Online CBT always seems to be based on the assumption that the website is the therapist, and this in turn is based on the assumption that CBT is just a collection of techniques that you can learn for yourself from the pages in a book or on a screen.
But CBT is much more than that, and computer systems are much more than that, too.
CBT is a form of psychotherapy, and like any psychotherapy it depends on having a close, trusting relationship with a therapist so that you can spend time together dealing with your most troublesome thoughts and emotions.
A computer can’t do that…
Famously, back in 1966 a computer was programmed to hold a conversation of sorts, based on the kind of conversations that a certain kind of psychotherapist might have. That original program, Eliza, has reappeared in many incarnations and has been the inspiration for many modern chatbots. If you have never tried chatting with a chatbot, I recommend the following.
Here’s a direct reincarnation of the original: Eliza
ELIZA: How do you do. Please tell me your problem.
CBTish: I am trying to write.
ELIZA: Do you enjoy being trying to write ?
CBTish: Yes, very much. Have you ever tried it?
ELIZA: I understand.
CBTish: I don’t think you really understand.
ELIZA: We were discussing you — not me.
CBTish: There is no need to be aggressive!
ELIZA: Why ‘no’ ?
CBTish: You are impossible!
ELIZA: What makes you think I am impossible ?
CBTish: It is just that you are a bot and I am human.
ELIZA: Is it because you are human that you came to me ?
And here’s a modern chatbot: Program-O
Bot: Hi there!
CBTish: Can you help me?
Bot: What kind of help would you like?
CBTish: I am trying to write.
Bot: What is the difficulty?
CBTish: I don’t think you would understand.
Bot: Do you know any robots who would understand? Yes I try to would understand as often as possible, do you? I chat with people on the Web.
CBTish: I chat with people too.
Bot: Everyone talks — sooner or later.
It will be a long time before programs like these can do CBT.
Even so, computers can do something else that is perhaps significant — they can provide a medium for communication between real people.
Several online treatments for mental health problems are already well-established. I plan to review some of the free ones here at some time, starting with:
The Living Life to the Full course aims to provide easy access to CBT skills – and does so in a way that cuts through jargon. By empowering users to understand why they feel as they do, and to learn new ways of improving how they feel the course aims to provide ready access to key information. The course is based on “Helping people to help themselves”. A crucial element is to inform, educate and teach key life skills.
We would like to think that by the time you finish MoodGYM you will have:
- An understanding of how emotions arise, and how they might be modified
- Learned how to modify your thinking so that you are less prone to get upset
- Picked up a few hints on managing stress
- Learned a few things about what influences self-esteem
- Developed a better understanding of relationships and how they might be handled
- Developed some practical ways to help you cope better with difficult events
e-couch provides information about emotional problems – what causes them, how to prevent them and how to treat them. It includes exercises to help you understand yourself and others better. Even better, it provides you with a set of strategies that might help you to improve your life…
Your e-couch program includes information, exercises and a workbook to track your progress and record your experiences, and toolkits to help you improve your mood and emotional state, and tackle challenges that you may be facing.
As far as I can tell, all of these are like books converted into websites. There are things to read, and worksheets to fill in, with perhaps audio and video to make the site more interesting. The computer only stores and presents information.
There is probably a little logic to enable the computer to present you with information that is likely to be appropriate, but not enough to for the system understand what it is really like to be you.
The missing link
The missing link between online CBT and real CBT is the T — the therapist. Only one of those online systems, Living Life to the Full, seems to be able to involve real therapists, but I’m not sure what the extent of that involvement is.
The NHS model of ‘low-intensity CBT’ is that someone provides you with support as you use the website, but support is not the same as therapy. The idea of support is to prevent people from dropping out, in the hope that more people reach the end of the online course. So the support provides explanation and encouragement to help you get over any difficulties you might have with the site.
I’m interested in turning that model around, so that you have online communication with a real human therapist, and the website provides support. The therapist understands what it’s like to be you, and the website delivers information and worksheets. This way, humans and computers both get to do what they’re good at.
The difficulties with this are like the difficulties I described in Telephony, but worse. In addition to the loss of a sense of place and togetherness in therapy, and the loss of body language and presence in forming a therapeutic alliance, there is the difficulty of writing.
I suspect that few people are able to write fluently and spontaneously about emotion in the way that they would need in order to communicate effecticvely with a real therapist online.
It’s the same for therapists. For this to work, both you and your therapist would need to be able to get past the barrier of writing. I suspect it’s asking too much.