Ebook: Annual Review of Cybertherapy and Telemedicine 2011

A shift is slowly and surely occurring in the realm of healthcare – the field of cybertherapy is becoming more commonly recognized and its wide array of innovative technologies is becoming more widely accepted and implemented throughout the world. Although small-scale projects may be more common than wide-scale adoption of new, cutting-edge technologies, trends are repeatedly pointing to the fact that the advantages that telehealth and mobile health, for example, have to offer – more readily accessible medical records, user friendly, reliable health advice at your fingertips, “patient-centric” care – are undeniable and work to meet the needs of all those involved in healthcare.

The growth of cybertherapy is resulting in exciting advancements in the ways in which healthcare addresses patient and caregivers' needs alike. The resulting flexibility and innovative options mean that patients are becoming more educated, more responsible, and more proactive in taking charge of their own health. This, in turn, leads to adopting and adhering to healthier lifestyle choices. The end goal of healthier bodies, healthier minds, and more efficient, effective healthcare is becoming more real and attainable each and every day.

Although the task of fully adopting and integrating these new types of healthcare into existing healthcare systems may seem a daunting task, we aim to increase awareness on a basic level. In light of the proactive nature encouraged by cybertherapy and its components, we work to provide informative research and ongoing studies of innovative teams of researchers from around the globe. We hope that this volume helps to increase awareness of developing projects, and to identify fields which are in need of further attention.

We have put a great deal of effort into the definition of the structure of the volume 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 different chapters into four main sections:

1. Critical Reviews: These chapters summarize and evaluate emerging cybertherapy topics, including technology-enhanced rehabilitation, Interreality, and Intersubjectivity;

2. Evaluation Studies: These chapters are generally undertaken to solve some specific practical problems and yield decisions about the value of cybertherapy interventions;

3. Original Research: These chapters research studies addressing new cybertherapy methods or approaches;

4. Clinical Observations: These chapters include case studies or research protocols with long-term potential.

For both health professionals and patients, the selected contents will play an important role in ensuring that the necessary skills and familiarity with the tools are available, as well as a fair understanding of the context of interaction in which they operate.

In conclusion, this volume underlines how cybertherapy has made initial progress in treating a variety of disorders. However, there is more work to be done in a number of areas, including the development of easy-to-use and more affordable hardware and software, the development of objective measurement tools, the need to address potential side effects, and the implementation of more controlled studies to evaluate the strength of cybertherapy in comparison to traditional therapies.

We sincerely hope that you will find this year's volume to be a fascinating and intellectually stimulating read. We continue to believe that together we can change the face of healthcare.

Brenda K. Wiederhold, Stéphane Bouchard, Giuseppe Riva

Although Virtual Reality (VR) treatment and Internet-based cognitive behavior therapy (CBT) have been found to be effective in a large series of studies, dissemination of these therapies in the community at large is still in its infancy. A number of reasons for the lack of dissemination are discussed, including clinicians' resistance, lack of representation of samples studied, and lack of cost-effectiveness studies. Challenges for further studies are pointed out.

Since 1996, researchers of the Interapy research group of the University of Amsterdam have been examining the effects of online cognitive behavioral treatment (online CBT). Over the years, the group conducted nine controlled trials of online CBT for a variety of mental health disorders, among a total of 840 participants. These studies suggest that online CBT is a viable and effective alternative to face-to-face treatment. Treatment adherence was 82%, and reductions in psychopathology represented a large between-group effect size of SMD = 0.9 (95% CI: .7 to 1.1), which was maintained over long periods. The research culminated in the foundation of the Interapy clinic, which received Dutch health regulatory body approval in 2005. Since then, costs of online CBT are reimbursed through public health insurance. A large study of the treatment outcome of 1,500 patients of the Interapy clinic showed that effects in clinical practice are similar to those observed in the controlled trials, and comparable to selected benchmarks of naturalistic studies of face-to-face CBT. The accumulated evidence provides compelling support for the efficacy and effectiveness of online CBT.

Disciplines such as Internet Research, the Psychology of Cyberspace and the Social Psychology of Cyberplaces call for an epistemological reflection not merely on the universe of objects they deal with, but also, and perhaps especially, on the research settings used to investigate them. With this work, we intend to make a contribution to the debate on three issues: psychosocial interpretation of the new environments, the “mediated” nature of the researcher-setting-study object relationship, and cyberplaces as settings for mediated interaction research.

In the exploration of a person's self-image in the Internet, it seems that there is one representing profile. But, is it coherent with the real self? Today we are able to perform counseling and therapeutic practices, and we can affect and change the human self and mindset in virtual spaces. Using the connection between neuroscience and philosophy, we show that there are different types of the self people adopt in cyberspace. By showing how their disposition changes many questions can be answered. What mind state provokes addictive impulses and enables therapy? How does the sense and concept of reality change? Can we transfer the experiences we gain in the virtual into real life? By investigating how the virtual affects us in a positive or negative way, support to successful treatment applications are possible. The goal of this study is to find answers for the virtual space usage as a treatment tool and to see what the future holds for such therapeutic tendencies.

The present study is aimed at analyzing the process of building and programming robots as a metacognitive tool of mathematics. Quantitative data from a study performed on a sample of students attending an Italian secondary school are described. Results showed that robotics activities may be used as a new metacognitive environment allowing students to improve their attitude towards mathematics, and to increase their attitude to reflect on themselves and on their own learning, and their higher-level control components, such as forecasting, planning, monitoring and evaluation exercises and problems related to implementation.

University students were surveyed to learn what they know about virtual realities. The two studies were administered with a half-year interval in which the students (N=90, specializing either in mathematics and science, or in social science and humanities) were asked to name particular examples of virtual realities. The second, but not the first study, was administered after the participants had the chance to see the movie “Avatar” (no investigation was held into whether they really saw it). While the students in both studies widely believed that activities such as social networking and online gaming represent virtual realities, some other examples provided by the students in the two studies differ: in the second study the participants expressed a better understanding of the items related to virtual realities. At the same time, not a single participant reported particular psychological states (either regular or altered) as examples of virtual realities. Profound popularization efforts need to be done to acquaint the public, including college students, with virtual realities and let the public adequately understand how such systems work.

In this paper we introduce a novel augmented reality based exposure therapy system for phobia treatment. This allows patients to see virtual fear stimuli overlaid onto the real world and to fully interact with them in real time. Extending on previous work, we focus on creating a controllable and interactive system (through gesture recognition and physiological sensors) with a visually realistic context. Our goal is a very life-like system that allows full parameterization over stimulus intensity and other factors necessary for an effective exposure therapy system.

The isolated effect of Virtual Reality Based Exposure Therapy (VRBET) for agoraphobia was analyzed through a comparative trial involving the first 10 agoraphobic participants. The participants were randomly assigned to two groups: VREBT only and VREBT combined with cognitive therapy. All the required Virtual Environments (VE) were created with an inexpensive Game Level Editor (GLE). Outcome measures supported the immersive effect of the VEs. Questionnaires, behavioral tests and physiological measures indicated a positive effect of VRBET alone. The addition of cognitive therapy to VREBT did not appear to generate any significant differences. Consequences for future research and practice are discussed.

In this study the effects of virtual reality exposure therapy (VRET) were investigated in patients with panic disorder and agoraphobia. The level of presence in VRET was compared between using either a head-mounted display (HMD) or a computer automatic virtual environment (CAVE). Results indicate that there was no relationship between the level of experienced presence and treatment outcome. Analyses indicate that VRET in general was more effective than no treatment. No differences in effectiveness were found between VRET using an HMD or CAVE.

A Stress Inoculation Training-based protocol tested if multimedia audio-video content induced emotional changes and reduced exam anxiety in university students. Seventy-five participants took part in six experimental sessions consisting of viewing multimedia content and performing relaxation exercises. Participants were randomly assigned to five experimental groups: 1) audio and video narrative on mobile phone (UMTS); 2) audio and video narrative on DVD (DVD), 3) audio narrative on MP3 player (M3), 4) audio narrative on CD (CD), 5) control group (CTRL). Results showed that audio/video content induced a significant reduction in exam anxiety and an increase of relaxation in students, compared to the audio-only contents.

Several forms of treatment for nicotine dependence that combine the classical smoking cessation strategies with new Virtual Reality (VR) exposure techniques to smoking-related cues are in development. In this line, the main goal of our study was to develop a virtual platform in order to induce cravings in smokers. Sixty undergraduate students were randomly assigned to two different virtual environments (high-arousal cues and low-arousal cues). Both environments were based on a three-room apartment with commercial music playing and virtual characters interacting in a social event. The assessment was carried out before and after exposure through psychophysiological activation and self-report data for craving and nicotine dependence levels. No statistical differences were observed between smokers and non-smokers in psychophysiological activation. As far as self-report data is concerned, smokers revealed a significant increase in craving after the VR exposure to high arousal environments. Overall results were in line with previous studies suggesting the use of virtual environments as a tool for the existing smoking cessation programs.

The current study explores the effects of interactive versus passive Virtual Reality (VR) distraction on the sense of presence and pain intensity. Sixty-eight healthy students (mean age 21.8, SD = 4.3) underwent two consecutive cold-pressor trials (subject's hand immersed into 6 °C water as long as possible, with a time limit of five minutes), one without VR and another providing a VR distraction “Surreal World.” Participants were randomly assigned to an interactive VR distraction condition, where a number of interactions with the environment were possible, or to a passive VR distraction condition, where they were also exposed to the surreal world, but instead of interacting with the virtual environment, they watched the navigation generated by another participant assigned to the interactive condition. After the VR cold-pressor trial, each subject provided ratings of pain intensity and rated the degree to which they had felt “present” in the virtual environment. Results showed that most of the participants who experienced the interactive VR distraction reported less pain intensity relative to the no-VR trial. However, in the passive VR condition, only 5.9% of participants showed a decreased level of pain intensity relative to the no-VR trial. Also, the amount of presence reported was significantly higher during the interactive VR distraction and correlated negatively with pain intensity scores.

The use of Virtual Reality (VR) could be a useful tool for the improvement of Cue Exposure Therapy (CET) for smoking cessation. Nevertheless, it is necessary to know the appropriate parameters of exposure in order to develop efficacious treatment programs. This study was conducted to analyze the pattern of tobacco desire in a sample of smokers exposed to VR. Results showed that the environments were able to generate two different patterns of craving response. These results could contribute to determine exposure parameters when using VR technology in CET.

The aim of this study was to examine the influence of several modulating variables on subjective discomfort experienced by patients with eating disorders while exposed to virtual environments that were emotionally significant for them. Severity of symptoms and sense of presence were analyzed. Both variables influenced the level of subjective discomfort during the exposure to virtual environments.

A Virtual Reality (VR) environment was created to study psychotic symptoms in patients and non-patients. Participants' task was to find five virtual characters that each had a small number label on his or her chest. The density and ethnic appearance of the virtual characters in the bar was controlled. For a non-patient group (N=24), results showed a significant main effect for density on participants' physiological responses, their behavior, reported level of discomfort, and their ability to remember place and location of the numbered avatars. The avatar's ethnicity had a significant effect on non-patients' physiological responses. Comparison between two patients and non-patient group showed differences in physiological responses, behavior and reported level of discomfort.

The purpose of this study was to establish ecological validity and initial construct validity of the Virtual Reality (VR) version of the Multiple Errands Test (MET) (Shallice & Burgess, 1991; Fortin et al., 2003) based on the NeuroVR software as an assessment tool for executive functions. In particular, the MET is an assessment of executive functions in daily life, which consists of tasks that abide by certain rules and is performed in a shopping mall-like setting where items need to be bought and information needs to be obtained. The study population included three groups: post-stroke participants (n = 5), healthy, young participants (n = 5), and healthy, older participants (n = 5). Specific objectives were (1) to examine the relationships between the performance of three groups of participants in the Virtual Multiple Errands Test (VMET) and at the traditional neuropsychological tests employed to assess executive functions and (2) to compare the performance of post-stroke participants to those of healthy, young controls and older controls in the VMET and at the traditional neuropsychological tests employed to assess executive functions.

Research has indicated that use of cognitive skills training tools can produce positive benefits with older adults. However, little research has compared the efficacy of technology-based interventions and more traditional, text-based interventions which are also available. This study aimed to investigate cognitive skills improvements experienced by 40 older adults using cognitive skills training tools. A Solomon 4 group design was employed to determine which intervention demonstrated the greatest improvement. Participants were asked to use the interventions for 5-10 minutes per day, over a period of 60 days. Pre and post-tests consisted of measures of numerical ability, self-reported memory and intelligence. Following training, older adults indicated significant improvements on numerical ability and intelligence regardless of intervention type. No improvement in selfreported memory was observed. This research provides a critical appraisal of brain training tools and can help point the way for future improvements in the area. Brain training improvements could lead to improved quality of life, and perhaps, have financial and independent living ramifications for older adults.

For decades, empirical studies have shown the effectiveness of exposure techniques when used in cognitive-behavioral therapy (CBT) treatment for anxiety disorders. A few studies are now suggesting that using Virtual Reality (VR) may be an effective way to conduct exposure and overcome some of the limitations of in vivo exposure. The aim of this study is to validate the Specific Work for Exposure Applied in Therapy (SWEAT) questionnaire that measures costs and efforts required to conduct in vivo and in virtuo exposure. A total of 265 exposure sessions (in vivo = 140; in virtuo = 125) were rated by experienced psychologists. Reliability analysis revealed three main factors in the construct of the SWEAT questionnaire. Results also showed that conducting exposure in VR is less of a burden and more readily adapted to the patients' needs than in vivo.

The main aim of this study is to investigate whether the control the user has over a virtual environment (VE) influences the sense of presence. A secondary purpose is to explore the relationship between Virtual Reality (VR) presence and pain tolerance during a cold-pressor experience. Ninety-four participants underwent two consecutive cold-pressor trials, one without VR exposure and the other providing a VR stereoscopic figure used as a symbolic representation of the sensation of pain. Participants were randomly assigned to an interactive condition in which they could actively manipulate the VR figure to achieve a pleasant, tranquil environment (analogous to no-pain situation) or to a passive intervention, in which they observed the changes in the VR figure. Results showed that the amount of VR presence reported was significantly higher in the interactive condition. Participants had a higher pain tolerance during both VR conditions than in the no-VR trial, with a greater increase in pain tolerance from the non-VR trial in the interactive condition. Presence scores correlated significantly and positively with pain tolerance scores. We discuss the importance of VR interaction and control over the VR environments used in VR pain interventions designed to increase cognitive control over pain.

Within perceptual psychology, visual masking describes a process whereby the presentation of one image, the mask, affects the conscious perception of another, the target. Given the right conditions the target can effectively be rendered invisible. There is a dearth of research into the effects of visually masked stimuli within virtual environments, particularly with regard to affect psychology. Of the two studies presented here, the first study was used to establish the efficacy of visual masking using three dimensional, masked objects. Usually, mask and target stimuli are co-planar, with no internal depth disparity. This study found that visual masking is possible within a virtual space using target objects with internal depth disparity. The second study investigated affect driven, choice reactions to three dimensional, masked facial expressions. This study also found an effect, specifically an unconscious bias to navigate away from angry, masked faces and towards smiling, masked expressions. These two studies form a foundation for a wider project: using visual masking within a virtual environment for mood induction, primarily as a cybertherapeutic aid.

We herein report an experimental study examining the potential positive effects of Virtual Reality (VR) feedback during an indoor bicycling exercise. Using a regular bike coupled to a VR system, we compared conditions of no VR feedback, VR feedback and VR feedback with the presence of a virtual coach, acting as a pacer. In VR feedback conditions, we observed a decreased level of perceived exertion and an increased level of enjoyment of physical activity, when compared to a regular exercise situation (no VR feedback). We also observed a shift in the subjects' attentional focus, from association (in the absence of VR feedback) to dissociation (in VR feedback conditions). Moreover, the presence of a virtual coach in the VR environment triggered a systematic regulation of the (virtual) displacement speed, whose relationship with perceived enjoyment and exertion require further work.