The psychiatrist as clinical computerologist in the treatment of adolescents: old barks in new bytes.

Psychiatry is in the midst of deciding how to join the computer revolution (1). We would like to contribute to this effort by suggesting that whatever psychiatrists decide to do with computers, we should remain mindful of what makes for good psychiatry. What has changed is technology; what should remain constant are the hard-won principles and guidelines of good psychiatry. We suggest—and illustrate with two case vignettes—that whatever previously unimagined psychiatric endeavors psychiatrists ultimately birth using computers, we will put them to some very old uses. Furthermore, we can be guided in our decisions about what to do with computers and how to do it by what we have learned from our past. We hope to i l lustrate that, to no one’s surprise, these new technologies help fashion further examples of classic psychotherapeutic phenomena and dilemmas—old psychiatric wines in new digital bottles but all very recognizable varietals. As Tom Standage discussed in The Victorian Internet (2), much of what we regard as unique and novel about the computer age would have been very familiar to Victorians first encountering the growth of telegraphy. Similarly, the growing literature on virtual communities (3–5) has provided new examples of such familiar human themes as aggression, love, rivalry, sex, friendship, loneliness, growth, and loss. While manifesting their own unique elements, activities such as hacking, programming, and web design are not essentially different from other human experiences involving exploration, analysis, and creativity. Over the years clinicians have incorporated many technological innovations into their practices—the telephone (6), the one-way mirror (7), videotape (8), and the pager (9, 10), for example. Each innovation has presented physicians with new challenges, and each has enhanced our ability to care for patients. Computers present us with but the latest in a long history of technological history in medicine. Physicians are already using computers to assess clinical problems (11), offer treatment advice or collegial consultation (The Virtual Home of Dr. Bob, http:// www. dr-bob.org), foster therapeutic communities (Starbright Foundation, http:// www.starbright.org), enhance or conduct psychotherapy (Calipso, http://www.calipso. co.uk/html/index.htm; Mindstreet, http://www.mindstreet. com), educate (Mayo School of Continuing Medical Education, http://www.mayo.edu/cme/cme.htm; Grand Rounds, Department of Psychiatry, University of Chicago Pritzker School of Medicine, http://psychiatry.uchicago. edu/grounds), and advocate for the mentally ill (National Alliance for the Mentally Ill, http://www.nami.org)—all new but familiar. Of course, our patients have also adopted these technologies and have thereby repackaged some familiar clinical phenomena. For example, when we hear of “cyber-addictions” (Center for Online Addiction, http:// www.netaddiction. com), “day-trading tragedies,” and “24-7” Silicon Valley workweeks, do we not recognize compulsions, gambling, and obsessive overwork? The following two cases are quite different; our intent is to illustrate the Internet both as a feature of the modern psychiatric landscape and as a tool for modern psychiatric intervention. We hope to launch discussions of the variety of issues likely to face clinicians venturing forth in this brave new World Wide Web.