer conferencing could play a useful rote in health promotion. o 1986 Academic press. IK
Computer conferencing allows any number of individuals to take part in a discussion, even though they may be far apart from each other and unable to all be present at the same moment. Participants in a computer conference call a central computer and read and enter conference comments at any time, from any terminal. The technique has become increasingly popular in business and professional organizations. Unlike business meetings or telephone conferences, computer conferences can accommodate lengthy discussions without the need for time and travel, or even for all the participants to be present simultaneously. Computer conferencing has not been widely used for health promotion groups. However, there may be a useful application among the peopie who form groups to help themselves give up smoking, lose weight, grapple with an alcohol or cocaine problem, and so on. Self-help groups which used computer conferencing would be available to the participants at all times, and remain as near as a terminal and modem. Participants who wished to remain anonymous could enter their conference comments under a pseudonym. The present paper is to discuss the potential uses and problems of computerized conferencing in
I To whom requests for reprints should be addressed. 274 0010~4809/86 $3.00 Copyright AU rights
0 1986 by Academic Press, Inc. of reproduction in any form reserved.
SELF-HELP
COMPUTER
275
CONFERENCING
self-help groups and to report on a recent trial of a stop-smoking computer-conferencing network. COMPUTER
CONFERENCING
AND SELF-HELP
group on a
GROUPS
One of the basic findings of communications research has been that the nature of the medium used for a message affects the content of the message itself. As electronic mail and computer bulletin boards and conferences have proliferated, it has become clear that they have a special impact on the way their users communicate. Messages which were usually exchanged orally must be typed out in acomputer-mediated conversation. All visual cues and nonverbal feedback such as smiles, nods, and shifting tones of voice are absent. There is no way to detect hesitations or the speed with which a message is presented. In a computer conference, there is no one at the head of a table, no one speaking more loudly or assuredly than the rest, no one whose dress conveys status or power. There is no impressive letterhead stationery, no conspicuous secretaries and staffs. All aspects of communication are stripped away from the messages, except for the words themselves. Hiltz and Turoff (4) felt that the removal of the social cues from communication could actually enhance the communication. They pointed out that in a computer conference, participants can read comments over, while in face-toface communication, participants receive only the information that they hear the first time. Also, participants are more likely to stick to the topic and not be distracted by social cues when written comments are exchanged. Hiltz and Turoff (4) concluded that computer-mediated discussions could reach their goals and come to consensus at least as quickly as face-to-face discussions. At the same time, electronic communication can be impersonal specifically because there is no way to immediately acknowledge a message or provide even minimal immediate feedback (7). Without rapid feedback and nonverbal cues, messages can become strong and uninhibited. “Flaming,” or impassioned communications, might occur more frequently in computer-mediated communication than in face-to-face communication because of the lack of cues that speakers use to regulate their exchanges. Speakers cannot know rapidly whether their messages were correctly comprehended, and the norms that usually control a conversation can occasionally break down. Computer-mediated communication is relatively new and the rules for etiquette have not yet been firmly established (6). A self-help group that met via computer would certainly conduct itself differently than one that met face-to-face. First, it is likely that a computer-mediated group would attract a different group of participants. Only those who owned or worked at terminals and modems could participate, of course. Many individuals might participate who would not want to take part in face-to-face meetings. For example, a self-help smoking-cessation group that ran via computer conferencing need not require the participants to make a public commitment to quit
276
SCHNEIDER
AND
TOOLEY
smoking. The impersonal aspects of computerized communication might lead some people to fear failure less, because participants need never meet each other or risk being personally identified as a participant who failed. Moreover, people who lived in remote or rural areas, or whose schedules precluded participation in self-help groups, might prefer one that is available at any time, from any terminal. The goals of a self-help group are to provide mutual advice, and sharing of experience and perceptions about a single topic. Some, like Alcoholics Anonymous, begin with their own philosophies, but more often, self-help groups are leaderless and the direction of the groups is determined by the participants. Self-help groups often provide peer support, as in self-help groups for handicapped people or for people who live with Alzheimer victims. They can also provide peer pressure to conform to certain behaviors, as in weight loss or alcoholic groups. Self-help groups have helped people adopt more healthful lifestyles (13) by increasing the motivation to stop smoking, lose weight, and the like, and by providing the structure to accomplish these goals. The groups offer role models, the opportunity to discuss problems, and concerned others who can monitor behavior and prevent setbacks. Several reviews (22, 17) have concluded that successful self-help groups share several characteristics. First, the contact among members occurs frequently. Secondly, the group adheres to structure and rules. For example, group members might always report their cigarette intake or eating behavior since the last meeting. Third, self-help groups should encourage active participation. Passive lecture-oriented groups may be of less value. A self-help group that used a computer-conferencing format would not have to sacrifice any of these qualities. If computer conferences do minimize differences in status among the participants, and bring about goal-directed, uninhibited discussions, these features might enhance the active participation, role modeling, and adherence to group rules which are the qualities of successful self-help groups. However, computer conferencing might sacrifice the personal, immediate contact that face-to-face groups provide. Face-to-face contact is important in establishing attraction between individuals (I). Face-to-face contact does appear to permit positive feelings to develop among individuals faster than computer contact does. As a result, greater self-disclosure usually take place in face-to-face than in computer communications (7). A self-help group using computer conferencing might not develop mutual rapport and trust, and therefore mutual influence, as quickly as a face-to-face self-help group might. On the other hand, some studies have suggested that interpersonal contact is not a crucial factor in bringing about lifestyle changes (3). Self-monitoring, that is, the ability to detect urges to smoke, overeat, or deviate from the desired lifestyle, and the motivation to change to that desired lifestyle, might be more critical than the nature of any therapeutic interactions in predicting a person’s success in a health-promotion program (10). Stop-smoking programs offered
SELF-HELP
COMPUTER
CONFERENCING
277
over the television or in book form allow for no interpersonal contact. Even so, the programs are relatively successful (2). Work by Janis (5) suggests that participants in lifestyle change programs are most successful when they feel that they are viewed positively by those helping them, so that participation in the program enhances their self-esteem. Computer conferencing lacks the immediate face-to-face feedback that can create a climate of warmth and concern. However, this lack of direct contact might also make it easier for participants to discuss their problems and setbacks, because there is also less opportunity for immediate negative feedback. Also, since computer conferences are available at all hours, participants can share their views at those particular times that they are most ready to do so. Anonymous participation, which is impossible in face-to-face groups, could help eliminate the excuses and embarrassment that some people associate with lifestylechange groups. In this way, people who fear that participation in a self-help group might diminish their self-esteem might be drawn into groups run via computer conferencing. There has been little research on whether the qualities of computer conferencing have a generally positive or negative effect on selfhelp groups. To explore that issue, we established a smoking-cessation selfhelp group on EIES, a computer-conferencing network. A COMPUTERIZED
SELF-HELPPROGRAM
EIES, the Electronic Information Exchange System, is a computer messaging, conferencing, and notebook system administered from the New Jersey Institute of Technology. The entire system is programmed in the language Interact. Users who wish to add special-purpose routines to EIES simply add their Interact code to the system. For this on-line smoking-cessation program Interact routines were developed which permitted 1. Access to a conference of smokers who were trying to quit their habit. A psychologist also participated as the conference coordinator. 2. Interactive, personalized stop-smoking instruction. A 4-week program, aimed at total abstinence, was provided. There were seven sets of stop-smoking instructions available weekly. The program offered behavior modification treatment, tailored to each particular participant on the basis of his or her responses to questions that were posed by the system, and progress thus far. 3. Record keeping. The participants recorded on the system a “diary” of daily smoking behavior. 4. Help with immediate urges. Participants could choose to read messages designed to eliminate an immediate urge to light up. 5. Group progress report. The participants could see how well they were doing as a group. Sixteen smokers took part in the pilot run of the program. The content of the conferencing part of the system reveals how a computer-mediated self-help group might proceed.
278
SCHNEIDER
AND
TOOLEY
THE TRIAL
CONFERENCE
The subjects entered a total of 55 comments over the 3-month life of the conference. In the first comment, the psychologist explained and set the tone of the conference: “ . . . all participants in this conference are people who are trying to quit smoking, or who have already gone through the program. I hope that the conference becomes the place where people share . . . their opinions about the steps that they have taken to quit smoking . . . and the pitfalls that they have encountered. I hope that when people reach a point where they are struggling with their smoking . . . they can turn to the others in the conference . . .” The next day, one participant joined in under the pseudonym “Sir Walter Raleigh” : “This is my nth attempt to stop smoking. . . . For a long time 1 haven’t smoked at the office. Officially. If I go out to lunch and am sure I won’t be seen by anyone from the office, I may light up. It would kill me if my secretary found out; she would be very disappointed in me. . . . I . . . believe I can really quit this time.” This initial bit of self-disclosure was not matched by any other participant. Only two participated in the conference for the first 2 weeks. They conversed at an intellectual level about the physiology of smoking cessation. Then, one user wrote under her real name: “I’m here and reading, but not participating. And wondering why: it’s surely not ‘lurking’ or casual observation; putting a good amount of energy and anguish into trying to stop smoking for good this time, this conference is indeed very important to me. Guess part of it is the reluctance to bare my sour, even though I know I can use a pen name or anonymity if I want to. . . . The instructions tell us to reward ourselves for not smoking. What kinds of rewards are you people using, I’m having trouble thinking of any other than food and I Will Not Gain Weight!” The comment was the first of several emotive ones: “Irritable? Grrr! Argh! What do you mean irritable you son of a bitch?” “I’m not yet irritable . . . maybe it’ll get worse . . .” “Not only am I irritable, but my concentration and memory are affected. . _ . What do I do, take vitamin E?” “Here is what I did for the tremendous urge to eat. 1 bought all this fresh vegetable and fruit stuff. . . and ate. _ . . I still wanted to stuff things in my mouth but there was no more room in my stomach . . .” “I find that exercise is somewhat effective both as a reward . . . and also compensates for eating (sometimes). . . . I wish I could go to the equivalent of a ‘drying out’ facility, preferably a posh one, for the next few weeks . . .” “The biggest challenge will be right after my quit date . . . I think my chances of holding out will be increased if I advance my quit date . _ . what do you think?” “ . . . I feel as if I sort of have two people within me. My dark side says,
SELF-HELP
COMPUTER
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‘Forget it! You love smoking and can’t live without it!‘. . . . Do I still qualify for this program?” ‘Can’t seem to get to sleep without a cigarette. There I lay, even though I was tired, and smelled my husband’s G-- d--- pipe.” “Until recently, I thought that I smoked only 20 cigarettes a day. Now that I am counting, I have noticed that I smoke double or even triple that amount. . . . As my failure in my two previous attempts to quit illustrate, my ability to avoid any of my many vices drops after a drink or two . . .” “ . . . I am dragging out old yoga books . . .” “ . . . I am taking Nicorette gum and no cigarettes on my trip . . .” “I haven’t bitten off any heads in the last few days. I do chew a lot of gum . . .” “It seems that for every situation I master I find myself in another one where I smoke . . . ” “ . . . I quit. . . . I look forward to being able to tell the diary that I’m at ZERO again. . . . I have painted myself into a corner now so that it would be too humiliating to report I was off the wagon . . .” The conference comments contained very little “small talk” or conversation away from the topic of smoking, once the conversation began. At many points, the conversation did become uninhibited, with participants cursing about their husband’s pipe, or the inability of the smoking-cessation instructions to eliminate the urge to smoke. Many participants did disclose personal information, some using pen names. There was no instance of participants attacking another participant; there were a number of very supportive comments. In sum, the conference had the characteristics of a good self-help group: active participation, a clear set of goals and rules, and frequent contact. The lack of direct face-to-face contact may have helped keep the comments relevant to the task of quitting smoking, and responsive to each other as Hiltz and Turoff (4) might have predicted. RESULTS
The outcome
of the trial was as follows:
5 quit smoking for at least 3 months. 2 quit smoking, but resumed smoking within 3 months. 9 dropped out or did not quit smoking. This success rate appears superior to those of many televised stop-smoking programs (2), and is similar to that of many face-to-face programs (9). The success rate appears superior to that of computerized stop-smoking programs that lacked computer conferencing (14, 15). However, the smokers who succeeded in this pilot trial were relatively light smokers (14.6 cigarettes per day, compared with 31.7 for the non-quitters). Those who quit had been smoking for 24.6 years (22.6 for the non-quitters). The successful subjects had relatively low scores on on-line tests which measure the strength or the urge to smoke.
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The actual power of the computerized smoking-cessation program can be evaluated only with a much larger sample. That work is under way, and should reveal whether the program can be helpful even to heavy smokers. CONCLUSIONS
Some 90% of smokers wish that they did not smoke (11). Yet, only 30% have any interest in face-to-face smoking-cessation sessions and only one-tenth of that number actually attend (16). Weight-loss, tension-reduction, and other health-promotion programs are also underused by those who could benefit. Computer conferencing may provide a way to bring selfihelp interventions to the substantial number of individuals who seek to change their lifestyles, feel unable to do so alone, and yet do not wish to go to face-to-face meetings. Computer conferencing does sacrifice the immediate, interpersonal contact of face-to-face meetings. Most computer users would not associate computers with self-disclosure. However, computer conferencing also has characteristics which could encourage the kinds of interactions that are appropriate for selfhelp groups. Computer conferencing can supplement, though not replace, existing health promotion campaigns, reaching large numbers in their homes and workplaces. ACKNOWLEDGMENTS The authors thank Anthony DeVito, Murray Turoff, Starr Roxanne Hiltz, and Hugh Lafave. This work was supported by Small Business Innovation Research Grant lR43 HL33053-01 from the National Heart, Lung, and Blood Institute, and Contract SBIR 85-24 from the New York State Science and Technology Foundation. This paper is dedicated to the memory of Jay Tooley, Ed.D. (1936-1985). REFERENCES 2. BERSCHEID, E., AND WALSTER, E. H. “Interpersonal Attraction.” Addison-Wesley, Reading. Mass., 1969. 2. BEST, J. A. Mass media, self management, and smoking modification. In “Behavioral Medicine: Changing Health Lifestyles” (P. 0. Davidson and S. M. Davidson, Eds.), pp. 371-390. Brunner-Mazel, New York, 1980. 3. GLASGOW, R. E. Effects of a self-control manual, rapid smoking, and amount of therapist contact on smoking reduction. J. Consult. Clin. Psychol. 44, 1439 (1978). 4. HILTZ, S. R., AND TUROFF, M. “The Network Nation: Human Communication via Computer.” Addison-Wesley, Reading, Mass., 1978. 5. JANIS, I. The role of social support in adherence to stressful decisions. Amer. Psycho/. 38, 143 (1983). 6. KERR, E. B., AND HILTZ, S. R. “Computer-Mediated Communication Systems.” Academic Press, New York, 1982. 7. KIESLER, S., SIEGEL, J., AND MCGUIRE, T. W. Social psychological aspects of computermediated communication. Amer. Psycho/. 39, 1123 (1984). 8. KIESLER, S., ZUBROW, D., MOSES, A. M., AND GELLER, V. Affect in computer-mediated communication: An experiment in synchronous terminal to terminal discussion. Hum. Comput. Interact. 1, 77 (1985).
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9. LICHTENSTEIN, E., AND DANAHER, B. G. Modification of smoking behavior: A critical analysis of theory, research and practice. In “Progress in Behavior Modification” (M. Hersen, R. M. Eisler, and P. M. Miller, Eds.), Vol. 3, pp. 70-132. Academic Press, New York, 1976. IO. MCFALL, R. M., AND HAMMEN, C. L. Motivation, structure, and self-monitoring: Role of nonspecific factors in smoking reduction. J. Consult. Clin. Psychol. 37, 80 (1971). II. National Clearinghouse on Smoking and Health. “Adult Use of Tobacco.” U.S. Government Printing Office, Washington, D.C., 1975. 12. PERRI, M. G. Unpublished manuscript. University of Indiana, 1984. 13. PERRI, M. G., MCADOO, W. G., SPEVAK, P. A., AND NEWLAN, D. B. Effect of a multicomponent maintenance program on long-term weight loss. J. Consult. Clin. Psychol. 52,480 (1984). 14. SCHNEIDER, S. J. Who quits smoking in a behavioral treatment program? Addict. Behau. 9,373 (1984). 15. SCHNEIDER, S. J., BENYA, A., AND SINGER, H. Computerized direct mail to treat smokers who avoid treatment. Compuf. Biomed. Res. 17, 409 (1984). 16. SCHWARTZ, J. S., AND DUBITZKY, M. Requisites for success in smoking withdrawal. In “Smoking, Health. and Behavior” (E. F. Borgatta and R. R. Evans, Eds.), pp. 231-242. Aldine, Chicago, 1968. 17. STUART, R. B. Self-help group approach to self-management. In “Behavioral Self-Management” (R. B. Stuart, Ed.). Brunner-Mazel, New York, 1979.