Ebook: Cybertherapy

The “Psychology of Cyberspace” [1, 2] and related fields, such as the “Psychology of the Internet” [3] and the “Psychology of Internet Behavior” [4], are new areas of study that have attracted psychologists in various specializations—clinical, counseling, educational, organizational, cognitive, social, and more—as well as researchers in other disciplines, among them communication, medicine, sociology, education, psychiatry, social work, and nursing.

These new areas have developed rapidly, accumulating knowledge and making innovative assertions and propositions that can generally be divided into two major directions: understanding the influence and impact of human experience with computers in cyberspace, on the one hand, and applying psychological procedures through (or with the help of) computers and the Net, on the other [5]. A vast majority of the psychological applications have been clinical and clinical-related and are considered a significant advancement in this field [6].

In being an extremely interdisciplinary field of study, psychology of cyberspace exemplifies unique cooperation among various distinctive professions: software programmers, computer and Web designers, and computer engineers at one end, and psychologists of different specialties at the other. The results of this collaboration have created exemplary works, represented by the VEPSY Updated (http://www.cybertherapy.info) project collaborators in the present collection of chapters.

The combination of ergonomics (human engineering), software engineering and programming, and computer design and graphics, on the one hand, and psychological and medical interventions, on the other, brings about innovative perspectives and effective implementations, whose aim is to serve humanity by offering better vehicles with which to heal physical and emotional deficiencies and injuries.

Although the projects presented in this volume represent significant breakthroughs, in the sense of creatively exploiting new technologies to attend to human miseries, further work is still required to fill the gap existing between the conceptualization of the cybertherapy experience and the actual implementations. As conceptualized and well presented by Mantovani [7] and Riva [8], interpersonal communication in virtual environments, though problematic and often erroneous, constitutes an efficient basis for interpersonal relationship. In Riva's [9] words, “Communication is as the outcome of a complex coordinated activity, an event that generates conversational space within the weave of personal and social relationships. Thus, communication is not only—or not so much—a transfer of information, but also the activation of a psychosocial relationship, the process by which interlocutors co-construct an area of reality. In CMC this happens inside a rather special kind of container – cyberspace - that tends to rarefy the structural and process features of communication” (pp. 595-596).

This interpersonal relational basis - so central to human existence and functioning - seems to be missing from some of the actual cybertherapy applications, thus potentially limiting the implementation of more effective interventions. As criticized by Jacobson [10] in the context of the concept of “presence”, human experience consists qualitatively of more than a physical environment, information received by the senses, and information processed by the brain; it includes, too, psychologically based dynamics, as evident in textual communications in virtual environments. In other words, as a clear touching point between body and mind, it seems that the “mind” aspect has been downplayed, compared with the “bodily” aspects. Thus, a further development of the current cybertherapy position will be an increased focus on the relational factor between therapists and patients as a significant therapeutic element of the clinical process. A better focus on this issue, as advocated by Riva and Galimberti [11, 12] in relation to conceptualizing cyberspace in general, will probably produce more targeted interventions.

Another point, related somewhat to the previous one, refers to the nature of the clinical interventions presented in this collection. Not surprisingly, three out of four of the therapeutic techniques discussed here are based on, or related to, the Cognitive-Behavioral Model (CBM). In fact, this approach has not only been found to be effective in treating numerous behavioral problems [13], but also can be translated relatively easily into computerized intervention programs. Notwithstanding the relevancy, effectiveness, and legitimacy of CBM to treat psychological problems, the understanding and exploiting of the client’s personal dynamics - consisting of needs, desires, frustrations, conflicts, daydreams, emotions, and so on – are critical issues for an effective therapy. Thus, a more flexible, open, comprehensive, and eclectic approach might produce more effective cybertherapy tools. Some processes that are typical of and unique to human experience in synthetic environments, such as the powerful impact of the online disinhibition effect [14] and the process of transference in cyberspace [15], actually call for differently oriented therapeutic procedures to complement cognitive-behavioral interventions.

All in all, the current volume contributes significantly to the cumulative knowledge of emerging psychotherapy and the psychology of virtual environments. The writings in this book are evidence of apparent science fiction just two decades ago becoming scientific reality today. Specifically, what many psychologists once considered futuristic therapy is now a clinical actuality. Though paradoxical, and perhaps cliched, the future is present, at least in the human mind. Like the Japanese warrior, we might profit tremendously from the gifts of the future by concentrating on and experiencing the state-of-the-art present—and thereby avert professional avoidance caused by fear of the unknown future.

Azy Barak, Ph.D.

Department of Psychology, University of Haifa, Israel

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.

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.

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.

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.

Panic disorder with agoraphobia (PDA) is considered an important public health problem [1-3]. The efficacy of cognitive-behavioral therapy (CBT) for PDA has been widely demonstrated [4, 5]. The American National Institute of Health [6] 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.