A Second Life for E-Health:
Prospects for the Use of Virtual
On-Line Worlds in Clinical
Psychology
Alessandra Gorini
Andrea Gaggioli, Giuseppe Riva
Applied Technology for Neuro-Psychology Lab
Istituto Auxologico Italiano, Milan, Italy
OUTLINE
• Origins, definition and limitations of e-health
• Introduction to the WEB 2.0 and the on line
virtual worlds
• Is it possible to use the on line virtual worlds
for therapeutical purposes?
• Presentation of a case study
• Conclusions
At the beginning was e-health…
WHAT IS E-HEALTH?
– the use of technology (mobile phone, email,
chat…) to provide access to medical
assessment, diagnosis, intervention, and
information across distance
– key advantages (Glueckauf et al. 2003):
• deliver health information and services across
geographical distance for underserved population
• enhance the quality of health information and
services in particular areas or for specific populations
• ensure continuous medical and psychological
service
MAIN LIMITATIONS
– It does not take advantages of all the possibility
offered by Internet being limited to e-mail, chat,
and videoconferences
– The sense of presence is limited
– Conventional e-therapy tools (i.e. email)
typically do not support multiple users
WEB 2.0 AND 3-D VIRTUAL
WORLDS: A NEW FRONTIERS FOR
E-HEALTH?
WEB 2.0
• Web 2.0 is a read-write web
• It allows users to rate, comment, annotate, edit,
create, mix and share content from different
locations
• It is a “people-centric social Web”, that facilitates
social networking and active collaboration between
users
WEB 2.0, VR AND E-HEALTH
The combination of WEB 2.0 and Virtual Reality
(VR) allows the creation of distributed on line
VEs that enhance the communication between
therapists and patients, increasing the sense of
PRESENCE during the virtual interaction
3-D VIRTUAL WORLDS FOR E-HEALTH
Hp: Virtual worlds may convey higher
feelings of presence and social presence
than conventional e-therapy tools do
• facilitating the clinical communication
process
• creating higher levels of interpersonal
trust between therapist and patient
ON LINE VIRTUAL WORLDS OFFER
THEIR USERS THE POSSIBILITY TO:
• Share common VE being in different
physical places
• Have digital characters representing
themselves
• Communicate in real-time using chat or
voice in public or private way
• Experience a great sense of presence
ON LINE VIRTUAL WORLDS FOR
PSYCHOLOGICAL INTERVENTIONS: AN
EXPLORATIVE PROTOCOL
• Single case study
• AIM: evaluate the potential of the virtual
support sessions when, for contingent
causes, patient and therapist can have
only one face-to-face encounter per
month.
WHAT’S NEW?
• The use of on line virtual worlds (SECOND
LIFE) for psychological support/therapy
• The use of VR environments for a
psychoanalitic-oriented approach
THE PATIENT C.B.
•
•
•
•
•
Sex: female
Age: 47
Education: academic degree in engineering
Status: married (since 1995)
Son: 1 (8 year old)
• Diagnosis (2002): dependent personality disorder (DSM-IV) also
characterized by obsessive-compulsive traits and severe physical
somatizations that needed a pharmacological treatment.
• Treatment: from 2002 to 2006 psychoanalytic treatment based on two
sessions per week that produced a significant symptomatic remission
and an increasing in self and work efficiency.
• From 2006 to now: sporadic consultation sessions, with a recent
request to start a second phase of analytic-oriented treatment,
apparently uncompatible with her work engagement which often
demanded her to travel in italy and abroad.
• Technological abilities: basic knowledge of the main Windows
applications; no familiarity with videogames and VR systems.
THE THERAPIST
• Sex: male
• Age: 51
• Education: MD, both psychiatrist and psychoanalist, with a
personal interest in studying the relationship between
human mind-body and technological devices of prosthesis.
• He has recently changed his homeplace and life-style, living
for half a week in Milan, and the rest of the time in another
Italian city, located about 300 Km far from Milan.
• Technological abilities: basic knowledge of the main
Windows applications; no familiarity with videogames and
VR systems.
• The difficulty in combining their working
commitments and the physical distance have
been some of the reasons pushing C.B. and
her therapist to try this innovative approach.
• Privacy issues: all the chat transcriptions
were countersigned by both the therapist
and the patient.
ASSESSMENT
Betts
questionnaire
Imaginative
abilities
Before the
beginning of the
treatment
Computer
knowledge and
experience
questionnaire
Barfield
Presence
questionnaire
Computer
abilities
Before the
beginning of the
treatment
Level of
Presence
Every 2 weeks
from the
beginning of the
treatment
THE SL VIRTUAL OFFICE
Eureka (152,184,44)
TREATMENT SCHEDULES
• 2 virtual sessions per week (45 min each)
• 1 face to face session per month
• The patient and the therapist agree on
date and time of the virtual appointments
with the same modalities they use for real
ones.
TECHNICAL REQUIREMENTS
• 2 laptops and an ADSL internet
connection.
• Way of interaction: text-based chat
PRELIMINARY DATA FROM 8
VIRTUAL SESSIONS + 2 FACE
TO FACE ENCOUNTERS
QUANTITATIVE DATA (1)
Betts questionnaire
Computer knowledge and
experience questionnaire
Barfield Presence
questionnaire:
1) If your level in the real world is 100, and your
level of presence is 1 if you have no presence,
rate your level of presence in this virtual world
2) How strong was you sense of presence,
“being there”, in the virtual environment (1-5
scale)
CB The therapist
39/70
43/70
2/5
3/5
50
60
3
3
QUANTITATIVE DATA (2)
• CB interrupted the spasmolytic therapy
and restarted her regular job activity AS
EXPECTED FROM A TRADITIONAL
THERAPY
QUALITATIVE OBSERVATIONS
• First virtual appointment: slowness
• Analysis of text chats: formal aspects and
relation style were comparable to those
observed during the face-to-face sessions
(CB refers her emotional contents and
reactions, makes free associations,
reports dreams waiting for therapist’s
interpretation.
• No sign of inhibition
THE 3 FOUNDAMENTAL RULES
OF PSYCHOANALYSIS
• The fundamental rule: it urges that patients say “whatever
comes into their heads, even if they think it unimportant or
irrelevant or nonsensensical…or embarrassing or
distressing”
• The rule of abstinence: it designates a number of technical
recommendations that Freud stated regarding the general
framework of the psychoanalytic treatment, including, for
example, the prescription to have no physical or gaze
contacts with the patient
•
• The constancy of setting: virtual reality offers the therapist
the possibility to create a therapeutic environment more
stable than any other real physical setting, other than to
maintain the avatar’s aspect unchanged over time
THE PRIVACY PROBLEM
• The only critical point emerged regards the
privacy of the virtual setting.
• The virtual office is complitely safe and
only invited and authorizad people can
have access.
CONCLUSION
• The presence of a medium between the
patient and the therapist does not interfere
with the therapeutical relationship
• SL is intuitive: the scarce ability in the use
of computer and technological devices
does not significantly limit the virtual
interaction between the patient and the
therapist
…BUT MOST IMPORTANT…
• The possibility to share a common on-line
virtual space, gives the patient and the
therapist the opportunity to “meet” each
others twice a week even if they are
physically distant.
NEXT STEPS
• Collect more data
• Make a controlled study (virtual world vs
simple chat)
• Test the virtual setting in different
situations (patients with severe physical
disabilities, underserved population,
prisoners, etc)
CRITICAL REMARKS
• The proposal sounds very innovative, but we
would like to underline that in our view virtual
therapy can be effective only if used as an
adjunct to traditional therapy, or as part of an
aftercare plan.
• We advise against any kind of therapy being
practiced exclusively on the web because of its
supportive rather than exhaustive nature. This
point must be made clear to online therapy
providers and the general public.
THANK YOU FOR YOUR ATTENTION!
[email protected]