Cybertherapy

 

Internet and Virtual Reality as Assessment and Rehabilitation Tools for Clinical Psychology and Neuroscience

NOW indexed by PsycLIT® and MedLine (as "Studies in Health Technology and Informatics", 99)

 

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(C) 2004, 2005, 2006, IOS PRESS,

Book Series: Studies in Health Technology and Informatics

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Edited by:

G. Riva
Istituto Auxologico Italiano, Milan, Italy

C. Botella
Universitat Jaume I,  Castellón, Spain

P. Légeron
Unité de Thérapie Comportementale et Cognitive, Hôpital Sainte-Anne, Paris, France

and

G. Optale
Association of Medical Psychotherapists, Venice, Italy

 

Also check the other FREE VR books:



Virtual Reality  in Clinical Psychology and Neuroscience

 

Virtual Reality in Neuro-Psycho-Physiology

 

Being There:Concepts, Effects and Measurements
 of user Presence in Synthetic Environments

 

 

and our HOME PAGE

 

Please, cite this book as:

G. Riva, C. Botella, P. Légeron, G. Optale (Eds.), Cybertherapy: Internet and Virtual Reality as Assessment and Rehabilitation Tools for Clinical Psychology and Neuroscience, Amsterdam: Ios Press, 2004.


 

INTRODUCTION

 

Our observations suggest that working online is only suitable for therapists who have been specifically trained in the use of the powerful and yet challenging medium. As Internet usage continues to grow, and becomes integrated into our daily lives, newly trained therapists as well as experienced (f2f) therapists will increasingly seek to develop online practices. They will need to concentrate— through graduate training and also continuing education—on developing the skills and understanding which will promote “best practice” when engaging in online clinical work as a mental health professional.

 

Fenichel, Suler, Barak et al., 2002

 

Telehealth means “medicine at distance” where “medicine” includes not only medical activities - involving ill patients - but also public health activities - involving well people. In other words telehealth is a process and not a technology, including many different health care activities carried out at distance.

         Since the development of methods of electronic communication clinicians have been using information and communication technologies for the exchange of health-related information: Telegraphy - signaling by wires - telephony, radio and television has been used for distance medicine since mid 19th century. However, rapid and far-reaching technological advances are changing the ways in which people relate, communicate, and live. Technologies that were hardly used a few years ago, such as the Internet, e-mail, video teleconferencing and shared virtual reality are becoming familiar methods for modern communication.

         Health care is one of the areas that could be most dramatically reshaped by these new technologies. Distributed communication media could become a significant enabler of consumer health initiatives. In fact they provide an increasingly accessible communications channel for a growing segment of the population. Moreover, in comparison to traditional communication technologies, shared media offer greater interactivity and better tailoring of information to individual needs.

         Cybertherapy, the integration of and telehealth technologies with the Internet and shared virtual reality, is the next logical step. Although cybertherapy is a branch of telehealth, it is differentiated in several important ways: telehealth to date has been largely non-Internet based and has been characterized by point-to-point (e.g., T1) and dial-up (e.g., telephone, ISDN) information exchange. Cybertherapy, on the other hand, is more accessible due to its increasingly affordable ability to communicate through a common set of standards and across operating systems.

         In general, there are two reasons why cybertherapy is used: either because there is no alternative, or because it is in some sense better than traditional medicine. In this sense telehealth has been used very successfully for optimizing health services delivery to people who are isolated due to social and physical boundaries and limitations. Nevertheless, the benefits of cybertherapy, due to the variety of its applications and their uneven development, are not self-evident. However, the emergence of cybertherapy is supporting the cost-effectiveness of certain applications, such as assessment, rehabilitation and therapy in clinical psychology and neuroscience. Its key advantage is the possibility of share different media and different health care tools in a simple to use and easily accessible interface.

         To date, some cybertherapy applications have improved the quality of health care, and later they will probably lead to substantial cost savings. However, cybertherapy is not simply a technology but a complex technological and relational process. In this sense, clinicians and health care providers that want to successfully exploit cybertherapy need a significant attention to clinical issues, technology, ergonomics, human factors and organizational changes in the structure of the relevant health service.

         The goal of this volume is to analyze the processes by which cybertherapy applications will contribute to the delivery of state-of-the-art health services. Particular attention is given to the clinical use of virtual reality technology. The starting point of this overview are the clinical results coming from the European Union VEPSY Updated - Telemedicine and Portable Virtual Environments for Clinical Psychology - research project (http://www.cybertherapy.info).

More in detail, this volume aims at supporting clinicians and scientists, interested in the cybertherapy innovative approach.

For the complexity of this topic, we have put a great deal of effort in the definition of the structure of the book and in the sequence of the contributions, so that those in search of a specific reading path will be rewarded. To this end we have divided the book in five main Sections comprising 14 chapters overall:

  1. Cybertherapy rationale: advantages of new technologies for Clinical Psychology

  2. Cybertherapy experiences: clinical trials in the treatment of mental disorders

  3. Cybertherapy technology: advanced tools for Clinical Psychology

  4. Cybertherapy ergonomics: how to design effective Cybertherapy tools

  5. The future of Cybertherapy: new scenarios and applications

Each chapter begins with a brief abstract, helping the readers in identifying the relationships among its sections.

Section I - Cybertherapy rationale: advantages of new technologies for Clinical Psychology

In Chapter 1, Riva and colleagues present the VEPSY UPDATED Project, whose aim is to understand to and exploit the potential offered by an emerging field – cybertherapy – whose focus is the use of communication and information technologies to improve the health care processes. The clinical and technical rationale behind the cybertherapy applications is provided, focusing on the advantages provided by the three different faces of virtual reality in the cybertherapy field: technological, experiential and communicative.

An integration of different Internet-based tools developed within the VEPSY UPDATED Project - the VEPSY website - is presented in Chapter 2, by Castelnuovo and colleagues. It is an example of clinical application matching traditional practices with innovative media for the treatment of different mental disorders. With the aim of giving a framework for the integration of old and new tools in mental health care, the rationale of the chapter consists on providing the possible scenarios for the use of the VEPSY website in the clinical process.

Botella and colleagues in Chapter 3 provide an historical review of Virtual Reality (VR) as therapeutic tool in clinical psychology. The authors present a comparison between the “traditional” VR-based treatments and the innovative ones. Moreover data on the effectiveness of this technology application in the treatment of different psychological disorders, such as anxiety, eating and sexual disorders are presented with a particular attention to the actual limitations of VR and to the future perspectives. 

Morganti in Chapter 4, starting from the analysis of existing VR-based applications, outlines the possibility of developing virtual reality tools for the assessment and treatment of neuropsychological diseases. The investigation on the possibilities and challenges related to the virtual-reality-based neuropsychological application is focused both on patient’s and therapist’s point of view. More in detail, an explanation of neuropsychological-oriented VR applications is discussed in order to highlight their usefulness and effectiveness in clinical treatments of memory, motor abilities, executive functions and spatial representation impairments.

Session II - Cybertherapy experiences: clinical trials in the treatment of mental disorders

Chapter 5 by Botella and colleagues shows one of the possible applications of virtual reality in mental disorders: the treatment of Panic Disorder with Agoraphobia (PDA). Furthermore the chapter discusses how Virtual Reality treatments could help to achieve specific therapeutic goals. The clinical program developed for the treatment of PDA is described together with the efficacy and effectiveness of this particular treatment. The chapter presents the data of a study where a cognitive-behavioral program including VR for the exposure component is compared with a standard cognitive-behavioral program including in vivo exposure and with a waiting list control condition.

The chapter by Klinger and colleagues (Chapter 6), presents a VR-based clinical protocol to treat social phobia. The novelty of this work is to address a larger group of situations that the phobic patients experience with high anxiety. In the presented protocol, the efficacy of the virtual reality treatment is compared to the established and well validated group cognitive-behavioral treatment.

Riva and colleagues in Chapter 7 present a new Virtual Reality-enhanced treatment, named Experiential Cognitive Therapy (ECT), detailing its rationale and therapeutical protocols for the treatment of obesity and eating disorders. Moreover, the chapter presents the data from a clinical trial where the results of this treatment are compared with the mostly used approaches in the treatment of these disturbances (cognitive-behavioral therapy and the nutritional therapy).

Finally, the chapter by Optale and colleagues (Chapter 8) describes a therapeutic approach in which psycho-dynamic psychotherapy is integrated with Virtual Environments (VEs) to treat male sexual dysfunctions of presumably psychological or mixed origin. The presented data show that the particular way in which full-immersion VR involves the patient, is able to speed up the therapeutic psycho-dynamic process and produces better results than traditional treatments.

Section III - Cybertherapy technology: advanced tools for Clinical Psychology

Chapter 9 by Rey and colleagues presents new technologies that will provide psychological treatment and help at any place and any time. Examples of this scenario are dynamic web pages, that include information prepared by the therapist for different patients and that receive information from them. These pages can be linked with other tools such as e-mail or chats, offering a direct patient-therapist communication. According to this view Virtual Environments can also be integrated in web pages to deliver advanced therapy support.

Alcañiz and colleagues in Chapter 10 focus on user interface design as a critical component of any Virtual Envi­ronment application, and especially for VEs applied to health care. The authors show how non-traditional devices and interface components are quickly proliferating and how three-dimensional, multisensory output technologies are also becoming more common. These considerations are supported from an overview of 3-D inter­action and user interfaces technologies for VEs.

Section IV - Cybertherapy ergonomics: how to design effective Cybertherapy tools

Within this section, Chapter 11 by Spagnolli and colleagues describes the usability evaluation of the Virtual Environment for the treatment of male sexual dysfunctions presented in Chapter 8. After the description of the conceptual framework adopted, the chapter dwell on one method among those deployed for the evaluation, namely the analysis of “situated actions”. The main parameters used for the evaluation are the goals and the intended meanings of the simulation as set by the designers. 

The identification of the usability requirements of specific community of practices is discussed in Chapter 12, by Galimberti and colleagues.  Two of the four VR modules in the framework of the VEPSY project are considered: Panic Disorders – Agoraphobia and Eating Disorders, depicted in Chapter 5 and Chapter 7. The theoretical background used in this analysis is based upon an ethnomethodological approach, a perspective that gives evidence of how people, in specific social situations, are able to solve complex tasks producing shared meanings and achieving their goals during interaction. 

Section V -  The future of Cybertherapy: new scenarios and applications

Within this section, which tries to outline the current state of research and technology that will be relevant to the development of innovative communication interfaces in health care, Riva and colleagues (Chapter 13) describe the Immersive Virtual Telepresence (IVT) technology. This innovative tool merges virtual reality environments with wireless multimedia facilities and advanced input devices, including biosensors and brain-computer interfaces. The authors discuss the clinical principles and possible advantages associated with the use of IVT in cybertherapy.

Chapter 14 by Wiederhold B. and Wiederhold M. deals with the novel applications of VR-Based technologies, highlighting both the advantages over traditional treatment modalities, and the problems experienced by the first clinical trials using these tools. Future directions for research are given, including improvements of objective measures of efficacy as fMRI and physiological monitoring devices. Finally, suggestions are provided to verify if VR and advanced technologies can be used in the treatment of many disorders, including depression, schizophrenia, drug addiction, and autism.

The wide array of perspectives described in the five Sections strengthens the importance of cybertherapy in health care. As this approach continues to develop, it is largely expected a wider comparison with existing methods. In order to achieve this goal, an interdisciplinary approach is essential. Moreover the integration of knowledge coming from different disciplines, such as clinical social and cognitive psychology, neuroscience, ergonomics, multimedia development, or communication engineering, will be crucial to incorporate ongoing insights from these fields into powerful future-generation clinical applications.

         Within this effort, the Editors want to thank all the people and institutions that have supported this book and the work described in it. We have benefited from European Union support and in particular from Luciano Beolchi and Diane Whitehouse friendship. In particular Diane has not only provided detailed comments on many issued faced by the VESPY Updated project, but has also discussed the content and the status of this project with us over many months.

         Moreover, Riva wants to thank his bosses and colleagues at the Istituto Auxologico Italiano, one of the leading research and health care center in Italy, for believing in the possibility of including cybertherapy in their counseling and rehabilitation activities. In particular, his thanks go to the President of the Institute, Prof. Giovanni Ancarani, to the General Manager, Dr. Mario Colombo, to the Scientific Secretary, Dr. Furio Gramatica, and to Prof. Enrico Molinari, who shared a significant part of Riva’s research work.

         Also thanks to Prof. Carlo Galimberti, Full Professor of Social Psychology at the Università Cattolica del Sacro Cuore, Milan, Italy, and to Prof. Eugenia Scabini, Dean of the Faculty of Psychology at the Università Cattolica del Sacro Cuore, Milan, Italy for the continuous support provided during the last decade. A final “thank you” goes to Prof. Luigi Anolli, Full Professor of Cultural Psychology at the State Universiy of Milan Bicocca, Milan, Italy, for his help and his continuing research work in the communication and cultural areas.

In conclusion, we expect that the contents of this book will stimulate more clinicians and professionals in finding new solutions both to expand their intervention interests and in making better use of traditional and innovative cybertherapy tools.

 

G. Riva, Ph.D.

Istituto Auxologico Italiano Milan, Italy

C. Botella, Ph.D.

Universitat Jaume I, Castellón, Spain

 

P. Légeron, M.D.

Unité de Thérapie Comportementale et Cognitive, Hôpital Sainte-Anne, Paris, France

G. Optale, M.D.

Association of Medical Psychotherapists,Venice, Italy

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CONTRIBUTORS

 

Mariano ALCAÑIZ
MedICLab, Universidad Politécnica de Valencia, Valencia, Spain

Monica BACCHETTA
Applied Technology for Neuro-Psychology, Istituto Auxologico Italiano, Verbania, Italy.

Rosa M. BAÑOS
Universidad de Valencia, Valencia, Spain

Azy BARAK
Department of Psychology, University of Haifa, Haifa, Israel

Gloria BELLONI
LICENT, Catholic University, Milan, Italy

Diego BORDIN
Information and Internet Technologies Developer, Venice-Spinea, Italy.

Cristina BOTELLA
Universitat Jaume I, Castellón, Spain

Claudio BUSELLI
ELSAG spa, Genova, Italy

Gianluca CASTELNUOVO
Applied Technology for Neuro-Psychology, Istituto Auxologico Italiano, Milan, Italy.

Department of Psychology, Catholic University, Milan, Italy

Laboratory of Psychology, Department of Preclinical Sciences LITA Vialba, University of Milan, Milan, Italy

 

Alberto CATTANEO

LICENT, Catholic University, Milan, Italy

 

Gianluca CESA

Applied Technology for Neuro-Psychology, Istituto Auxologico Italiano, Verbania, Italy

 

Isabelle CHEMIN

Groupe de Recherche en Informatique, Image, Automatique et Instrumentation de Caen  (GREYC), Caen, France

 

Sara CONTI

Applied Technology for Neuro-Psychology, Istituto Auxologico Italiano, Verbania, Italy

Paolo COTTONE
Department of General Psychology, University of Padua, Padua, Italy.

Roberta DE FERRARI
ELSAG spa, Genova, Italy

Andrea GAGGIOLI
Applied Technology for Neuro-Psychology, Istituto Auxologico Italiano, Milan, Italy.

Laboratory of Psychology, Department of Preclinical Sciences LITA Vialba, University of Milan, Milan, Italy

Carlo GALIMBERTI
LICENT, Catholic University, Milan, Italy.

Luciano GAMBERINI
Department of General Psychology, University of Padua, Padua, Italy.

Azucena GARCÍA PALACIOS
Universitat Jaume I, Castellón, Spain

Maddalena GRASSI
LICENT, Catholic University, Milan, Italy.

Evelyne KLINGER
Groupe de Recherche en Informatique, Image, Automatique et Instrumentation de Caen  (GREYC), Caen, France

Françoise LAUER
Stimulus, Paris, France

Patrick LÉGERON
Unité de Thérapie Comportementale et Cognitive, Hôpital Sainte-Anne, Paris, France

José Antonio LOZANO
MedICLab, Universidad Politécnica de Valencia, Valencia, Spain

Valentina MANIAS
LICENT, Catholic University, Milan, Italy

Fabrizia MANTOVANI
Applied Technology for Neuro-Psychology, Istituto Auxologico Italiano, Milan, Italy.

Department of Psychology, Catholic University, Milan, Italy

Giuseppe MANTOVANI
Department of General Psychology, University of Padua, Padua, Italy

Silvia MARIN
Association of Medical Psychotherapists, Venice, Italy

Luca MENTI
LICENT, Catholic University, Milan, Italy

Enrico MOLINARI
Department of Psychology, Catholic University, Milan, Italy

Laboratorio Sperimentale di Psicologia, Istituto Auxologico Italiano, Verbania, Italy

Francesca MORGANTI
Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Milan, Italy

Centre for Cognitive Science, Department of Psychology, University of Turin, Turin, Italy

 

Alberto NASTA

Division of Urology, Public Hospital, Venice-Mestre, Italy

 

Pierre NUGUES

LTH Department of Computer Science, Lund University, Lund, Sweden

 

Gabriele OPTALE

Association of Medical Psychotherapists, Venice, Italy

 

Division of Urology, Public Hospital, Venice-Mestre, Italy

 

Massimiliano PASTORE

Department of Psychology, University of Cagliari, Cagliari, Italy

Conxa PERPIÑÁ
Universidad de Valencia, Valencia, Spain

Carlo PIANON
Division of Urology, Public Hospital, Venice-Mestre, Italy

Soledad QUERO
Universitat Jaume I, Castellón, Spain

Beatriz REY
MedICLab, Universidad Politécnica de Valencia, Valencia, Spain

Giuseppe RIVA
Applied Technology for Neuro-Psychology, Istituto Auxologico Italiano, Milan, Italy

Department of Psychology, Catholic University, Milan, Italy

Stéphane ROY
Unité de Thérapie Comportementale et Cognitive, Hôpital Sainte-Anne, Paris, France

Anna SPAGNOLLI
Department of General Psychology, University of Padua, Padua, Italy

Helena VILLA
Universitat Jaume, Castellòn, Spain

Marco VILLAMIRA
IULM University, Milan, Italy

Brenda K. WIEDERHOLD
Virtual Reality Medical Center, San Diego, CA, USA

Mark D. WIEDERHOLD
Virtual Reality Medical Center, San Diego, CA, USA

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CONTENTS

 

Please, cite this book as:

G. Riva, C. Botella, P. Légeron, G. Optale (Eds.), Cybertherapy: Internet and Virtual Reality as Assessment and Rehabilitation Tools for Clinical Psychology and Neuroscience, Amsterdam: Ios Press, 2004.

 

Preface, A. Barak                                                                                                                v       

Introduction, G. Riva, C. Botella, P. Légeron and G. Optale                                             ix

 

       Section I.  Cybertherapy rationale: advantages of new technologies for Clinical Psychology

The possible role of virtual reality (VR) in clinical psychology derives prevalently from the central role occupied by the imagination and by memory in psychotherapy... VR pro­duces a change with respect to the traditional relationship between client and therapist. The new configuration of this relationship is based on the awareness of being more skilled in the difficult operations of recovery of past experiences through the memory and of foreseeing fu­ture experiences through the imagination. At the same time, subjects undergoing treatment perceive the advantage of being able to recreate and use a real experiential world within the confines of their therapists' clinical offices.

Vincelli, 1999

Chapter 1.  Cybertherapy in Practice: The VEPSY Updated project                                   3

                        G. Riva, C. Botella, G. Castelnuovo, A. Gaggioli, F. Mantovani and E. Molinari

Chapter 2.  New tools in cybertherapy: the VEPSY Web Site                                            15

       G. Castelnuovo,  C. Buselli, R. De Ferrari,A. Gaggioli, F. Mantovani, E. Molinari,

       M. Villamira and G. Riva

 

Chapter 3.  Virtual Reality and Psychotherapy                                                                    37

C. Botella, S. Quero,R. M. Baños, C. Perpiñá,

A. García Palacios and Giuseppe Riva

 

Chapter 4.  Virtual Interaction in Cognitive Neuropsychology                                              55

                        F. Morganti

 

 

       Section II. Cybertherapy experiences: clinical treatment of mental disorders

The recent growth of technology in the mental health field is a reflection of the continuous advances and discoveries of hundreds of investigators who use virtual reality and other simulation and advanced technologies to help patients with both mental and physical disorders. Over the past five years an increasing number of professional publications have high lighted clinical applications of virtual reality in the assessment and treatment of anxiety disorders, eating disorders, and sexual dysfunction as well as in neuropsychiatric and neuropsychological assessment and training, with particular adjunctive applications in the fields of physical therapy, training, and rehabilitation. Further applications have included distraction from unpleasant or painful medical procedures and treatment for posttraumatic stress disorder. A wide variety of other fascinating concepts and applications are ongoing.

Wiederhold & Wiederhold, 2003

Chapter 5.  The use of VR in the treatment panic disorders and agoraphobia                       73

C. Botella,H. Villa, A. Garcia-Palacios, S. Quero, R.M. Banos and M. Alcaniz

Chapter 6.  Virtual Reality Exposure in the Treatment of Social Phobia                                91

E. Klinger, P. Légeron, S. Roy, I. Chemin, F. Lauer and P. Nugues

Chapter 7.  The use of VR in the treatment of Eating Disorders                                           121

G. Riva, M. Bacchetta, G.  Cesa, S. Conti and E. Molinari

Chapter 8.  Male Sexual Dysfunctions: immersive Virtual Reality and multimedia therapy     165                    

G. Optale, M. Pastore, S. Marin,D. Bordin, A. Nasta and C. Pianon

 

 

Section III. Cybertherapy technology: advanced tools for Clinical Psychology

We contend that the use of technology does not require changes in basic clinical principles and practices: E-therapy does not modify theories, techniques, and methods typical of each approach (psychoanalytic, systemic, cognitive, behavioral, interpersonal, strategic, etc.) but could affect the level of communication and thus the possible relationship and alliance between the therapist and the patient. A psychotherapist, regardless of theoretical orientation, can move from the traditional face-to-face setting to an environment based on Internet tools. Basic techniques, such as cognitive reframing or discussion about particular feelings and emotions, can be used in this new medium, which differs from the old only in terms of novelty. Old (and functional) practices can be used through new (and promising) media. Therefore, in e-therapy, the focus of the treatment does not shift into technology but remains on the traditional process of psychotherapy.

Castelnuovo et al., 2003

Chapter 9.  New Technologies for Providing Remote Psychological Treatments                181

                                                                                            

       B. Rey, M. Alcañiz and  J.A. Lozano,  

Chapter 10. Technological Background About VR                                                           199

       M. Alcañiz, J.A. Lozano and B. Rey  

 

 

Section IV. Cybertherapy ergonomics: how to design effective cybertherapy tools     

Although 21St century technology does not allow the level of realism portrayed in Star Trek, new research methods relying on virtual reality are changing the way we study the mind and brain, as well as how we apply the fruits of this research in the “real world”. “It is not true that the laboratory can never be like life. The laboratory must be like life!” exclaimed the eminent perceptual psychologist J. J. Gibson in 1979. Inspired by this philosophy and by improvements in technology, we and others have created virtual reality laboratories to investigate how humans interact with their surroundings under more realistic conditions.

Tarr & Warren, 2002

Chapter 11. Ergonomics of Virtual Environments for Clinical Use                                      217

A.     Spagnolli, L. Gamberini, P. Cottone and G. Mantovani

Chapter 12. An Integrated Approach to the Ergonomic Analysis of Vr in Psychotherapy: Panic Disorders, Agoraphobia

and Eating Disorders The use of VR in the treatment  of Eating Disorders                          231

C. Galimberti, G. Belloni, A. Cattaneo, M. Grassi, V. Manias and L. Menti

 

Section V. The future of Cybertherapy: new scenarios and applications  

The most profound technologies are those that disappear. They weave themselves into the fabric of everyday life until they are indistinguishable… This is not just a "user interface" problem… Such machines cannot truly make computing an integral, invisible part of the way people live their lives. Therefore we are trying to conceive a new way of thinking about computers in the world, one that takes into account the natural human environment and allows the computers themselves to vanish into the background. Such a disappearance is a fundamental consequence not of technology, but of human psychology…. Only when things disappear are we freed to use them without thinking and so to focus beyond them on new goals.

Weiser, 1991

Chapter 13. Immersive Virtual Telepresence: Virtual Reality meets mHealth                     255

                 

                 G. Riva, F. Morganti and  M. Villamira

Chapter 14. The future of Cybertherapy: Improved options with advanced  technologies 263                        

                                                           

B. K. Wiederhold and M.D. Wiederhold.

 

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ABSTRACTS

 

Please, cite this book as:

G. Riva, C. Botella, P. Légeron, G. Optale (Eds.), Cybertherapy: Internet and Virtual Reality as Assessment and Rehabilitation Tools for Clinical Psychology and Neuroscience, Amsterdam: Ios Press, 2004.
 

          1. Cybertherapy in Practice:
            The VEPSY Updated project

Giuseppe RIVA, Ph.D. 1-2 Cristina BOTELLA, Ph.D.3,

Gianluca CASTELNUOVO, M.S. 1-2, Andrea GAGGIOLI, M.S. 1,

 Fabrizia MANTOVANI, Ph.D. 1-2, Enrico MOLINARI, Ph.D. 2-4

 

1 Applied Technology for Neuro-Psychology Lab., Istituto Auxologico Italiano, Milan, Italy

2 Department of Psychology, Catholic University, Milan, Italy

3 Universitat Jaume I, Castellon de la Plana, Spain

4 Laboratorio Sperimentale di Psicologia, Istituto Auxologico Italiano, Verbania, Italy

 

Abstract: Rapid and far-reaching technological advances are changing the ways in which people relate, communicate, and live. Technologies that were hardly used ten years ago, such as the Internet, e-mail, and video teleconferencing are becoming familiar methods for diagnosis, therapy, education and training. This is producing an emerging field – cybertherapy – whose focus is the use of communication and information technologies to improve the health care processes.

To exploit and understand this potential was the aim of the “ Telemedicine and Portable Virtual Environment in Clinical Psychology” - VEPSY UPDATED – a European Community funded research project (IST-2000-25323, http://www.cybertherapy.info).

The chapter describes the clinical and technical rationale behind the cybertherapy applications developed by the project. Further, the actual role of virtual reality in the cybertherapy field is discussed, focusing on the advantages provided by its three different faces: technological, experiential and communicative.

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      2. New tools in cybertherapy:
           the VEPSY Web Site

Gianluca CASTELNUOVO, M.S.1-2-3, Claudio BUSELLI, Eng.4,

Roberta DE FERRARI, Eng.4, Andrea GAGGIOLI, M.S.1-3,

Fabrizia MANTOVANI, Ph.D. 1-2, Enrico MOLINARI, Ph.D. 2-5,

Marco VILLAMIRA, M.D. 6, Giuseppe RIVA, Ph.D. 1-2

 

1 Applied Technology for Neuro-Psychology Lab.,

Istituto Auxologico Italiano, Milano, Italy

2 Department of Psychology, Catholic University, Milan, Italy

3 Laboratory of Psychology, Department of Preclinical Sciences LITA Vialba, University of Milan, Milan, Italy

Laboratory of  Psychology, Istituto Auxologico Italiano,

Verbania Italy

4 ELSAG spa, Genova, Italy

      6 IULM University, Milan, Italy

 

Abstract In the last years the rapid development of the Internet and new communication technologies has had a great impact on psychology and psychotherapy. Psychotherapists seem to rely with more and more interest on the new technological tools such as videophone, audio and video chat, e-mail, SMS and the new Instant Messaging Tools (IMs). All these technologies outline a stimulating as well as complex scenario: in order to effectively exploit their potential, it is important to study which is the possible role played by the Internet-based tools inside a psychotherapeutic iter. Could the technology substitute the health care practitioners or are these tools only a resource in addition to the traditional ones in the therapist’s hand? The major aim of this chapter is to provide a framework for the integration of old and new tools in mental health care. Different theoretical positions about the possible role played by e-therapy are reported showing the possible changes that psychotherapy will necessarily face in a cyber setting. The VEPSY website, an integration of different Internet-based tools developed within the VEPSY UPDATED Project, is described as an example of clinical application matching between old (and functional) practices with new (and promising) media for the treatment of different mental disorders. A rationale about the possible scenarios for the use of the VEPSY website in the clinical process is provided.

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    3.Virtual Reality and Psychotherapy

 

Cristina BOTELLA, Ph.D. 1, Soledad QUERO, PhD. 1,

Rosa M. BAÑOS, PhD. 2, Conxa PERPIÑÁ, PhD. 2,

Azucena GARCÍA PALACIOS, PhD.

and Giuseppe RIVA, Ph.D. 3-4

 

1 Universitat Jaume I, Castellón, Spain

2 Universidad de Valencia, Valencia, Spain

3 Istituto Auxologico Italiano, Milan, Italy

4 Catholic University, Milan, Italy

 

Abstract Virtual Reality (VR) is a new technology consisting on a graphic environment in which the user, not only has the feeling of being physically present in a virtual world, but he/she can interact with it. The first VR workstations were designed for big companies in order to create environments that simulate certain situations to train professionals. However, at this moment a great expansion of this technology is taking place in several fields, including the area of health. Especially interesting for us is the use of VR as a therapeutic tool in the treatment of psychological disorders. Compared to the “traditional” treatments, VR has many advantages (e.g., it is a protected environment for the patient, he/she can re-experience many times the feared situation, etc.). There are already data on the effectiveness of this technology in the treatment of different psychological disorders; here anxiety disorders, eating disorders and sexual disorders are reviewed. Finally, this chapter ends with some words about the limitations of VR and future perspectives. 

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    4. Virtual interaction
       in cognitive neuropsychology

Francesca MORGANTI, Ph. D.1-2

 

1 Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Milan, Italy

2 Centre for Cognitive Science, Department of Psychology, University of Torino, Italy

 

Abstract Several recent studies have investigated whether knowledge representation turns possible within virtual reality simulated environments. According to these affirmative results different clinical applications were developed in psychology. Among these applications virtual reality seems to have a specific role in assessment and treatment of neuropsychological diseases. This chapter will firstly investigate possibilities and challenges carried from virtual-reality-based neuropsychological application focusing both on patient’s and therapist’s point of view. Afterward it will provide a survey of research and intervention application examples. More in detail a clear explanation of contribution goals will be discussed, in order to place research and applied works within a cognitive neuroscience frame of reference, according with their usefulness and effectiveness in clinical treatment. Fulfilling these objectives neuropsychological virtual reality approaches in memory, motor abilities, executive functions and spatial representation will be shown.

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        5.The use of VR in the treatment of panic

           disorders and agoraphobia

 

Cristina BOTELLA, Ph.D. 1, Helena VILLA, Ph.D. 1,

Azucena GARCIA-PALACIOS, Ph.D.1, Soledad QUERO, Ph.D.1,

Rosa M. BANOS, Ph.D.2 , Mariano ALCANIZ, Eng. 3

 

1 Department of Clinical Psychology, Universitat Jaume І, Castellón, Spain

2 Universidad de Valencia, Spain

3 Universidad Politécnica de Valencia

 

Abstract Panic disorder with agoraphobia (PDA) is considered an important public health problem. The efficacy of cognitive-behavioral therapy (CBT) for PDA has been widely demonstrated. The American National Institute of Health recommended Cognitive-Behavioral programs as the treatment of choice for this disorder. This institution also recommended that researchers develop treatments whose mode of delivery increases the availability of these programs. Virtual Reality based treatments can help to achieve this goal. VR has several advantages compared with conventional techniques. One of the essential components to treat these disorders is exposure. In VR the therapist can control the feared situations at will and with a high degree of safety for the patient, as it is easier to grade the feared situations. Another advantage is that VR is more confidential because treatment takes place in the therapist's office. It is also less time consuming as it takes place in the therapist's office. Considering the wide number of situations and activities that agoraphobic patients use to avoid, VR can save time and money significantly. Another advantage in treating PDA using VR is the possibility of doing VR interoceptive. VR could be a more natural setting for interoceptive exposure than the consultation room because we can elicit bodily sensations while the patient is immerse in VR agoraphobic situations. Finally, we think that VR exposure can be a useful intermediate step for those patients who refuse in vivo exposure because the idea of facing the real agoraphobic situations is too aversive for them.

In this chapter we offer the work done by our research team at the VEPSY-UPDATED project. We describe the VR program we have developed for the treatment of PDA and we summarize the efficacy and effectiveness data of a study where we compare a cognitive-behavioral program including VR for the exposure component with a standard cognitive-behavioral program including in vivo exposure and with a waiting list control condition. Our findings support the efficacy and effectiveness of VR for the treatment of PDA.

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        6. Virtual Reality Exposure

     in the Treatment of Social Phobia

 

Evelyne KLINGER, ENG 1, Patrick LÉGERON, M.D.2,

Stéphane ROY, PsyD 2, Isabelle CHEMIN, M.A.1,

Françoise LAUER, Psy 3, Pierre NUGUES, Ph.D.4

 

1 Groupe de Recherche en Informatique, Image, Automatique et Instrumentation de Caen  (GREYC), Caen, France

2Unité de Thérapie Comportementale et Cognitive, Hôpital Sainte-Anne, Paris, France

3Stimulus, Paris, France

4 LTH Department of Computer Science, Lund University, Sweden

 

Abstract. Social phobia is one of the most frequent psychiatric disorders and is accessible to two forms of scientifically validated treatments: anti-depressant drugs and cognitive-behavioral therapies. Graded exposure to feared social situations (either in vivo or by imagining the situations) is fundamental to obtain an improvement of the anxious symptoms. Virtual reality (VR) may be an alternative to these standard exposure techniques and seems to bring significant advantages by allowing exposures to numerous and varied situations. Moreover studies have shown that human subjects are appropriately sensitive to virtual environments.

This chapter reports the definition of a VR-based clinical protocol and a study to treat social phobia using virtual reality techniques. The virtual environments used in the treatment reproduce four situations that social phobics feel the most threatening: performance, intimacy, scrutiny and assertiveness. With the help of the therapist, the patient learns adapted cognitions and behaviors when coping with social situations, with the aim of reducing her or his anxiety in the corresponding real life situations. Some studies have been carried out using virtual reality in the treatment of fear of public speaking, which is only a small part of the symptomatology of most of social phobic patients. The novelty of our work is to address a larger group of situations that the phobic patients experience with high anxiety. In our protocol, the efficacy of the virtual reality treatment is compared to well established and well validated group cognitive-behavioral treatment.

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        7. The use of VR in the treatment
   
   of Eating Disorders

                Giuseppe RIVA, Ph.D. 1-2, Monica  BACCHETTA, Psy.D 3, Gianluca CESA, M.S. 3,
                Sara  CONTI, M.S. 3, Enrico MOLINARI, Psy.D 4

1 Applied Technology for Neuro-Psychology

 Istituto Auxologico Italiano, Milan,  Italy
2 Centro Studi e Ricerche di Psicologia della Comunicazione,
Università Cattolica Milan, Italy
3 Applied Technology for Neuro-Psychology
Istituto Auxologico Italiano, Verbania, Italy
4 Laboratorio Sperimentale di Ricerche Psicologiche,
Istituto Auxologico Italiano, Verbania, Italy

 

Abstract. In the treatment of eating disorders, the cognitive behavioral therapy (CBT) is still considered the best approach but could present different limitations related to costs of behavioural procedures (such as exposure and desensitization) or difficulty of cognitive techniques (such as imagination of daily scenarios). The major aim of this contribution is the description of a new Virtual Reality-enhanced treatment named Experiential Cognitive Therapy (ECT). Rationale and protocols about this new approach are explained. Moreover data about clinical trials, carried on with the VEPSY Project, are shown comparing different groups: experimental group (ECT), cognitive-behavioural therapy group (CBT), nutritional group and control group.

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   8. Male Sexual Dysfunctions:
      immersive Virtual Reality and
      multimedia therapy

       Gabriele OPTALE, M.D.1,4, Massimiliano PASTORE,Ph.D.2,
       Silvia MARIN, M.S.1, Diego BORDIN 3,
       Alberto NASTA, M.D.4, Carlo PIANON, M.D.4

1 Association of Medical Psychotherapists, Venice Italy.

2 Department of Psychology, University of Cagliari, Italy.

3 Information and Internet Technologies Developer, Venice-Spinea, Italy.

4 Department of Urology, Public Hospital of Mestre-Venice, ULSS 12, Italy.

 

Abstract The study describes a therapeutic approach using psycho-dynamic psychotherapy integrating virtual environment (VE) for resolving impotence or better erectile dysfunction (ED) of presumably psychological or mixed origin and premature ejaculation (PE). The plan for therapy consists of 12 sessions (15 if a sexual partner was involved) over a 25-week period on the ontogenetic development of male sexual identity, and the methods involved the use of a laptop PC, joystick, Virtual Reality (VR) helmet with miniature television screen showing a new specially-designed CD-ROM programs using Virtools with Windows 2000 and an audio CD. This study was composed of 30 patients, 15 (10 suffering from ED and 5 PE) plus 15 control patients (10 ED and 5 PE), that underwent the same therapeutic protocol but used an old VR helmet to interact with the old VE using a PC Pentium 133 16Mb RAM. We also compared this study with another study we carried out on 160 men affected by sexual disorders, underwent the same therapeutic protocol, but treated using a VE created (in Superscape VRT 5.6) using always Windows 2000 with portable tools. Comparing the groups of patients affected by ED and PE, there emerged a significant positive results value without any important differences among the different VE used. However, we had a % increase of undesirable physical reactions during the more realistic 15-minute VR experience using Virtools development kit. Psychotherapy alone normally requires long periods of treatment in order to resolve sexual dysfunctions. Considering the particular way in which full-immersion VR involves the subject who experiences it (he is totally unobserved and in complete privacy), we hypothesise that this methodological approach might speed up the therapeutic psycho-dynamic process, which eludes cognitive defences and directly stimulates the subconscious, and that better results could be obtained in the treatment of these sexual disorders. This method can be used by any psychotherapist and it can be used alone or associated with pharmacotherapy prescribed by the urologist/andrologist as part of a therapeutic alliance.

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        9. New Technologies for Providing Remote
            Psychological Treatments

Beatriz REY, M.S.1, Mariano ALCAÑIZ, Ph.D.1,

José Antonio LOZANO, M.S.1

 

1 MedICLab, Universidad Politécnica de Valencia, Valencia, Spain

 

Abstract.  New technologies lead us to a series of new applications that we could not imagine just a few years before.

Many services have appeared for Internet, the global computer network: FTP, e-mail, World Wide Web… Psychological treatments are one of the multiple applications that can be developed using these tools. Dynamic web pages that include information prepared by the therapist for different patients and that receive information from them can be generated. Other tools such as e-mail or chats can be used to provide a direct communication.

Databases can be integrated in web applications for storing data about different patients. Several formats can be used for storing the information, and some of them such as XML provide a promising method of psychological data standardization.

Using different development tools, virtual environments can also be generated and integrated in web pages, so new psychological treatments such as virtual environment exposure are also possible from web applications.

This entire basis provides the structure that allows that new applications can be imagined and developed. In a few years, new trends will appear, probably one of them will be the use of wireless devices to provide psychological treatment and help at any place and any time.

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         10. Technological Background About VR

  Mariano ALCAÑIZ, Ph.D.1,

  José Antonio LOZANO, M.S.1, Beatriz REY, M.S.1

     1 MedICLab, Medical Image Computing Laboratory,
    Universidad Politécnica de Valencia, Valencia, Spain

Abstract.  User interface (UI) design is a critical component of any virtual envi­ronment (VE) application, and especially for VE applied to medicine. User interfaces for VE are becoming more di­verse. Mice, keyboards, windows, menus, and icons - the standard parts of tra­ditional WIMP interfaces- are still prevalent, but nontraditional devices and interface components are proliferating rapidly. These include spatial input de­vices such as trackers, 3-D pointing devices, and whole-hand devices allowing gestural input. Three-dimensional, multisensory output technologies -such as stereoscopic projection displays, head-mounted displays (HMDs), spatial audio systems, and haptic devices- are also becoming more common. In this chapter we present a brief overview of 3-D inter­action and user interfaces technologies for VE.

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 11. Ergonomics of Virtual Environments for Clinical Use

Anna SPAGNOLLI, Ph.D.1; Luciano GAMBERINI, Ph.D.1;
Paolo COTTONE 1; Giuseppe MANTOVANI, Ph.D.1

1 Department of General Psychology, Padova, Italy

Abstract. Usability is defined by the International Standards Organization as “the effectiveness, efficiency and satisfaction with which a certain user may achieve a specific objective in a particular environment" (ISO DIS 9241-11). This definition highlights the need for considering the specific destination of a certain technology and reflects the current trends in Human-Computer Interaction (HCI). In compliance with these remarks, the evaluation will be described here of a Virtual Environment (VE) for the treatment of male sexual dysfunctions; the common assumption will be avoided according to which a VE is a space separated from its ‘real’ surroundings [6, 7] and the full environment where the Virtual session takes place will be addressed instead. After a description of the conceptual framework adopted, the paper will dwell on one method among those deployed for the evaluation, namely the analysis of ‘situated actions’. Four aspects will be dealt with: (a) the interplay of various concurrent settings during the virtual session; (b) the users’ comprehension of the symbols used in the VE; (c) the structure of the relationship between users and guide; (d) the breakdowns during the human-VE  interaction. The goals and the intended meanings of the simulation as set by the designers became the  main parameters for the evaluation.

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 12. An Integrated Approach to the Ergonomic Analysis of VR in Psychotherapy:
Panic Disorders, Agoraphobia and Eating Disorders

    Carlo GALIMBERTI, Ph.D 1; Gloria BELLONI, M.A. 1;
    Alberto CATTANEO, M.A. 1; Maddalena GRASSI, M.S.1
    Valentina MANIAS, M.S. 1; Luca MENTI, M.S. 1

      1Catholic University, Milan, Italy

Abstract. To face the aspects connected with VR environments’ usability for psychotherapeutic applications means to dare a double challenge from a methodological point of view: from one side, the need to adapt and to integrate on a heuristic basis classic usability evaluation methods to specific artefacts such as 3D Virtual Environments for clinical applications; from the other hand, the problems arisen by integration of expert evaluation of VR environments user-based tests carried out in real context of use. The theoretical background of our analytical stance is based upon an ethnometodological approach, a perspective that gives evidence of how people, in specific social situations, are able to solve complex tasks producing shared meanings and achieving their goals during interaction. According to this perspective, the methodological objective consisted also in the identification of the usability requirements of the specific community of practice. The virtual environments considered were two of the four VR modules in the framework of the VEPSY project: Panic Disorders – Agoraphobia and Eating Disorders.

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13. Immersive Virtual Telepresence

       Virtual Reality meets eHealth

       Giuseppe RIVA, Ph.D. 1, Francesca MORGANTI, Ph.D.1-2
        
Marco VILLAMIRA, M.D.

1 Applied Technology for Neuro-Psychology Lab.,

Istituto Auxologico Italiano, Verbania, Italy

2 Centre for Cognitive Science, Department of Psychology,

 University of Torino, Torino, Italy

3 IULM University, Milan, Italy

 

Abstract Immersive Virtual Telepresence (IVT) tools are virtual reality environments combined with wireless multimedia facilities - real-time video and audio – and advanced input devices – tracking sensors, biosensors, brain-computer interfaces.  For its features IVT can be considered an innovative communication interface based on interactive 3D visualization, able to collect and integrate different inputs and data sets in a single real-like experience.

In this paper we try to outline the current state of research and technology that is relevant to the development of IVT in medicine. Moreover, we discuss the clinical principles and possible advantages associated with the use of IVT in this field.

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      14. The future of Cybertherapy:
  
     Improved options with advanced technologies

       Brenda K. WIEDERHOLD, Ph.D., MBA, BCIA 1
       Mark D. WIEDERHOLD, M.D., Ph.D. FACP 1

       1 Virtual Reality Medical Center, San Diego, CA, US

Abstract: Cybertherapy is a field that is growing rapidly due to today’s technology and information boom. Virtual reality and advanced technologies have been used successfully to in a variety of healthcare issues, including treatment of anxiety disorders and phobias, treatment of eating and body dysmorphic disorders, neuropsychological assessment and rehabilitation and distraction during painful or unpleasant medical procedures. The novel applications of these technologies yield many advantages over traditional treatment modalities, and the disadvantages that accompanied the first trials of virtual reality are quickly being addressed and eliminated. Virtual reality peripherals such as data gloves, physiological monitoring and Internet worlds are swiftly demonstrating their usefulness in cybertherapy applications. Future directions for research include improvements of objective measures of efficacy such as fMRI and physiological monitoring devices, and investigations are being carried out to determine if virtual reality and advanced technologies can be used to treat a broader scope of disorders, including depression, schizophrenia, drug addiction, and autism.

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