“The long-held belief that improvement in psychotherapy requires a relationship with a therapist may be true for some patients.”—Dr. Isaac Marks, British Journal of Psychiatry, 2007
England is crazy, and so am I.
Because she is older and larger, let’s start with England. In June 2006, a policy group at the London School of Economics led by Lord Richard Layard, a Labor peer, economist, and the author of Happiness: Lessons From a New Science, announced that mental illness was incapacitating the country. At the time, 1 million Brits were receiving disability benefits due to depression and anxiety, resulting in untold misery and an annual drain on the GDP of 17 billion pounds. The government already knew how to combat this scourge: A national agency had earlier determined that cognitive-behavior therapy, which teaches people to modify their dysfunctional thoughts, beliefs, and behaviors, was the most cost-efficient, long-lasting treatment for many common psychiatric disorders. The problem was that there were far too few therapists to go around. The nation was facing a craziness backlog.
Now me. Nine months ago, my wife gave birth to our first child, a spirited, wide-eyed girl whose arrival has brought unmitigated joy. Yet, as we almost immediately discovered, with parental joy comes innumerable costs, the first and highest of which is sleeplessness. For nearly four months, in an often futile attempt to soothe our fussy daughter, my wife and I spent several hours each night bouncing up and down on a giant blue exercise ball—the blinds drawn, the lights out, and all communication in whispers, as if we lived in a giant Skinner box. I speak only for myself when I say that, consequently, all natural tendencies toward mental disorder came rushing to the fore. I grew irritable, gloom-ridden, beset by a nagging, directionless worry. These symptoms were hardly unfamiliar—I’d been in therapy for them before, most successfully, in fact, with CBT—but a number of factors, among them inadequate mental-health benefits and the drying-up both of my freelance work and my free time, blocked any access I had to the talking cure. I needed help, but had no way to get it.
It is here that England’s needs and my own coincide. Only 10 weeks into parenthood and already depleted, I discovered that the British government had recently embarked on a novel experiment in health care delivery. In order to bridge the gap between psychotherapy demand and supply, it had directed the National Health Service to begin making available therapy conducted not by a psychiatrist, psychologist, or social worker but by a computer program. Computerized cognitive-behavior therapy, delivered either over the Web or by software, was one-quarter as expensive as face-to-face therapy, according to one estimate, and if widely used would save the government as much as 136 million pounds a year. In March of 2007, the Department of Health mandated that cCBT be disseminated to all 153 medical “trusts” in the NHS system. Anxious, increasingly desperate, and intrigued, I considered that there was no good reason why the British government’s mandate should not extend to a sensory-deprived, stressed-out citizen of its ally and former colony, and with eager anticipation, I turned to my laptop for help.
According to an editorial published recently in the British Journal of Psychiatry by Isaac Marks, a venerable fixture of the Institute of Psychiatry in London, there are currently 97 computerized psychotherapy programs in existence. These programs have been designed to treat a range of disorders and problems, including obsessions and compulsions (BT Steps),the development of eating disorders in youths (Student Bodies), sexual dysfunction (Sexpert, now defunct), and, improbably, encopresis, a disorder characterized by defecating in inappropriate places (UCanPoopToo). So far, the British government has endorsed only the two of these programs for which it has deemed there are good clinical data to support their effectiveness: the muscularly titled Beating the Blues, for mild-to-moderate depression, and FearFighter, for phobia, panic, and anxiety.
Given the nature of my complaint, I opted for the latter and got in touch with CCBT Ltd., the London-based company that licenses the system. The company’s management was strangely cagey; they were at first willing only to send me a brochure replete with vague statistics (“FearFighter™ has undergone extensive testing and trials, involving 700 patients. …”) and patient endorsements (“To date I’ve travelled on the underground train [200 feet below ground] without a twinge of anxiety—I still can’t believe it!”). Eventually, however, prodded by my claims of journalistic necessity, they granted me access, though with limitations. Most patients work through the program—a Web-based system you log on to with a username and password—in eight to 12 weeks. I was given only four, and I would not benefit, as local patients do, from “6 calls from a support worker, lasting in 5 to 10 minutes duration.” No, there was to be no tech support for the American sufferer! Still, something was better than nothing, and shortly after the company gave me my password, I logged on for the first time.
The first thing I noticed about the program—I suppose it’s the first thing I would have noticed about a human therapist as well—was not the treatment’s content but its style. FearFighter has the look and feel of one of the computer games my brothers and I used to play as children on our clunky, premodern Commodore 64: the flat interface; the sketchy, clip-art graphics, the if-this-then-that logic.
FearFighter is divided into nine steps, from “Welcome” to “Troubleshooting.” My first task was to fill out a series of questionnaires in order to establish a diagnosis and to provide a base-line reading of my emotional state, with which the results of later questionnaires could be compared and progress measured. (Questionnaires are standard in CBT, which prides itself on its empirical cast.) As I’ve already suggested, my problem is what Freud called “free-floating” anxiety—its particular torture is that it has no object. The program, however, was unable to detect this. It asked specific questions, I gave specific answers, and it drew specific, and incorrect, conclusions. When asked how much I avoid “injections or minor surgery,” I answered that I “definitely avoid it.” When asked how much I avoided “being watched or stared at,” I answered that I “markedly avoid it.” The result of these and other exchanges was that I was diagnosed with agoraphobia, blood/medical phobia, and depression. But not generalized anxiety disorder, the best clinical description of my state of mind.
Once, I had a therapist who fell dead asleep in session. These misdiagnoses corrupted my confidence more than that considerable indignity. On the other hand, the kink was understandable. FearFighter applies a subset of CBT known as exposure therapy; it identifies specific “triggers” of anxiety and encourages patients to face those triggers squarely. For Bill, the presumably fictional elevator phobic used as an example in Step 2 (“How to beat fear”), this is sensible; if Bill rides the elevator a bit at a time, he’ll probably recover. But how does one expose oneself to fears about the loss of one’s youth, to intimations of imminent catastrophe, to abject terror that one’s firstborn will suddenly stop breathing? Actually, there are ways, but they are linguistic and cognitive—in short, outside of the purview of a computer program, at least so far.
Yet, as I knew well, in recovery persistence itself can be salubrious, and I resolved to take from my computer treatment what I could. Over the next few weeks, I marched steadily through Step 3 (“Problem sorting”), in which I perused a list of potential triggers that ranged from “driving/traffic jams” to “vomiting” to “sex”; Step 4 (“How to get a helper”), which urged me to find a supportive partner who would not rush me, mock me, or encourage me to drink; and Step 5 ("Setting goals”), in which I was instructed to devise therapeutic actions that were neither too easy nor too hard, and in which I heard the poignant tale of my namesake, Daniel, who, when anxious for more than 90 minutes, evacuates his bladder. Step 6 ("Managing anxiety”), which suggested approaches for reducing anxiety in real time, was from my perspective measurably more useful. It offered some thin methods, such as reciting the ditty “I feel so embarrassed/ I’m dying of shame/ But it’s only a feeling/ And those I can tame!” But it also suggested methods I knew from experience to be rather helpful. For instance, “diaphragmatic breathing,” a system of respiration that reduces anxiety by restoring the balance of oxygen and carbon dioxide in the blood, and forcing oneself to imagine the worst possible thing that can occur until the fear grows small.
Following Step 6, I admit that my attention waned, though only for a lack of applicable treatment. Step 7 (“Rehearsing goals”) was intended to help me practice coping skills by projecting photographs of things many anxious people fear and avoid but which I don’t. (A picture of the exterior of a British council flat, which would send any housebound agoraphobic into a freefall, filled me with little but warmth: I adore London.) Step 8, aptly titled “Carrying on,” was essentially the end of the line. I was urged by the program to visit regularly—to inspect graphs tracking the (hopefully southward) route of my pathology; to add, delete, or revise the focus of my treatment as the need arose; to consult the extensive list of troubleshooting topics in Step 9; and, above all, to continue practicing and practicing until equilibrium was established.
I didn’t. It wasn’t just that the program was not well-suited to my particular brand of insanity, but that eventually the circumstances that had gotten me into my quavering state dissipated. Slowly, my daughter began sleeping better, the freelance sluices opened back up, and a decent rhythm asserted itself into my young family’s life. Before long the anxiety had, if not disappeared—it will probably never do that—tamped down to a level that seemed appropriate in light of the risks of existence. I felt better, and not long after I’d completed my treatment, I expunged the FearFighter Web site from my bookmarks menu and said a quiet prayer that England should feel as well as me.