NHS Stress Self-Help Clinic, London
Maudsley Hospital, London
Imperial College, London
Correspondence: Mark Kenwright, NHS Stress Self-Help Clinic, 303 North End Road, London W114 9NS. E-mail: m.kenwright{at}hotmail.com
Declaration of interest One of the authors (I.M.) shares intellectual property rights in the computer-guided system.
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ABSTRACT |
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Aims To test the feasibility of computer-guided exposure therapy for phobia/panic.
Method Self-referrals were screened for 20 min and, if suitable, had six sessions of computer-guided self-help (from a system called FearFighter). Pre- and post-treatment ratings of 54 patients were compared with those of 31 similar out-patients with phobia/panic who received the same treatment guided by a clinician.
Results At pre-treatment, computer-guided cases were slightly less severe than clinician-guided patients. In a post-treatment intent-to-treat analysis, both groups improved comparably but computer-guided patients spent 86% less time with a clinician than did purely clinician-guided patients, who had no access to the computer system.
Conclusions Computer-guided self-exposure therapy appeared feasible and effective for self-referrals and saved much clinician time. A controlled study is now needed.
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INTRODUCTION |
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Phobia/panic patients who seek help often fail to access effective treatment: GPs refer them to the practice counsellor or a local anxiety management group for education and relaxation, which is ineffective and wastes resources because they often return to their GP after failed treatment. When a GP refers patients with agoraphobia to a cognitive-behavioural therapist some distance away, the nature of their problem stops them travelling for treatment. Effective computer self-help systems can take over the treatment process locally, with only brief support from a clinician (Marks, 1999). The present naturalistic study tests whether a computer system can save clinician time in treating phobias without impairing outcome in a meta-analytical comparison with results in routine clinician-guided out-patients.
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METHOD |
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Mode of operation
After seeing advertisements in GP surgeries, or through self-help groups
such as Triumph Over Phobia, phobia/panic patients self-referred by
telephoning for an appointment. The Centre was confidential (users got no
mental health record) and offered computer-guided care without a waiting list.
Two clinical nurse specialists ran the Centre; each worked just 1 day a week,
with access to a system manager in case of technical problems. A nurse
screened first-attenders for up to 20 min to ensure that problems were
suitable for computer-guided care and there was no serious mental illness,
severe depression, or drug or alcohol misuse requiring referral elsewhere.
The nurse introduced suitable patients to FearFighter and showed them how to use it. Patients completed self-ratings and learnt the treatment rationale (Steps 1 and 2) in about 50 min, after which they arranged the next appointment. In subsequent sessions they spent the first 10 min with the nurse, reviewing progress and exposure homework. For the next 40 min they worked at the computer. They then had a final 10 min with the nurse to discuss further homework, solve problems and set the next appointment. Brief screening time apart, FearFighter users thus spent two-thirds of their time at the computer and one-third with a nurse.
The amount of nurse time per session varied with patients' self-reliance, motivation and computer literacy. Some needed almost no help. Others needed help from the nurse to fine tune computer-prompted targets, work on them effectively, problem-solve difficulties that the computer could not address and use further interventions as needed (e.g. activity scheduling or interoceptive exposure, planning pleasurable activities or rewards to improve mood and educating partners or relatives).
Meta-analytical comparison with clinician-guided out-patient
care
Outcomes at the Self-Care Centre were compared with those of all
out-patients with phobias treated routinely by nurse therapists in an adjacent
behavioural psychotherapy unit over the same year for whom data were available
on the unit's computerised Clinical Outcome and Resource Monitoring (CORM)
system. The CORM system stores results of clinical measures for each patient
at every treatment stage. Patients and therapists enter ratings into the
computer, which can print progress graphs for either individual or aggregated
patients. Out-patient referrals came from GPs and psychiatrists and were
screened by nurse therapists after a mean wait of 3 months. If suitable at
screening (mean total time of 90 min), patients were given a treatment
rationale and attended weekly and then fortnightly sessions. Measures were
completed at pre- and post-treatment and then at 1- and 3-month
follow-ups.
Measures
The Self-Care Centre patients used FearFighter to rate progress on
the Fear Questionnaire (Marks &
Mathews, 1979), Work and Social Adjustment (WSA;
Marks, 1986), their main phobic
trigger and their main goal. The out-patients had ratings on the same measures
in the CORM system.
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RESULTS |
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Of the patient's mean total of 202 min spent in the Centre, 139 min (69%) were spent on computer guidance and 63 min (31%) with a nurse, including screening. The mean number of sessions in the Centre was four for all patients who began computer guidance. The proportion of the patients' total time at the Centre spent on the computer was greater for those with agoraphobia and specific phobias than for those with social phobias.
An intent-to-treat analysis regarded all non-completers as unchanged. On paired t-tests, mean self-rated improvement from pre- to post-treatment was highly significant on all measures (Table 1). The mean therapist-rated improvement was 44%.
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Meta-analytical comparison with clinician-guided out-patient
care
Outcome of the 54 self-help patients was compared with that of the 31
out-patients with phobia/panic (16 women, 15 men, mean age 40 years) who had
nurse-therapist-guided self-exposure therapy without computer guidance over
the same year and who had CORM ratings. They comprised 12 individuals with
agoraphobia, 11 with social phobia and 8 with specific phobias; the mean
problem duration was 29 years. The 31 out-patients spent a mean of 444 min
with the therapist over eight sessions. Complete CORM data were available for
19 of the out-patients. The remaining 12 (40%) had incomplete data because
they dropped out of treatment (a rate similar to the drop-out rate of
computer-guided patients); drop-outs from both groups were regarded as
unimproved in the intent-to-treat analysis.
At pre-treatment, computer-v. clinician-guided patients were comparably severe on six measures but significantly less severe (one-way analysis of variance) on five measures: Fear Questionnaire Agoraphobia and Global Phobia, Main Goal and WSA Social and Private Leisure.
At post-treatment the two groups were of similar severity, except that computer-guided patients remained significantly less severe on Main Goal and WSA Social and Private Leisure. Both groups improved comparably from pre- to post-treatment (see Fig. 1). Far the biggest difference was that computer-guided cases had spent a mean of only 63 min over four sessions with a clinician, including screening, which is 86% less time than the mean of 444 min over eight sessions, including screening, that out-patients had spent with a clinician.
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DISCUSSION |
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Study limitations
Our small open study has obvious limitations. Follow-up data could not be
obtained from many drop-outs in either condition. Outcome data could be
obtained only from completers of six sessions. Caution is needed in drawing
conclusions from comparisons of the computer- v. clinician-guided
groups because they formed distinct populations. The computer-guided
self-referrals were less severe on several measures than were the
professional-referred clinician-guided out-patients, and also may have
differed in other unknown ways. Most of the self-referrals came to the
Self-Care Centre via primary care settings (posters/leaflets in GP surgeries,
to which many were directed by primary care staff). A randomised controlled
comparison of computer-guided with clinician-guided care is now being
analysed.
Patients used the Centre as a flexible resource, as needed. Some said that they used computer guidance for two or three sessions to learn about self-treatment as required and then chose not to bother continuing further because that involved travel and repetitive ratings. There is a tension between the researchers' need for ratings to analyse and the inconvenience that this causes clients using a system that is meant to give them autonomy and control.
Optimal use of computer self-help
The computer system allowed people with phobia/panic disorders to get
effective self-help while using far less clinician time than usual. Clients
who completed computer-guided self-help had spent only one-third of their time
at the Centre with a nurse therapist, without this reducing effectiveness
appreciably. This was achieved because the computer took over routine tasks
(e.g. explaining the treatment rationale, helping patients to work out
triggers for panic, writing personalised problem and goal statements,
providing feedback on progress), while the nurse gave the brief human contact
that patients often want to complete self-help successfully. The new feature
of FearFighter is that, unlike other computer self-help programs for
phobia/panic, it takes over most of the actual treatment process rather than
just relaying treatment instructions. Patients returned to the system over six
sessions to report on progress, get personalised feedback, receive help in
setting further treatment goals when they had improved or to get help in
problem-solving difficulties with treatment.
Implications for primary care
Self-help systems for phobia/panic might be made available in primary care
settings such as GP surgeries, self-help centres (there are three now in west
London) and community mental or general health centres. Effective self-help
for phobic disorders thus could be made accessible at a fraction of the cost
of a referral for purely human therapy. Self-help systems are likely also to
become accessible from home on the internet via a normal TV screen as well as
computer, with back-up from local mental health services or by telephoning
staff at a computer-aided self-help centre.
Nurse therapists at the Self-Care Centre added brief advice to computer guidance as needed. Primary care staff with little behavioural training could partner computer self-help systems to deliver effective treatment efficiently. Computer self-help systems also could educate staff. Medical students' skills regarding the planning and execution of exposure therapy improved as much after using a teaching version of FearFighter as after a face-to-face tutorial in the subject (McDonough & Marks, 2001).
Practitioners in primary care and in community mental health settings can continue to offer the brief advice and human contact that some patients need to complete treatment successfully, while computers guide the routine aspects of structured self-help. Self-help systems enable staff to deploy their time more efficiently by treating more patients while still completing other tasks. Time to write this paper was freed by patients using FearFighter in the room next door to the nurse (M.K.).
Future planners might come to regard it as a misuse of scarce resources to pay skilled professionals to treat self-reliant, motivated patients with phobia/panic when such patients could improve with computer-guided self-help and little or no time from a professional. Computers do not replace professionals, but rather allow them to help more sufferers in the time available. It would be economically unrealistic to train enough cognitivebehavioural therapists to help all sufferers from anxiety disorders. Harnessing computer self-help systems offers a way of making treatment accessible to far more people than before.
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Clinical Implications and Limitations |
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LIMITATIONS
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Received for publication February 23, 2001. Revision received June 18, 2001. Accepted for publication June 22, 2001.