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Hands-On Help: Computer-Aided Psychotherapy
Am J Psychiatry 2008;165:142-143. doi:10.1176/appi.ajp.2007.07101595
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by Isaac M. Marks, Kate Cavanagh, and Lina Gega. New York, Psychology Press, 2007, 296 pp., $43.95.

In our world of iPods and personal computers it makes sense to apply technology to help those with mental health problems that have various obstacles to accessing care. But sometimes our ideas flop in the real world. In the introduction to Hands-On Help: Computer-Aided Psychotherapy, Marks, Cavanagh, and Gega cite the example of the videophone: an interesting idea in theory, but when implemented, people found that they preferred keeping phones a one-dimensional device.

Computer-aided psychotherapy is at this same crucial point in its development: it sounds great, but we’re waiting to see how it fares in real life. Computer-aided psychotherapy encompasses any computerized system designed to aid “traditional” face-to-face therapy, such as interactive online programs, handheld computers that prompt patients to engage in therapeutic exercises, automated text messages, and psychoeducational video games. As a result of logistical, financial, systemic, cultural, and personal barriers, most people do not get the care they need. From a public health perspective, computer-aided psychotherapy has exceptionally worthy goals—to make therapy more accessible, cost-effective, and empowering. In their well written and easily digestible text, Marks and colleagues underscore that most computer-aided psychotherapy systems are intended to be used in conjunction with some degree of therapeutic human contact and professional oversight. For technophobes, so far, so good.

Yet computer-aided psychotherapy also has the potential to go the way of the videophone. Despite great promise, there is limited institutional support for practitioners to develop or improve existing systems, and research on computer-aided psychotherapy is not always convincing. Poor study design or high attrition rates muddy the results, and even studies with encouraging findings are difficult to compare given the wide variety of systems, populations, and outcomes evaluated. Although computer-aided psychotherapy has appeal, it is unclear whether it will be embraced. Just as we are touched when we receive a handwritten letter in an age where e-mail is ubiquitous, most patients (and therapists) will undoubtedly resist computer-aided psychotherapy given the option. Such obstacles may make the transition into regular clinical use difficult for this otherwise good idea.

The book exhaustively reviews current computer-aided psychotherapy systems and provides an easy-to-use and comprehensive primer for those interested in catching up on the literature. The authors catalog 175 studies examining nearly 100 systems used worldwide for a variety of disorders, describing each study in detail and noting caveats of each system. Each chapter addresses a particular disorder or cluster of problems, including depression, phobias, substance use disorders, and eating disorders. For readers less interested in comparing nuances of multiple studies, the authors provide a concise summary at the start of each chapter.

Although the focus is extant systems, important and challenging issues facing computer-aided psychotherapy are also discussed. For example, adherence to computer-aided psychotherapy is better when augmented by phone conversations or face-to-face contact. Yet human support costs money and time. At what point do the costs outweigh the benefits? And how much human support is necessary? Do patients fare better with five minutes of phone contact daily, or with an hour of face-to-face contact once a month? The authors are careful to note that these and similar questions can only be answered with continued research, and are not much different from questions posed when any new therapy is introduced.

Despite the many questions posed by this emergent mode of therapy, the authors are cautiously optimistic about its ability to stand the test of time. Their optimism is partially supported by their findings, as their meticulous review of the data shows some net benefits for computer-aided psychotherapy. Time in therapy was drastically reduced in the majority of studies and users generally benefited from computer-aided psychotherapy, even if the benefits were immediate and not long-term. Interest in exploring computer-aided psychotherapy is also gaining momentum. Although it is frequently noted in the book that more research is warranted, a brief literature search shows that several new studies examining elements of computer-aided psychotherapy have been published in 2007 alone.

The authors’ cautiousness is warranted. It is up to the field to determine if computer-aided psychotherapy will integrate smoothly into the palette of therapeutic options, by either conducting research, contributing to the development of systems, testing in clinics and practices, or gathering information about its helpfulness from current and former users. Furthermore, just as the theoretically appealing videophone was rejected by users in favor of the traditional telephone, it is possible that patients too will reject computer-aided psychotherapy in favor of traditional therapy. Time will tell. In the meantime, computer-aided psychotherapy remains a promising option.

+Book review accepted for publication October 2007 (doi: 10.1176/appi.ajp.2007.07101595).




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