Psychiatric Annals

Ethics of Computer-Assisted Psychotherapy

Kenneth Mark Colby, MD

Abstract

Computer anxieties come in various forms, for example, a dreaded Frankenstein monster will be unleashed; ora Big Brother government is watching; or computers will create unemployment. As computers are increasingly used in patient care, a number of ethical issues arise.1,2,5 In psychiatry, interfacing patients with computers has been deemed "dehumanizing." Dchumanization can mean a computer is taking the place of a human in a situation traditionally involving only people; or it can mean that the patientcomputer situation is so assembly-line and mechanical thai it deprives a patient of his individuality. The deprivation of such a valued human quality as individuality is harmful and thus unethical. It is argued that in psychiatry the use of computerassisted psychotherapy would be unethical, violating a fundamental ethical principle of primum non nocere.

Before one can evaluate whether or not a technological method is harmful, one must have a clear idea of what the method involves. In imagining computer-assisted psychotherapy, one might see a patient sitting alone in a room and interacting with a computer by means of a keyboard. Such a psychotherapeutic situation can be viewed as dehumanized in the sense that no human therapist, an ingrethent considered to be vital in all psychotherapies, is present physically. No such impersonal scenarios in computer-assisted psychotherapy exist. In contrast, the patient sits at a terminal in a room with nine other patients and their terminals, along with a human therapist trained in carrying out the procedures of this method. The patients have been diagnoslically screened and only those suitable for the method are selected. The patient interacts with a computer program (a therapeutic learning program), discusses his problems with the human therapist, listens to the other patients describe their problems, and then returns for further interactions with the program. The program represents a large treestructure of text, designed by experienced psychiatrists, from which the patient makes selections of information pertinent to his individual problem situation. He receives a hard copy of his interactions to study along with homework assignments. There are five such weekly sessions with each session lasting 2 hours. Thus, (he method provides an individuali/ed therapy in a group setting.

The presence and activities of the professional therapist provide the human elements of warmth, empathy, humor, and intuition considered desirable in the helping relationship of psychotherapy. The other patients add further human qualities of group support and examples of similar personal problems. It deserves emphasis here that a computer is simply an instrument, like a violin, designed for human purposes, By itself Jt does nothing; it is the program governing the instrument with which the patient interacts. The program is written by humans who are addressing important human concerns. In the method described, the program represents the best thinking of three psychiatrists with a total of 90 years of clinical experience. The patient well realizes by the nature of the interactions that the program was written by experts very familiar with the problem domain. He depends on the integrity of such experts who, while attempting to increase the scope and quality of patient care, arc also sensitive to the ethics of helping, and not harming, that apply tu any form of psychotherapy.3

It might be claimed that a computer program is dehumanizing because it treats everyone in the same standardized, assembly-line way. failing to recognize a person's individuality. This claim misunderstands the properties of complex computer programs having hundreds of choice points organized in a large tree-structure. Such a structure has so many combinational possibilities that it would be a highly improbable event for any two patients to move through such a tree-structure in…

Computer anxieties come in various forms, for example, a dreaded Frankenstein monster will be unleashed; ora Big Brother government is watching; or computers will create unemployment. As computers are increasingly used in patient care, a number of ethical issues arise.1,2,5 In psychiatry, interfacing patients with computers has been deemed "dehumanizing." Dchumanization can mean a computer is taking the place of a human in a situation traditionally involving only people; or it can mean that the patientcomputer situation is so assembly-line and mechanical thai it deprives a patient of his individuality. The deprivation of such a valued human quality as individuality is harmful and thus unethical. It is argued that in psychiatry the use of computerassisted psychotherapy would be unethical, violating a fundamental ethical principle of primum non nocere.

Before one can evaluate whether or not a technological method is harmful, one must have a clear idea of what the method involves. In imagining computer-assisted psychotherapy, one might see a patient sitting alone in a room and interacting with a computer by means of a keyboard. Such a psychotherapeutic situation can be viewed as dehumanized in the sense that no human therapist, an ingrethent considered to be vital in all psychotherapies, is present physically. No such impersonal scenarios in computer-assisted psychotherapy exist. In contrast, the patient sits at a terminal in a room with nine other patients and their terminals, along with a human therapist trained in carrying out the procedures of this method. The patients have been diagnoslically screened and only those suitable for the method are selected. The patient interacts with a computer program (a therapeutic learning program), discusses his problems with the human therapist, listens to the other patients describe their problems, and then returns for further interactions with the program. The program represents a large treestructure of text, designed by experienced psychiatrists, from which the patient makes selections of information pertinent to his individual problem situation. He receives a hard copy of his interactions to study along with homework assignments. There are five such weekly sessions with each session lasting 2 hours. Thus, (he method provides an individuali/ed therapy in a group setting.

The presence and activities of the professional therapist provide the human elements of warmth, empathy, humor, and intuition considered desirable in the helping relationship of psychotherapy. The other patients add further human qualities of group support and examples of similar personal problems. It deserves emphasis here that a computer is simply an instrument, like a violin, designed for human purposes, By itself Jt does nothing; it is the program governing the instrument with which the patient interacts. The program is written by humans who are addressing important human concerns. In the method described, the program represents the best thinking of three psychiatrists with a total of 90 years of clinical experience. The patient well realizes by the nature of the interactions that the program was written by experts very familiar with the problem domain. He depends on the integrity of such experts who, while attempting to increase the scope and quality of patient care, arc also sensitive to the ethics of helping, and not harming, that apply tu any form of psychotherapy.3

It might be claimed that a computer program is dehumanizing because it treats everyone in the same standardized, assembly-line way. failing to recognize a person's individuality. This claim misunderstands the properties of complex computer programs having hundreds of choice points organized in a large tree-structure. Such a structure has so many combinational possibilities that it would be a highly improbable event for any two patients to move through such a tree-structure in exactly the same way. The program provides for highly individualized interactions that are supplemented by unique interactions with the human therapist.

Methods for the delivery of medical care in this country are currently undergoing a great change, with the individual fce-for-servicc rapidly disappearing. As more people enroll in prepaid health plans, there will be a greater number of patients seeking psychotherapeutic help that they could not afford previously. Psychotherapy is a type of education in self-understanding.4 A computer-assisted method involving therapeutic learning is as much "educational" as it is "medical." Presented as a type of adult education in understanding one's self and one's problems of living, a computer-assisted method removes much of the stigma still associated in our culture with having emotional problems.

In the long run, it is what patients and therapists find acceptable and valuable that will determine the adoption of an innovative technology, regardless of what "humanists" may decry (often, ironically, on television). For patients, the method is non-stigmatic and economically feasible in a prepaid health plan. For therapists, the method provides a way of helping many more patients than with conventional methods. Resistance to innovative technology has always been part of the acceptance process. The resistance is simply swamped over time by the sheer weight of the accepting relevant constituencies - in this case patients and therapists. If computer-assisted psychotherapy proves to be more effective, or even as effective as current methods, it would be unethical not to use it because it makes therapy available to everyone and not just to the select few who currently can afford psychotherapy.

In conclusion, the method of computer-assisted psychotherapy described herein is not dehumanizing either in the sense of removing humans from the therapeutic situation or in the sense of depriving patients of their individuality. The use of the method is consistent with the ethics of helping professions that attempt to provide effective and up-to-date care extendable to everyone in our society.

REFERENCES

1. Blois MS: Clinical judpmcm and tompuicn. N Engl J Med 1980: 501:192-197.

2. Colby KM: Reloading a human memory: A new ethical question in arificial intelligence technology. Artificial Intelligence Magazine 1985: 6:63-65.

3. Colby |M: Computer psychotherapists, in Sidowski JB. Johnson JJ. Williams SA (eds): Technology m Menial Health Care Delivery Systems. New lersev, Ablex Publishing Corporation. 1480.

4 Colby KM: Psychological treatment of mental disorders, in Sills JL. (ed): International Encyclopedia of the Social Sciences. New York. Macmillan and the Free Press, 1408. pp 72-178. vol 10.

5. Miller RA. Schaffner KP. Meisel A: Ethical and legal issues related Io lhe use of computer programs in clinical medicine. Ann Intern Med 1985; 102:529-536.

10.3928/0048-5713-19860701-11

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