Ebook: Annual Review of Cybertherapy and Telemedicine 2014

Healthcare delivery systems have been evolving to rely more heavily on technology. There has been a shift in care prevention, diagnosis and treatment which has decreased the importance of traditional methods of care delivery.

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 six main sections:

1. Editorial: This introductory text expresses the position of the Editors – Brenda K. Wiederhold and Giuseppe Riva – about the focus of this year issue;

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

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

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

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

6. Work in Progress: These chapters include papers describing a future research work.

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 started to make 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 are grateful to Chelsie Boyd from the Virtual Reality Medical Institute for her work in collecting and coordinating chapters for this volume. 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

Secretary General

International Association of CyberPsychology

Training, and Rehabilitation (iACToR)

Giuseppe Riva

President

International Association of CyberPsychology

Training, and Rehabilitation (iACToR)

How do we lastingly change our lives for the better? There is not an easy answer to this question. However, due to the advances in psychology and neuroscience, now we have a better view of personal change, that is not limited to a specific viewpoint. In particular, the emergence of integrative and transdiagnostic accounts suggests that change is contextual, depending on the person, the issues, and the situation. More, personal change is a process, happening in discontinuous and nonlinear ways, following life transitions and traumatic events. In this process a key role can be played by technology: using the “Positive Technology” approach it is possible to use technology to manipulate the quality of experience, with the goal of increasing wellness, and generating strengths and resilience in individuals, organizations and society.

Academic and managerial interest in patient engagement is rapidly earning attention and becoming a necessary tool for researchers, clinicians and policymakers worldwide to manage the increasing burden of chronic conditions. The concept of patient engagement calls for a reframe of healthcare organizations' models and approaches to care. This also requires innovations in the direction of facilitating the exchanges between the patients and the healthcare. eHealth, namely the use of new communication technologies to provide healthcare, is proved to be proposable to innovate healthcare organizations and to improve exchanges between patients and health providers. However, little attention has been still devoted to how to best design eHealth tools in order to engage patients in their care. eHealth tools have to be appropriately designed according to the specific patients' unmet needs and priorities featuring the different phases of the engagement process. Basing on the Patient Engagement model and on the Positive Technology paradigm, we suggest a toolkit of phase-specific technological resources, highlighting their specific potentialities in fostering the patient engagement process.

We describe the main features and preliminary evaluation of Positive Technology, a free mobile platform for the self-management of psychological stress (http://positiveapp.info/). The mobile platform features three main components: (i) guided relaxation, which provides the user with the opportunity of browsing a gallery of relaxation music and video-narrative resources for reducing stress; (ii) 3D biofeedback, which helps the user learning to control his/her responses, by visualizing variations of heart rate in an engaging 3D environment; (iii) stress tracking, by the recording of heart rate and self-reports. We evaluated the Positive Technology app in an online trial involving 32 participants, out of which 7 used the application in combination with the wrist sensor. Overall, feedback from users was satisfactory and the analysis of data collected online indicated the capability of the app for reducing perceived stress levels. A future goal is to improve the usability of the application and include more advanced stress monitoring features, based on the analysis of heart rate variability indexes.

Carrying out a diagnostic interview requires skills that need to be taught in a controlled environment. Virtual Reality (VR) environments are increasingly used in the training of professionals, as they offer the most realistic alternative while not requiring students to face situations for which they are yet unprepared. The results of the training of diagnostic skills can also be generalized to any other situation in which effective communication skills play a major role. Our aim with this study has been to develop a procedure of formative assessment in order to increment the effectiveness of virtual learning simulation systems and then to assess their efficacy.

With the emergence of mobile health (mHealth) apps, there is a growing demand for better tools for developing and evaluating mobile health interventions. Recently we developed the Personal Health Intervention Toolkit (PHIT), a software framework which eases app implementation and facilitates scientific evaluation. PHIT integrates self-report and physiological sensor instruments, evidence-based advisor logic, and self-help interventions such as meditation, health education, and cognitive behavior change. PHIT can be used to facilitate research, interventions for chronic diseases, risky behaviors, sleep, medication adherence, environmental monitoring, momentary data collection health screening, and clinical decision support. In a series of usability evaluations, participants reported an overall usability score of 4.5 on a 1-5 Likert scale and an 85 score on the System Usability Scale, indicating a high percentile rank of 95%.

This study aimed to evaluate the reliability and validity of the Neuro-Virtual Reality as tool for the neuropsychological assessment in OCD patients. We used the neuropsychological battery and a virtual version of the Multiple Errand Test (V-MET), developed using the NeuroVR software, in order to evaluate the executive functions, the ability to plan ahead on complex problem solving tasks in daily life in 30 obsessive compulsive disorder (OCD) patients and 30 healthy controls. The results showed the presence of difficulties of OCD patients: lower levels of divided attention and higher levels of errors; higher mean rank of inefficiencies, interpretation failures and rule breaks and longer time of execution of the whole task. By contrast, controls have higher level of efficiency and better performance. In addition, a significant correlation was found between the V-MET and the neuropsychological battery which confirms and supports the ecological validity of neurocognitive assessment through NeuroVirtual Reality.

Yukendu is a personal mobile coaching service that supports people in reaching good levels of psychological and physical wellbeing through the use of an app and a relationship with a health coach. Presenting Yukendu's app functioning, this paper aims not only to show that by means of web 2.0 tools is possible to manage in a functional way effective eHealth coaching interactions, but also that relationships between a coach and a coachee managed in such a way give birth to what we could call a ‘cyber-wellbeing-place’.

Adults with serious mental illnesses (e.g., Autism Spectrum Disorder [ASD], schizophrenia, post-traumatic stress disorder [PTSD]) often have difficulties obtaining employment. The Job Interview Training System with Molly Porter, developed in collaboration with Yale and Northwestern Universities and vocational rehabilitation specialists with funding from The National Institutes of Health (R43/44MH080496), allows learners to practice job interviews on computers in a stress free environment. The system includes user-driven educational materials, an interactive job application, a practice simulation with a fictional interviewer (Molly Porter), and extensive feedback. SIMmersion's PeopleSIM™ technology allows each conversation with Molly to provide a unique interview experience, enabling users to gain confidence while building skills. The on-screen coach provides insight during the conversation, and a comprehensive after-action review provides learners with feedback on the entire interview. In a randomized control trial, the system was proven effective at improving participants' interview skills and confidence. Ninety-six (96) unemployed adults with ASD (n=26), schizophrenia/other (n=37) or PTSD (n=33) were recruited. Participants were randomized into control (n=32) and experimental (n=64) conditions. The control group was “wait-listed” to receive training, and the experimental group used the training system with Molly Porter. Both groups completed pre- and post-intervention role-play interviews and self-assessment questionnaires. Analyses of covariance showed that the simulation provided a highly significant training effect, with experimental group participants scoring better in the role-play interviews and self-assessing higher than control group participants. By increasing skills and confidence, this system may ultimately reduce the length of unemployment for adults with mental illnesses.

Although virtual reality exposure has been reported as a method to induce paranoid thought, little is known about mechanisms to control specific virtual stressors. This paper reports on a study that examines the effect of controlling the stream of potential paranoia evoking events in a virtual restaurant world. A 2-by-2 experiment with a non-clinical group (n = 24) was conducted with as two within-subject factors: (1) the cycle time (short/long) for when the computer considers activation of a paranoia evoking event and (2) the probability that a paranoia-evoking event (low/high) would be triggered at the completion of a cycle. The results showed a significant main effect for the probability factor and two-way interaction effect with the cycle time factor on the number of paranoid comments participants made and their self-reported anxiety.

Functional magnetic resonance imaging (fMRI) is helping us better understand the neurologic pathways involved in posttraumatic stress disorder (PTSD). We previously reported that military service members with PTSD after deployment to Iraq or Afghanistan demonstrated significant improvement, or normalization, in the fMRI-measured activation of the amygdala, prefrontal cortex and anterior cingulate gyrus following exposure therapy for PTSD. However, our original study design did not include repeat scans of control participants, rendering it difficult to discern how much of the observed normalization in brain activity is attributable to treatment, rather than merely a practice effect. Using the same Affective Stroop task paradigm, we now report on a larger sample of PTSD-positive combat veterans that we treated with exposure therapy, as well as a combat-exposed control group of service members who completed repeat scans at 3-4 month intervals. Findings from the treatment group are similar to our prior report. Combat controls showed no significant change on repeat scanning, indicating that the observed differences in the intervention group were in fact due to treatment. We continue to scan additional study participants, in order to determine whether virtual reality exposure therapy has a different impact on regional brain activation than other therapies for PTSD.

Realistic models in virtual reality training applications are considered to positively influence presence and performance. The experimental study presented, analyzed the effect of simulation fidelity (static vs. animated audience) on presence as a prerequisite for performance in a prototype virtual fear of public speaking application with a sample of N = 40 academic non-phobic users. Contrary to the state of research, no influence was shown on virtual presence and perceived realism, but an animated audience led to significantly higher effects in anxiety during giving a talk. Although these findings could be explained by an application that might not have been realistic enough, they still question the role of presence as a mediating factor in virtual exposure applications.

The objective of this study was to identify frequent situations and specific cues that produce the craving to binge in Spanish and Italian samples of patients with eating disorders (ED). There were two main aims: to assess transcultural differences in the contexts and cues that elicit food craving; and to develop valid, reliable VR environments for effective cue-exposure therapy (CET) for patients from both countries. Twenty-six Spanish and 75 Italian ED patients completed an ad hoc questionnaire to assess contexts and cues that trigger the craving to binge. No differences between groups were found. All patients reported experiencing higher levels of craving in the afternoon/early evening and in the late evening/night, between meals, when alone, and more frequently at the end of the week. Being in the dining room, the kitchen, the bedroom, the bakery and the supermarket were the specific situations that produced the highest levels of craving to binge. We used the questionnaire results to develop a virtual reality application for CET.

Using the dual mediation hypothesis, this study investigates the role of interestingness (the power of attracting or holding one's attention) attitude towards the news, in the formation of Facebook Fan Page users' electronic word-of-mouth intentions. A total of 599 Facebook fan page users in Taiwan were recruited and structural equation modeling (SEM) was used to test the research hypotheses. The results show that both perceived news entertainment and informativeness positively influence interestingness attitude towards the news. Interestingness attitude towards the news subsequently influences hedonism and utilitarianism attitudes towards the Fan Page, which then influence eWOM intentions. Interestingness attitude towards the news plays a more important role than hedonism and utilitarianism attitudes in generating electronic word-of-mouth intentions. Based on the findings, the implications and future research suggestions are provided.

The INTERSTRESS project developed a completely new concept in the treatment of psychological stress: Interreality, a concept that combines cognitive behavioral therapy with a hybrid, closed-loop empowering experience bridging real and virtual worlds. This model provides the opportunity for individual citizens to become active participants in their own health and well-being. This article contains the results of the Marketing Trial and analysis of the opinions of individual consumers/end users of the INTERSTRESS product. The specific objective of this study was to evaluate the feasibility, efficacy and user acceptance of a novel mobile-based relaxation training tool in combination with biofeedback exercises and wearable biosensors. Relaxation was aided through immersion in a mobile virtual scenario (a virtual island) featuring pre-recorded audio narratives guiding a series of relaxation exercises. During biofeedback exercises, a wearable biosensor system provided data which directly modified the virtual reality experience in real-time. Thirty-six participants evaluated the product and overall feedback from users was positive, with some variation seen based on participant gender. A larger market study is now underway to understand if there are cultural variations in acceptability of the device.

Chronic stress in young adults has become a growing problem within recent decades and many are unable to find cost-effective and accessible treatment for psychological stress in their daily lives. We analyze the market of using a mobile application, Positive Technology, as a solution. Eleven participants, aged between 18 and 24, participated in the exercise. Self-reported stress reduction was measured via an online marketing survey, while physiological measurements were monitored via peripheral devices. Secondary goals assessed the app's ease-of-use, accessibility, and cost. Results indicate that participants enjoyed the availability of the mobile solution and found the app to be fun and easy to learn. Stress levels were reduced in 73% of the participants, with higher effects in females and in participants aged 18–24. We conclude that the mobile platform is an effective means of delivering psychological stress reduction, and could provide an accessible, cost-effective solution.

Sensory pathways, consisting of chains of neurons, which spread from the receptor organ to the cerebral cortex, are responsible for the perception of sensations (including pain). In this study, we set out to determine how effective virtual reality (VR) could be in distracting patients from pain experienced through thermoreceptors on the skin. Six healthy subjects were exposed to uncomfortable pain stimuli with and without VR distraction. Subjects reported a drop in pain while in the VR environment, and mean pain rating was significantly lower than the session with no VR distraction. These results indicate that VR distraction can diminish pain experienced by subjects, thus we conclude by eliciting future directions for quantifying effectiveness of VR as a pain management solution.

Parents use active and restrictive mediation strategies to guide and regulate children's online participation and the online risks they encounter. However, changes in parental mediation do occur over time and the effectiveness of these strategies on cyberbullying demands for further empirical investigation. The current study addresses these issues with a sample of 1084 students (49% girls) in a longitudinal, three-wave design. Gender differences were tested via multi-group analyses. Longitudinal growth models showed that parental use of both active and restrictive mediation decreased over time. For both types of mediation, the mean rate of change had a significant effect on boys' engagement in cyberbullying, but not for girls. Initial levels of restrictive mediation, but not active mediation, were found to be significantly predictive of cyberbullying in both genders. Girls had higher initial levels of both parental mediation types in comparison to boys. The results reveal that the effectiveness of active and restrictive mediation in relation to students' cyberbullying differs and informs us on gender differences. The implications of these results for parental education in online mediation are discussed.

Stroke is a major cause of cognitive impairments. New technologies such as virtual reality and mobile apps have opened up new possibilities of neuropsychological assessment and intervention. This paper reports a controlled study assessing cognitive functioning through a mobile virtual reality application. Fifteen stroke patients recruited from a rehabilitation hospital and 15 healthy control subjects underwent neuropsychological evaluation with traditional paper-and-pencil tests as well as with a pilot version of the Systemic Lisbon Battery (SLB). The criterion validity was the performance of stroke patients vs. healthy controls – which was lower both on the neuropsychological tests and on the SLB for patients. The pattern of correlations between neuropsychological tests and the SLB sub-tests for the respective dimensions showed overall moderate correlations in the predicted directions. We conclude that the SLB applications were able to discriminate the dimensions that they were designed to assess.

The purpose of this study was to explore people's conceptual understanding of Social Networking Sites (SNSs) through exploring the combined use of a range of popular SNSs, including Facebook, Twitter, Myspace, Instagram, Tumblr, LinkedIn and Google Plus. Seventy-three adults, aged 18 to 63, participated in an online survey that used open-ended questions to ask how participants define and use different SNSs. Four themes were identified, including the explicit presentation and interpretation of different selves, the love-hate relationship with SNSs, privacy and danger concerns, and limited SNS knowledge. The findings from this study suggest that researchers need to consider how people use SNSs in combination as this influences the decisions people make about which SNS accounts they use and how they present themselves on these sites.

This study will examine the use of an online role-playing experiment as a cyberbullying intervention tool. The study will be carried out among 14 – to 18-year old adolescents (N = 200). Respondents will be assigned a fictitious character and a role (perpetrator, victim or bystander) in a cyberbullying situation. They will be asked to identify with this character and act accordingly in an initiated mock, but realistic online bullying situation. We expect, based on role playing literature and bullying prevention programs, a positive change in the adolescents' behavioral intentions (e.g. defending a victim).