The hidden structure
From Communication to
Internet and Virtual Reality as Assessment and Rehabilitation Tools for Clinical Psychology and Neuroscience
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 educationon 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:
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.
It can be used in the treatment of anxiety disorders, eating disorders, obesity, pain distraction and relaxation.
You can download the software for free (registration required) from the http://www.neurovr.org web site.
G. Riva, C. Botella, G. Castelnuovo, A. Gaggioli, F. Mantovani and E. Molinari
2. New tools in cybertherapy: the VEPSY Web Site
3. Virtual Reality and Psychotherapy
4. Virtual Interaction in Cognitive Neuropsychology
7. The use of VR in the treatment of Eating Disorders, 10. Technological Background About VR Section 5 - The future of Cybertherapy: new scenarios and applications Monica BACCHETTA Rosa M. BAÑOS Azy BARAK Gloria BELLONI Diego BORDIN Cristina BOTELLA Claudio BUSELLI Gianluca CASTELNUOVO Department of Psychology, Catholic University, Milan, Italy Alberto CATTANEO Gianluca CESA Isabelle CHEMIN Sara CONTI Paolo COTTONE Roberta DE FERRARI Andrea GAGGIOLI Laboratory of Psychology, Department of Preclinical Sciences LITA Vialba, University of Milan, Milan, Italy Carlo GALIMBERTI Luciano GAMBERINI Azucena GARCÍA PALACIOS Maddalena GRASSI Evelyne KLINGER Françoise LAUER Patrick LÉGERON José Antonio LOZANO Valentina MANIAS Fabrizia MANTOVANI Department of Psychology, Catholic University, Milan, Italy Giuseppe MANTOVANI Silvia MARIN Luca MENTI Enrico MOLINARI Laboratorio Sperimentale di Psicologia, Istituto Auxologico Italiano, Verbania, Italy Francesca MORGANTI Centre for Cognitive Science, Department of Psychology, University of Turin, Turin, Italy Alberto NASTA Pierre NUGUES Gabriele OPTALE Association of Medical Psychotherapists, Venice, Italy Division of Urology, Public Hospital, Venice-Mestre, Italy Massimiliano PASTORE Conxa PERPIÑÁ Carlo PIANON Soledad QUERO Beatriz REY Giuseppe RIVA Department of Psychology, Catholic University, Milan, Italy Stéphane ROY Anna SPAGNOLLI Helena VILLA Marco VILLAMIRA Brenda K. WIEDERHOLD Mark D. WIEDERHOLD
7. The use of VR in the treatment of Eating Disorders,
10. Technological Background About VR
Section 5 - The future of Cybertherapy: new scenarios and applications
Rosa M. BAÑOS
Department of Psychology, Catholic University, Milan, Italy
Roberta DE FERRARI
Laboratory of Psychology, Department of Preclinical Sciences LITA Vialba, University of Milan, Milan, Italy
Azucena GARCÍA PALACIOS
José Antonio LOZANO
Department of Psychology, Catholic University, Milan, Italy
Laboratorio Sperimentale di Psicologia, Istituto Auxologico Italiano, Verbania, Italy
Centre for Cognitive Science, Department of Psychology, University of Turin, Turin, Italy
Association of Medical Psychotherapists, Venice, Italy
Division of Urology, Public Hospital, Venice-Mestre, Italy
Department of Psychology, Catholic University, Milan, Italy
Brenda K. WIEDERHOLD
Mark D. WIEDERHOLD