computerised CBT: a quick cure on the NHS?

Such is the demand for treatment for depression on the NHS, that some primary care trusts are looking at computerised counselling programmes - such as Beating the Blues which has been in the news in recent weeks - to offer to patients. Clare Pointon investigates the use of such programmes and asks what will this mean for counsellors?

LOOK up ways of 'beating the blues' on Google and you'll find that after exercise, natural remedies, talking, hugs and houseplants, comes one of the newest ways of getting therapy
- an interactive computer programme designed for people suffering from depression and anxiety. Part of a range of
computer self-help products currently on the market, it's cognitive-behavioural in orientation and formulated to help a person change their outlook and mood without ever needing to meet or communicate with a live therapist.

'Beating the Blues', which went commercial four years ago, is currently being offered by some 40 NHS trusts around the country. It's mainly provided - alongside traditional counselling services - in primary care where practice managers have been buying the licence to use it in a package that works out at £100 per patient. It's hailed by Sir David Goldberg from the Institute of Psychiatry, who was involved in its development, as 'one of the most important advances in the treatment of anxious depression in the last 50 years'. So what does it offer - and for whom?

Opening up the package, myself, in its demo-tape form, a friendly-faced presenter takes me on a whistle-stop tour of depression - an introduction to symptoms via designer captions and a range of video clips of 'patients' played by actors, each offering a first-person take on the way in which the condition has impacted on their life. Moving further into the programme, week one starts with the presentation of a basic ABC cognitive-behavioural model presented via captions, one-line statements, video clips - all accessed smoothly by clear and simple instructions. The subsequent weeks set out the application of the model in practice - identifying negative automatic thoughts, evolving and practising challenges to these, unearthing core beliefs and getting to grips with behavioural work, including homework assignments. Basic CBT in a sexier interactive format, but which is undermined by the fact that the people featured in the fictional video clips are all white.

Who is this kind of therapy aimed at?
Professor Andre Tylee is a former GP who specialises in primary care mental health at the Institute of Psychiatry. He believes that computer programmes are likely to appeal to particular groups of patients - men, who might be more inclined to sign up for computerised therapy than to sit with a counsellor or psychotherapist, busy professional people who find it hard to get to counselling sessions during the day and young people who enjoy working at computers. The clinical categories of people who would benefit, however, are less clear:

'About a third of all people seen in primary care have some form of mental health problem,' he says. 'Of these there's a significant percentage with severe problems who would benefit from (face-to-face) cognitive-behavioural therapy. What we know less about is what benefits those suffering mild to moderate depression and anxiety. It appears from the research so far that with people in this category the work is more a question of simple problem-solving and support - probably using some CBT-based self-help material. So I would have thought that computerised CBT would help. The trouble is that at the moment, there isn't enough evidence.'

For the GP, Professor Tylee sees a range of potential advantages in the introduction of computer therapy programmes - quicker access to CBT work in a context where waiting lists are long and the availability of suitably trained practitioners limited, ongoing monitoring of a patient's progress from computer-generated progress reports - and, significantly in cases of mild depression, an alternative to medication. For the patient, he argues this system provides an extra layer of choice. It might be a more comfortable environment in which to disclose difficult feelings and for someone who would find it too challenging to show up for a live counselling session it could even prove to be a building block, supporting them to work on the social skills they felt they needed in order to take up this option at a later stage.

Professor Tylee is a collaborator on forthcoming papers on the effectiveness and cost-effectiveness of Beating the Blues. These are expected to play a key role in the current clinical debate on the use of computerised therapy programmes in general for which hard evidence of just how far they help whom, it seems, is currently lacking. Guidelines produced by the National Institute of Clinical Excellence (NICE) point to the need for more evidence of efficacy in random-controlled trials, as well as effectiveness out in the real world.

At Ultrasis, the company which sells Beating the Blues, senior psychologist Kate Cavanagh points out that this programme has had good feedback so far and is confident that it will prove itself in further research: 'Everything about the programme is based on good psychotherapeutic practice. It emulates as best it possibly can do what a well-trained and expertly-skilled therapist would do with a client.'

This, she stresses, includes careful contracting in the introductory section where the patient has the chance to think about whether s/he wants to commit to the eight sessions offered. It also includes clear statements about which parts of a client's responses are confidential and which go back to the doctor or mental health practitioner monitoring them. Among those passed on are the patient's responses to suicide risk assessment questions which form part of a weekly progress report printed off for both the user and the practitioner. Meanwhile all information stored on the computer's hard disk is encrypted so as to be incomprehensible to anyone hacking into the system.

So what about the therapeutic relationship?
The concept sounds good, particularly if, as several of the experts I spoke to pointed out, there really aren't enough CBT-trained practitioners in Britain to go round. But, as someone who uses a dialogic model, I can't help coming back to the most obvious question - what about the therapeutic relationship? CBT is clearly effective in short-term work, but, in administering it, why would we want to cut out the one factor that we do know from research is identified by clients as contributing to their healing?

For Kate Cavanagh, the question is partially addressed by the fact that in Beating the Blues, at least, the programme, whilst treating any specific problem as a generic problem, does have the capacity to respond with empathy. For example, every week it offers a patient the chance to say whether s/he has experienced any upsets or disappointments in recent days.

If s/he writes in 'yes', it will respond with, 'I'm sorry to hear that'. At this level, she argues it does embody aspects of 'a good therapeutic environment'. However, she acknowledges that to embrace the programme as a therapeutic agent does involve a new way of thinking:

'It's very early days for research, but it may be that what's required is a point of view shift regarding the use of the therapeutic alliance to thinking about the client as an agent of change who can choose to use a range of resources to help facilitate that change. They might choose to use another person - a therapist - to do that, but equally they might choose to use a self-help tool.''

This concept of choice is one that's welcomed by many specialists in the field. John Eatock, BACP's lead advisor in healthcare counselling and psychotherapy, believes such programmes can be useful as one of a range of options of psychological help available in the National Health Service - options ranging from self-help groups, to bibliotherapy, computer-based therapy and face-to-face solution-focussed work administered by a CBT practitioner or counsellor. But what does this expanding repertoire of options mean for the future of mainstream counselling? Is there a risk that NHS investment in computer programmes could siphon off funds used to employ face-to-face practitioners? John Eatock is sceptical:

'There's a whole well of need for people with psychological distress and I believe that counsellors are on the whole very much accepted within primary care,' he says. 'So they shouldn't feel too threatened by this; they need to be confident in their own professional identity and skills... in what they do. I am well aware that in the real world, we are not the panacea for everything. Patients need a variety of support to feel and be better.' But within the medical world of primary care, there may be different views about just what professional counsellors are there to do. Sue Bond, is acting co-ordinator for counsellors and psychotherapists in primary care in Powys, Mid-Wales. She argues that in this field some managers may find seductive the promise made by computer therapy programmes of a process that can be audited and accounted for. However, more insidious than this, she argues, is the risk that this way of working could fundamentally change the way we as practitioners see ourselves and our clients:

'I believe that therapy is not just about evaluation using these kinds of yardsticks,' she says. 'These things are important, but it's not just about that. If we take the person of the counsellor out of all of this - if all they are doing is evaluating information that has been keyed in by a patient, then we are confirming that they are transparent, not seen, not important. And if we have these kind of feelings about ourselves, we may project them onto the patient who then becomes transparent, so that in the end neither the therapist nor the client is seen.'

Users' views
Despite such misgivings, increasing numbers of GP practices across the country are clearly buying these products. So what are the views of the users?

'Very positive,' says one patient who opted for eight sessions of computer work over the anti-depressants her GP offered her when she found herself feeling overwhelmed with the demands of parenting a disabled child. 'It was absolutely right for me. It reminded me that I was doing all right really and helped me take small steps and rebuild my self-esteem. The effects have lasted and I'm still using what I learned.'

At Swindon Primary Care Trust, Geoff Degg, commissioning manager for mental health services, has bought Beating the Blues for each of the trust's 30 GP practices for a trial year starting in August. For him, the programme is a complementary service to face-to-face counselling. It's an extra screening tool for mild to moderate depression, one he sees as likely to be administered by a psychologist - and which he believes could have a wider impact on mental health services in the area:

'My big hope is that we can use it to help with problems at the beginning and so hopefully prevent people from getting more serious disorders which require secondary care services - anything from counselling and therapy to admission to hospital. We are seeing this as a preventative first-line measure. If the pressure is taken off secondary care, it will help the professionals there to manage people with more serious disorders better. Meanwhile, we will hopefully see more people treated for what might otherwise be undiagnosed depression and anxiety.'

Not everyone is suitable
But not everyone is quite as positive. Robert Ford introduced Beating the Blues at the counselling service he manages for the Welwyn Garden City and Hatfield Primary Care Trust more than two years ago. He bought a licence for 40 people to use it each year at an annual cost of £4,000.

However throughout those two years, just 50 people took up the option and this year he decided to drop his commission right down - to a licence for 10 patients.

'It seems to me there's a need to select quite carefully who will find the programme useful,' he says. 'Those who appear to have benefited are people who are well-motivated, who have some awareness of what their problem is and how to go about tackling it. With face-to-face work, the relationship seems to keep them going, but without that the person needs to have the commitment within themselves.'

His view on the cost? 'Overpriced. I often question how it really compares to hiring a therapist when you think that a therapist would also offer other services,' he says. And, while the company markets the programme as a 'stand-alone', surgeries in the WGC and Hatfield PCT have found that in practice, they need trained staff on hand both to help patients get on and off the system and to come to their aid when they get stuck. In many cases, he says, people find they have questions about CBT technique or homework. Robert Ford's sense in primary care is that what's needed is an interaction between face-to-face and self-help:

'I don't see computer programmes as a replacement for the counsellor. There's not enough through-put to get rid of a member of staff. This has always been an adjunct to therapy, but I believe it can be useful to warm people up before seeing a counsellor, so that if you've got six sessions, you know something about CBT before you start.'

In recent months, he has been broadening the range of products available in his service, including other computer-generated therapy programmes. Among these are 'Restoring the Balance', a psycho-educational system produced by the Mental Health Foundation which is 'less interactive', but cheaper, with a one-off cost for as many people as want to use it and 'Overcoming Depression', produced by Calypso, a programme he describes as 'not as pretty as Beating the Blues and more like a textbook', but which he views as helpful and more affordable.

What makes a good programme?
So what makes a good computer-generated therapy programme from the point of view of the maker? Steve Cottrell is a mental health nurse and clinical specialist for psychotherapy research and development in a North Wales NHS trust. He and a colleague are currently evolving a programme - 'Outreach Online' - which they hope will in time be available to a variety of people in a number of different ways:

'Our idea has been to develop a computerised self-help package that is very flexible and can support people either working alongside a mental health practitioner or on their own using the internet. It's also designed to be used on a touch screen for those who don't feel comfortable using a keyboard or a mouse. And people will be able to print off a paper manual from it, so that they can keep a record of their own material.'

Visually, he says, the programme will compare to Beating the Blues; it will be interactive, with cartoons, video clips and quizzes. Theoretically, however, its CBT component will be part of a 'holistic approach' integrating Transactional Analysis with the 'Mindfulness' work of Jon Kabbatt-Zin and bibliotherapy. In essence, he says, it's about learning to become aware, moment by moment, of thoughts and feelings before moving on to a more traditional CBT approach.

Funded to evolve the programme with an award from a subsidiary of the Royal College of GPs, Steve Cottrell's project is not a commercial one. If GPs want to use it, they will need to invest in the touch-screen computers and pay any distribution or installation costs, but he plans to give them the programme, itself, for nothing. His dream - that one day 'Outreach Online' will be available at the touch of a button to anyone who wants to use it on a computer in the privacy of their own home.

If such a dream were to come true, what safety net would there be for a vulnerable person going through a therapy programme alone on the web? Unlike Beating the Blues, this web-based programme does not yet have a built-in system of feedback, though there is an alert box which flashes up when someone shows signs of suicidal ideation, advising them to contact a real human being for help.

'It could happen that, even where you have a system of progress reports, clients may not report suicidal ideation to a machine,' says Steve Cottrell. 'But this programme doesn't yet report back directly to a practitioner and it is very important that the right people should be chosen to do it. It is not designed for people with a risk of suicide, so the system of referral for its use will be vital.'

The ethical edge of this new field is clearly one that calls for careful consideration. As Kate Anthony, CPJ's Associate Editor for Technology and also a psychotherapist and consultant on the use of technology in counselling and psychotherapy, argues, close monitoring by mental health professionals and bodies such as BACP will be key if such programmes are to be safe.

'It's all about working out who's suitable and making sure that
no-one slips though the net when they need face-to-face communication,' she says.

A Freudian in orientation, she practises both face-to-face and using email and text communication - both very different, she stresses, from computer-generated programmes which, in her view, would not be suitable for someone wanting psychodynamic work. But she believes that products such as Beating the Blues have a particular place in the spectrum of therapies offered - and one that is important.

'I think that computerised CBT is something that can reach a lot more people, people who wouldn't tend to be comfortable sitting with a therapist and in this way it makes therapy a lot less daunting for people. I see it as giving power back to the client and being able to offer them an alternative - not having to go through the anxiety of sitting opposite a total stranger.'

Kate is animated on the subject of future prospects in the field, particularly for work with phobias and obsessive compulsive disorders where she can already envisage ways of encorporating virtual reality into a programme that could, for example, take a client afraid of heights through a computerised experience of going up and down in a lift.

'It's all very exciting work,' she says. 'I would just say - let's not use technology because it's there. I think that sometimes people see technology as a dotcom opportunity - about money rather than reaching more clients. I think Beating the Blues is ethically produced - and as long as the research is done on these programmes and the people who use them are assessed and followed up, there's no reason to think that they can't be very successful.'

So, money-spinning fad or serious player in the multifaceted world of mental health? Only time will tell. What's clear is that people come for psychological help with very personal feelings about how they can or want to receive it. Perhaps listening to, respecting and accepting this is the first lesson for those of us who want to be relational.