Ebook: Annual Review of Cybertherapy and Telemedicine 2015

ARCTT is a peer-reviewed all-purpose journal covering a wide variety of topics of interest to the mental health, neuroscience, and rehabilitation communities. This mission of ARCTT is to provide systematic, periodic examinations of scholarly advances in the field of Cybertherapy and Telemedicine through original investigations in the telemedicine and cybertherapy areas, novel experimental clinical studies, and critical authoritative reviews.

Healthcare delivery systems have been evolving to rely more heavily on technology. There has been a shift in care diagnosis and treatment which has decreased the importance of traditional methods of care delivery. Technology has not only helped to extend our lifespan, but it has improved the quality of life for all citizens.

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, Giuseppe Riva, and Mark D. Wiederhold – 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 Julie Lebrun, Clemence Braissand, and Emily LaFond from the Virtual Reality Medical Institute for their 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

Giuseppe Riva

Mark D. Wiederhold

The 90s and 00s saw great hopes that virtual reality was poised to sweep health care and change everything. But it didn't. Though researchers could immerse themselves in more complex virtual environments, the chasm between that digital experience and the complexity of real life – using a VR system in an hospital without a dedicated technician was a real challenge – just was too great. Now the situation is changing quickly. The rise of Oculus Rift and the shift of virtual reality from PC to mobile phones thanks to both the Oculus designed Gear VR headsets for Samsung phones and the Google Cardboard project are going to transform health care tools and experiences.

To date, there has been a lack of consensus among researchers, practitioners, and laypersons about the definition of cyberbullying. Researchers have typically applied the key characteristics of intent to harm, power imbalance, and repetition from the definition of traditional bullying to cyberbullying, but how these characteristics transfer from the real world to a technology-mediated environment remains ambiguous. Moreover, very few studies have specifically investigated how cyberbullying is defined from the perspective of bullies, victims and bystanders. To this end, this article will propose a three-part definition of cyberbullying, which incorporates the perspective of bullies, victims and bystanders.

The purpose of this study is to theoretically develop and empirically examine a general coping theory model which explicates the indirect effects of key job-related techno-stressors on job exhaustion. Through this study, we show that techno-stress creators are detrimental to employee well-being and should be treated accordingly. Specifically, we first argue that key techno-stress creators on the job, namely techno-invasion and techno-overload, drive unpleasant states such as work-family conflict and distress. Next, we rely on general coping theory and argue that people respond to these states differently, but with both adaptive and maladaptive technology-specific coping strategies. Adaptive coping behaviors are argued to ultimately reduce work exhaustion, and maladaptive coping strategies are argued to increase it. The proposed model was tested and validated with structural equation modeling techniques applied to self-reported data obtained from a sample of 242 employees of a large organization in the United States. Implications for theory and practice are discussed.

Military service members (SMs) are surviving complex battlefield injuries at higher rates than ever before. Cutting-edge technologies are increasingly being employed to improve assessment and treatment of these complex injuries. The Computer Assisted Rehabilitation Environment (CAREN) is a comprehensive immersive environment, featuring a treadmill, curved panoramic screen, audio array, and infrared cameras to capture movement. While the CAREN has been progressively incorporated in treatment and research, little has been reported regarding participants' subjective experiences, particularly in relation to the signature wounds of the Iraq and Afghanistan wars, traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). Here we report participant presence, in a cohort of SMs with complex, frequently dual-diagnosis injuries (N=148; 95% TBI; 58% PTSD) engaging in CAREN-driven treatment. Using a presence questionnaire, participants rated aspects of the CAREN on a 7-point Likert scale and a presence score was calculated. The average presence score was 46.83 (SD=6.04; possible score range 7-63), with 95% of participants reporting scores >36. Those with motion sickness and eye discomfort reported lower presence, whereas those with PTSD reported higher presence. Presence did not vary according to TBI severity. Overall, SMs with complex injuries experience presence in the CAREN. However, presence may be adversely affected by CAREN-associated symptoms such as motion sickness.

Augmented reality based applications have been experimented with in various contexts. Typically, the interaction is supported by handled devices, which, in specific scenarios, may hinder the interaction and spoil the experience of use, as the user is forced to hold the device and to keep her eyes on it at all times. The recent launch on the market of light-weight, unobtrusive head-mounted displays may change this circumstance. Nevertheless, investigations are needed to understand if such head-worn devices effectively outperform handheld devices in terms of comfort and pleasant experience of use. Here we present two experiments aimed at assessing the comfort of wearing a head-worn, see-through AR viewer in both a controlled and a natural setting. Besides the comfort of wearing the device, aspects related to the user experience were also investigated in the field evaluation. Our findings suggest that the head-mounted display examined is comfortable to wear regardless of the context of use. Interestingly in the field trails, participants did not express concern for the impression they would have made on other people and the experience of use was overall pleasant. Possible issues related to visual fatigue emerged.

The main goal of this contribution is to present a methodological framework to study Networked Flow, a bio-psycho-social theory of collective creativity applying it on creative processes occurring via a computer network. First, we draw on the definition of Networked Flow to identify the key methodological requirements of this model. Next, we present the rationale of a mixed methodology, which aims at combining qualitative, quantitative and structural analysis of group dynamics to obtain a rich longitudinal dataset. We argue that this integrated strategy holds potential for describing the complex dynamics of creative collaboration, by linking the experiential features of collaborative experience (flow, social presence), with the structural features of collaboration dynamics (network indexes) and the collaboration outcome (the creative product). Finally, we report on our experience with using this methodology in blended collaboration settings (including both face-to-face and virtual meetings), to identify open issues and provide future research directions.

In the UNAM Faculty of Odontology, we use a stereoscopic 3D teaching method that has grown more common in the last year, which makes it important to know whether students can learn better with this strategy. The objective of the study is to know, if the 4th year students of the bachelor's degree in dentistry learn more effectively with the use of stereoscopic 3D than the traditional method in Orthodontics.

Methods: first, we selected the course topics, to be used for both methods; the traditional method using projection of slides and for the stereoscopic third dimension, with the use of videos in digital stereo projection (seen through “passive” polarized 3D glasses). The main topic was supernumerary teeth, including and diverted from their guide eruption. Afterwards we performed an exam on students, containing 24 items, validated by expert judgment in Orthodontics teaching. The results of the data were compared between the two educational methods for determined effectiveness using the model before and after measurement with the statistical package SPSS 20 version.

The results presented for the 9 groups of undergraduates in dentistry, were collected with a total of 218 students for 3D and traditional methods, we found in a traditional method a mean 4.91, SD 1.4752 in the pretest and X=6.96, SD 1.26622, St Error 0.12318 for the posttest. The 3D method had a mean 5.21, SD 1.996779 St Error 0.193036 for the pretest X= 7.82, SD =0.963963, St Error 0.09319 posttest; the analysis of Variance between groups F= 5.60 Prob > 0.0000 and Bartlett's test for equal variances 21.0640 Prob > chi² = 0.007. These results show that the student's learning in 3D means a significant improvement as compared to the traditional teaching method and having a strong association between the two methods.

Conclusion: The findings suggest that the stereoscopic 3D method lead to improved student learning compared to traditional teaching.

Three studies were conducted to examine the effect of audio on people's experience in a virtual world. The first study showed that people could distinguish between mono, stereo, Dolby surround and 3D audio of a wasp. The second study found significant effects for audio techniques on people's self-reported anxiety, presence, and spatial perception. The third study found that adding sound to a visual virtual world had a significant effect on people's experience (including heart rate), while it found no difference in experience between stereo and 3D audio.

The present work seeks to examine the importance of expectancies in computer-mediated treatment and training programs. Two studies examining the role of patient and trainee expectations are presented. Study 1 investigated how expectations of a training game for military surgical teams influence training performance outcomes. The findings have implications for the administration of game-based treatment and training systems. Study 2 explored how pre-treatment expectancies influence post-treatment reactions to a game-based intervention for post-traumatic stress disorder (PTSD). Results indicate that self-efficacy plays a mediating role in the relationship between expectancies and reactions. Together, these studies offer implications regarding the critical role of attitudes towards game-based training and treatment mechanisms.

Neuropsychological disorders are common in Obsessive-Compulsive Disorder (OCD) patients. Executive functions, verbal fluency and verbal memory, shifting attention from one aspect of stimuli to others, mental flexibility, engaging in executive planning and decision making, are the most involved cognitive domains. We focus on two aspects of neuropsychological function: decision making and cognitive behavioral flexibility, assessed through a virtual version of the Multiple Errand Test (V-MET), developed using the NeuroVR software. Thirty OCD patients were compared with thirty matched control subjects. The results showed the presence of difficulties in OCD patients with tasks where the goal is not clear, the information is incomplete or the parameters are ill-defined.

Virtual reality exposure therapy (VRET) applications use high levels of fidelity in order to produce high levels of presence and thereby elicit an emotional response for the user (like fear for phobia treatment). State of research shows mixed results for the correlation between anxiety and presence in virtual reality exposure, with differing results depending on specific anxiety disorders. A positive correlation for anxiety and presence for social anxiety disorder is not proven up to now. One reason might be that plausibility of the simulation, namely including key triggers for social anxiety (for example verbal and non-verbal behavior of virtual agents that reflects potentially negative human evaluation) might not be acknowledged in current presence questionnaires. A German scale for measuring co-presence and social presence for virtual reality (VR) fear of public speaking scenarios was developed based on a translation and adaption of existing co-presence and social presence questionnaires. A sample of N = 151 students rated co-presence and social presence after using a fear of public speaking application. Four correlated factors were derived by item- and principle axis factor analysis (Promax rotation), representing the presenter's reaction to virtual agents, the reactions of the virtual agents as perceived by the presenter, impression of interaction possibilities, and (co-)presence of other people in the virtual environment. The scale developed can be used as a starting point for future research and test construction for VR applications with a social context.

The general aim of the present study was to investigate the effect of an interactive aerial view of the experienced environment during the encoding and retrieving of spatial information on the feeling of presence. Our findings showed that this real-time interactive aerial view (both small and large) during the encoding and retrieval of spatial information seems to led to a greater sense of presence. It is argued that the use of this aerial view, which provides a real-time allocentric viewpoint-dependent spatial representation, would ease the translation of a stored allocentric representation into an egocentric one, and this process, consequently, would help individuals to feel present in space.

Therapists' attitudes towards the use of computerized therapies have been the focus of numerous studies. Nevertheless, little is known about therapists' perception of a combined model that uses computerized methods as adjuncts to face-to-face (FTF) therapy. Current study surveyed 87 Israeli therapists' attitudes towards such combined model. Results show that more than half of therapists find it as potentially more effective than regular therapy, better for providing feedback and maintaining continuity of care. More than a third of the therapists found it may elicit better patient satisfaction and engagement. With respect to different modalities, therapists indicated that e-mail correspondence are better suited for combining with FTF treatments. Theoretical orientation had little effect on practitioners' attitudes. Finally, more than half of the therapists showed willingness to undergo training for a combined model. Compared to previously researched computerized interventions, current study indicates more positive attitudes and acceptability among therapists towards an integrative model.

Enhancing the ability to perform differential diagnosis and psychopathological exploration is important for students who wish to work in the clinical field, as well as for professionals already working in this area. Virtual reality (VR) simulations can immerse students totally in educational experiences in a way that is not possible using other methods. Learning in a VR environment can also be more effective and motivating than usual classroom practices. Traditionally, immersion has been considered central to the quality of a VR system; immersive VR is considered a special and unique experience that cannot achieved by three-dimensional (3D) interactions on desktop PCs. However, some authors have suggested that if the content design is emotionally engaging, immersive systems are not always necessary.

The main purpose of this study is to compare the efficacy and usability of two low-cost VR systems, offering different levels of immersion, in order to develop the ability to perform diagnostic interviews in eating disorders by means of simulations of psychopathological explorations.

Teenage Internet users are the fastest growing segment in the Internet user population. These teenagers are at risk of sexual assault from Internet predators. This phenomenological study explored teacher and counselors' perceptions of how to prevent this sexual assault. Twenty-five teacher and counselor participants were interviewed. A modified van Kaam method was used to analyze the data and develop themes. Participants stated that mainly the lack of parental support and social networking website were the circumstances leading to teenage Internet sexual assault, while teen needs and gratification usually played a role in teen encounters with predators on the Internet. There were 5 emergent themes in this phenomenological study and those themes were; lack of parental support, social networking websites and chat rooms, teenage need for relationships, instant gratification among teenagers, improved parental support.

The advent of cloud computing and a multi-platform digital environment is giving rise to a new phase of human identity called “The Distributed Self.” In this conception, aspects of the self are distributed into a variety of 2D and 3D digital personas with the capacity to reflect any number of combinations of now malleable personality traits. In this way, the source of human identity remains internal and embodied, but the expression or enactment of the self becomes increasingly external, disembodied, and distributed on demand. The Identity Mapping Project (IMP) is an interdisciplinary collaboration between psychology and computer Science designed to empirically investigate the development of distributed forms of identity. Methodologically, it collects a large database of “identity maps” – computerized graphical representations of how active someone is online and how their identity is expressed and distributed across 7 core digital domains: email, blogs/personal websites, social networks, online forums, online dating sites, character based digital games, and virtual worlds. The current paper reports on gender and age differences in online identity based on an initial database of distributed identity profiles.

In the United States, most adolescents do not obtain the recommended amounts of physical activity for optimal health. Around 80% of adolescents own a mobile device, and social media is frequently used by adolescents on mobile devices. Few studies have examined the use of social media as part of an intervention to promote physical activity. The purpose of this study was to evaluate the use of a Facebook group as part of a mHealth physical activity intervention trial. Adolescents, ages 14-18 years, were recruited for a four week physical activity intervention using the FitBit Flex. Participants were also given the option to join a private Facebook group where they could interact and were given badges for fitness accomplishments. The research assistant moderator posted on the Facebook group an average of 25.3 times (SD=7.2). Post-intervention, participants completed a phone interview about their experience. Of 30 intervention participants (avg age 16.0 (SD=1.1), 60.0% female), 17 opted to join the Facebook group (avg age 16.3 (SD=1.2), 47.0% female) of which 10 completed a qualitative interview. Participants averaged 4.9 interactions (SD=8.7) on the Facebook group wall throughout the intervention. From the interview responses, major themes included enjoying the badge feature of the Facebook group and wanting more content and interaction. In conclusion, participants used and enjoyed having the Facebook group, particularly the badge feature of the group, as an adjunct to the physical activity intervention.

The current study investigated how adolescents behave on Social Networking Sites (SNSs) and how they interpret the feedback they receive online from others. Thirty-four Australian adolescents (26 girls, 8 boys) aged 13 to 17 years participated in the study. Five semi-structured focus groups (3 mixed groups, 2 all-girl groups) were conducted to explore how adolescents perceive their own and others' SNS behaviours, the motivation underlying these behaviours, and the expected outcomes related to particular behaviours. Teenagers reported that they spend a good deal of time planning their SNS posts, felt that the information they posted was a true reflection of them as a person, and thus interpreted feedback (“likes”) as measuring their self-worth. In contrast, some teenagers were perceived as “chasing the like” for status and popularity while not caring about how accurately their posts represented them as a person. A potential gender bias in these findings is discussed.

This paper provides an empirical research about virtual reality users' avatar embodiment. According to literature, users that are embodied/incarnated in their avatars show a tendency to perceive avatars' failures as their own mistakes. Therefore, they are likely to monitor their own hands on the device they're using (e.g.: keyboard) when they perceive a failure in the interaction (a behavior named “focus shift”). We hypothesize that the phenomenon of focus shift is sensitive to different types of failures that can affect the multiple elements involved in the interaction. Thirty participants guided an avatar through a videogame-like virtual environment. The participants were exposed to three experimental manipulations (defective keyboard, defective avatar, defective virtual environment). We counted the number of focus shifts that participants showed in response to these three manipulated anomalies. Results showed a significantly high number of focus shifts in the condition with defective virtual environment. The findings are discussed with reference to mediation theory, explaining the role of action/feedback matching in the phenomenon of avatar embodiment.

Research has indicated that online daters may pick up on language cues connected to personality traits in online dating profile texts, and act upon those cues. This research seeks to investigate the level of accuracy of detection of personality in dating profile texts, and the extent to which perceived or actual similarity of personality has an effect on attractiveness of the author. An online survey was conducted collecting the Ten Item Personality Inventory (TIPI) for each participant and text author, a peer-report TIPI score by participants for each text author, and an attractiveness rating on a Likert scale for each author. Participants correctly identified Extraversion, though the effect size was small. Contrary to the hypotheses, participants preferred texts when written by an author with a personality they perceived as dissimilar to their own, specifically in Openness and Conscientiousness, and no relationship was found between actual similarity of personality and attractiveness. Online daters may choose partners with complementary or desirable traits rather than similar traits, or other factors in attraction may be more salient in the initial stages of determining attraction.