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, , 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 , chat, and videoconferences –The sense of presence is limited –Conventional e-therapy tools (i.e. ) 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 Computer abilities Before the beginning of the treatment Barfield Presence questionnaire 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) CBThe therapist Betts questionnaire39/7043/70 Computer knowledge and experience questionnaire 2/53/5 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 ) How strong was you sense of presence, “being there”, in the virtual environment (1-5 scale) 33

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!