Outcomes of a health informatics technology-supported behavioral activation training for care managers in a collaborative care program

INTRODUCTION

Health informatics-supported strategies for training and ongoing support may aid the delivery of evidence-based psychotherapies. The objective of this study was to describe the development, implementation, and practice outcomes of a scalable health informatics-supported training program for behavioral activation for patients who screened positive for posttraumatic stress disorder and/or bipolar disorder.

METHOD

We trained 34 care managers in 12 rural health centers. They used a registry checklist to document the delivery of 10 behavioral activation skills for 4,632 sessions with 455 patients. Care managers received performance feedback based on registry data. Using encounter-level data reported by care managers, we described the implementation outcomes of patient reach and care manager skill adoption. We used cross-classified multilevel modeling to explore variation in skill delivery accounting for patient characteristics, provider characteristics, and change over time.

RESULTS

Care managers engaged 88% of patients in behavioral activation and completed a minimum course for 57%. The average patient received 5.9 skills during treatment, with substantial variation driven more by providers (63%) than patients (29%). Care managers significantly increased the range of skills offered to patients over time.

DISCUSSION

The registry-based checklist was a feasible training and support tool for community-based providers to deliver behavioral activation. Providers received data-driven performance feedback and demonstrated skill improvement over time, promoting sustainment. Future research will examine patient-level outcomes. Results underscore the potential public health impact of a simple registry-based skills checklist coupled with a scalable remote training program for evidence-based psychotherapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A virtual reality counterconditioning procedure to reduce methamphetamine cue-induced craving

The present work developed a virtual reality (VR) counterconditioning procedure (VRCP), and investigated its efficacy in treatment of cue-induced craving in individuals with methamphetamine (METH) dependence. In study 1, thirty-one patients diagnosed with METH dependence received VRCP, while twenty-nine METH-dependent patients in waiting-list group did not. In study 2, the VRCP was computerized as a VR treatment system. Six-hundred and twelve abstinent individuals with a history of METH dependence received the computerized VRCP, while two-hundred seventy-six abstinent individuals with a history of METH dependence in waiting-list group did not. Patients with METH dependence who received VRCP showed a significantly larger decrease on the score of METH-craving and METH-liking from baseline to follow-up assessments, compared to those who did not received VRCP. Participants received VRCP showed a significantly larger decrease in HRV indexes on time domain and non-linear domain from baseline to follow-up assessments during exposure to VR cues, compared to those in waiting-list group. These findings indicate that the counterconditioning procedure under VR environment may be a useful strategy in suppressing cue-induced reactivity for patients with METH dependence.

Study Protocol for a Randomized Controlled Trial Evaluating the Efficacy of an Evidence-Based iPad-App for Cognitive Rehabilitation in Patients with Primary Brain Tumors

BACKGROUND

Many patients with primary brain tumors suffer from cognitive deficits, which negatively impact their quality of life. However, cognitive rehabilitation programs for these patients are scarce. We developed an iPad-based cognitive rehabilitation program for brain tumor patients, which was based on our effective face-to-face cognitive rehabilitation program. After successful completion of a feasibility study, a randomized controlled trial has been started.

OBJECTIVE

To evaluate the immediate and long-term effects of the iPad-based program on cognitive performance and patient-reported outcome measures (PROMs) in patients with primary brain tumors in an early stage of the disease.

METHODS

Prior to surgery, patients with presumed low-grade glioma and meningioma are included. Before surgery and 3 mo after surgery, neuropsychological assessments are conducted. After the second neuropsychological assessment, patients are assigned to the intervention group or waiting-list control group. The intervention consists of psychoeducation, compensation training, and retraining. Patients are advised to spend 3 h per week on the program for 10 wk. Immediately after completion of the program and a half-year thereafter, postintervention assessments take place. Patients in the control group are offered the opportunity to follow the program after all study assessments.

EXPECTED OUTCOMES

We expect that early cognitive rehabilitation has beneficial effects on cognitive performance and PROMs in brain tumor patients.

DISCUSSION

The iPad-based program allows brain tumor patients to follow a cognitive rehabilitation program from their homes. Forthcoming results may contribute to further improvement of supportive care for brain tumor patients.

Rationale and design of a systematic review: effectiveness and acceptance of technology-based psychological interventions in different clinical phases of depression management

INTRODUCTION

Although many effective treatment options exist, depression is still undertreated indicating gaps in the healthcare system. The complementary provision of mental healthcare through technologies (eg, computer, smartphone) has the potential to fill treatment gaps and to overcome access barriers to mental healthcare. Until now, no systematic review integrates the evidence on different technology-based psychological interventions (TBIs) concerning their effectiveness and acceptance in different clinical phases of depression management (bridging waiting periods, acute treatment and aftercare). The aim of this project is to structure evidence on TBIs regarding different phases of depression management, and to determine effectiveness and acceptance for each clinical phase considering both active (eg, face-to-face treatment) and inactive (eg, waitlist) controls as comparators.

METHODS AND ANALYSIS

We will include studies on adults with a formal diagnosis of unipolar depression. Treatments delivered by technologies based on scientific psychological theories will be considered as experimental interventions. The primary effectiveness outcome will be depressive symptoms at study endpoint measured by symptom severity rating scales, and the primary acceptance outcome will be dropping out of the study due to any reason. We will consider only randomised controlled trials, which will be identified by key database searches (including Cochrane Central Register of Controlled Trials, Medline, PsycINFO, PSYNDEX, CINAHL) complemented through searches in clinical trial registries (eg, clinicaltrials.gov) and grey literature searches (eg, Open Grey). Two review authors will independently conduct study selection, data extraction and quality assessment of included studies (using the Cochrane Collaboration's tool for assessing risk of bias). Meta-analyses applying random-effect models as well as subgroup, meta-regression and sensitivity analyses will be performed.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study, as we conduct research on secondary data. We will disseminate results via peer-reviewed journal publications, presentations on conferences and via plain language summaries.

PROSPERO REGISTRATION NUMBER

CRD42016050413; Pre-results.

Bulimia nervosa: online interventions

INTRODUCTION

Up to 1% of people in the community may have bulimia nervosa, characterised by an intense preoccupation with body weight, binge-eating episodes, and use of extreme measures to counteract the feared effects of overeating. People with bulimia nervosa are of normal weight or are overweight, making the condition distinct from anorexia nervosa. After 10 years, about half of people with bulimia nervosa will have recovered fully, one third will have made a partial recovery, and 10% to 20% will still have symptoms.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of online interventions for people with bulimia nervosa? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found eight studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: applications (apps) or online programmes used as an adjunct to face-to-face therapy, delivery of self-help online, and delivery of therapy online.

[Information digital technologies and medical psychologic prevention of stress state in railway transport workers]

The authors determined criteria of medical and psychologic training of railway transport workers, with applied information digital technologies. The results obtained prove that application of software "Railway worker" ("Zheleznodorozhnik") reduces frequency and duration of "emotional stress states".

The use of electronic games in therapy: a review with clinical implications

Therapists and patients enjoy and benefit from interventions that use electronic games (EG) in health care and mental health settings, with a variety of diagnoses and therapeutic goals. We reviewed the use of electronic games designed specifically for a therapeutic purpose, electronic games for psychotherapy (EGP), also called serious games, and commercially produced games used as an adjunct to psychotherapy, electronic games for entertainment (EGE). Recent research on the benefits of EG in rehabilitation settings, EGP, and EGE indicates that electronic methods are often equivalent to more traditional treatments and may be more enjoyable or acceptable, at least to some consumers. Methodological concerns include the lack of randomized controlled trials (RCT) for many applications. Suggestions are offered for using EG in therapeutic practice.

Augmenting cognitive behaviour therapy for post-traumatic stress disorder with emotion tolerance training: a randomized controlled trial

BACKGROUND

Many patients do not adhere to or benefit from cognitive behaviour therapy (CBT) for post-traumatic stress disorder (PTSD). This randomized controlled trial evaluates the extent to which preparing patients with emotion regulation skills prior to CBT enhances treatment outcome.

METHOD

A total of 70 adult civilian patients with PTSD were randomized to 12 sessions of either supportive counselling followed by CBT (Support/CBT) or emotion regulation training followed by CBT (Skills/CBT).

RESULTS

Skills/CBT resulted in fewer treatment drop-outs, less PTSD and anxiety, and fewer negative appraisals at 6 months follow-up than Support/CBT. Between-condition effect size was moderate for PTSD severity (0.43, 95% confidence interval x0.04 to 0.90). More Skills/CBT (31%) patients achieved high end-state functioning at follow-up than patients in Support/CBT (12%) [Χ2(n=70)=3.67, p<0.05].

CONCLUSIONS

This evidence suggests that response to CBT may be enhanced in PTSD patients by preparing them with emotion regulation skills. High attrition of participants during the study limits conclusions from this study.

Computer-aided psychotherapy based on multimodal elicitation, estimation and regulation of emotion

Contemporary psychiatry is looking at affective sciences to understand human behavior, cognition and the mind in health and disease. Since it has been recognized that emotions have a pivotal role for the human mind, an ever increasing number of laboratories and research centers are interested in affective sciences, affective neuroscience, affective psychology and affective psychopathology. Therefore, this paper presents multidisciplinary research results of Laboratory for Interactive Simulation System at Faculty of Electrical Engineering and Computing, University of Zagreb in the stress resilience. Patient's distortion in emotional processing of multimodal input stimuli is predominantly consequence of his/her cognitive deficit which is result of their individual mental health disorders. These emotional distortions in patient's multimodal physiological, facial, acoustic, and linguistic features related to presented stimulation can be used as indicator of patient's mental illness. Real-time processing and analysis of patient's multimodal response related to annotated input stimuli is based on appropriate machine learning methods from computer science. Comprehensive longitudinal multimodal analysis of patient's emotion, mood, feelings, attention, motivation, decision-making, and working memory in synchronization with multimodal stimuli provides extremely valuable big database for data mining, machine learning and machine reasoning. Presented multimedia stimuli sequence includes personalized images, movies and sounds, as well as semantically congruent narratives. Simultaneously, with stimuli presentation patient provides subjective emotional ratings of presented stimuli in terms of subjective units of discomfort/distress, discrete emotions, or valence and arousal. These subjective emotional ratings of input stimuli and corresponding physiological, speech, and facial output features provides enough information for evaluation of patient's cognitive appraisal deficit. Aggregated real-time visualization of this information provides valuable assistance in patient mental state diagnostics enabling therapist deeper and broader insights into dynamics and progress of the psychotherapy.

Therapeutic uses of the WebCam in child psychiatry

OBJECTIVE

The authors provide examples for the use of the WebCam as a therapeutic tool in child psychiatry, discussing cases to demonstrate the application of the WebCam, which is most often used in psychiatry training programs during resident supervision and for case presentations.

METHOD

Six cases illustrate the use of the WebCam in individual and family therapy.

RESULTS

The WebCam, used during individual sessions, can facilitate the development of prosocial skills. Comparing individual WebCam video sessions can help to evaluate the effectiveness of medication and progress in therapy.

CONCLUSION

The WebCam has proven to be useful in psycho-education, facilitating communication, and treating children and families. The applications of this technology may include cognitive-behavioral therapy, dialectical-behavioral, and group therapy.

Adapting and testing telephone-based depression care management intervention for adolescent mothers

This phase 1 clinical trial combined qualitative and quantitative methods to modify a collaborative care, telephone-based, depression care management intervention for adolescent mothers and to determine the acceptability, feasibility, and initial efficacy of the intervention in a sample of adolescent mothers (n = 97) who were recruited from a Teen Parent Program. Outcomes included measures of depressive symptoms, functioning, and use of mental health services. Acceptability of the intervention was demonstrated, but feasibility issues related to the complex life challenges confronting the adolescent mother. Although only four adolescent mothers received mental health treatment, there was a trend for improved depressive symptoms over time. Results of the study provide data for the need of further refinement of the intervention before a large clinical trial is conducted for adolescent mothers with symptoms of depression.

Attrition from an internet-based psychological intervention for erectile dysfunction: who is likely to drop out?

The current study evaluated the dropout rate from an internet-based treatment program for erectile dysfunction (ED), and determined reasons for attrition from this program. Only 12 of 40 treatment group men and 19 of 20 control group men completed the post-test measures. Reasons for the men being excluded or dropping out of the study are discussed. These reasons included medical conditions that contributed to their ED, the man's partner not being interested in participating in the program, a lack of motivation from the man, or the time commitment being too demanding.

Post‐Traumatic Growth and Optimism as Outcomes of an Internet‐Based Intervention for Complicated Grief

This explorative study examines the effects of an internet-based cognitive-behavioural therapy for complicated grief on post-traumatic growth and optimism. The study is part of a larger randomized controlled trial described in Wagner, Knaevelsrud, and Maercker (2006). The patients were randomly assigned to either a treatment group (n = 26) or a waiting list control condition (n = 25). The internet-based intervention consisted of exposure to bereavement cues, cognitive reappraisal exercises, and a module on integration and restoration. A short form of the Post-traumatic Growth Inventory (PTGI), the Life Orientation Test-Revised (LOT-R), and measures of complicated grief and psychopathological outcomes were administered. Results indicate that post-traumatic growth increased in the treatment group. No treatment effect was found for optimism. These findings contribute to the growing literature on personal growth in psychotherapy.

Online mental health treatment: concerns and considerations

Concerns and considerations have emerged as mental health professionals contemplate the provision of mental health treatment over the Internet. This paper identifies perceptions of online mental health treatment among a national sample of 2,098 social workers, psychologists, and other professionals. These professionals were unlikely to provide online mental health treatment, although some used the Internet as an adjunct to clinical practice. They noted specific concerns related to the provision of mental health treatment online, including confidentiality of client information and liability issues. We explore these issues and discuss implications for professionals who provide mental health treatment.

In the eyes of the beholder: exploring psychologists' attitudes towards and use of e-therapy in Norway

Norwegian psychologists' use of and attitudes towards e-media such as email and mobile text messaging in interaction with clients (e-therapy) were explored. A two-dimensional scale for measuring attitudes towards e-therapy was developed. A total of 1040 (23%) members of the psychologist association responded to a questionnaire June 2003. Of these, 45% had used e-media in interaction with clients. The mean reported attitude towards e-therapy was neutral, with only 3% of the psychologists feeling that use of e-media between client and therapist is unacceptable. Having a psychodynamic theoretical stance was related to attitudes towards e-therapy. Positive attitude was related to clinical use of email and Short Messages Service (SMS). It appears likely that e-therapy will become more common, and that therapist's attitudes are related to such use.

A randomized trial of telephone psychotherapy and pharmacotherapy for depression: continuation and durability of effects

Randomized trial evidence and expert guidelines are mixed regarding the value of combined pharmacotherapy and psychotherapy as initial treatment for depression. This study describes long-term results of a randomized trial (N = 393) evaluating telephone-based cognitive-behavioral therapy (CBT) plus care management for primary care patients beginning antidepressant treatment versus usual care. In a repeated measures linear model with adjustment for baseline scores, the phone therapy group showed significantly lower mean Hopkins Symptom Checklist (HSCL) Depression Scale scores (L. Derogatis, K. Rickels, E. Uhlenhuth, & L. Covi, 1974) from 6 months to 18 months versus usual care, F(1, 336) = 11.28, p = .001. Average HSCL depression scores over the period from 6 months to 18 months were 0.68 (SD = 0.55) in the telephone therapy group and 0.85 (SD = 0.65) in the usual-care comparison group. Addition of a brief, structured CBT program can significantly improve clinical outcomes for the large number of patients beginning antidepressant treatment in primary care.

Virtual reality in mental health : a review of the literature

BACKGROUND

Several virtual reality (VR) applications for the understanding, assessment and treatment of mental health problems have been developed in the last 10 years. The purpose of this review is to outline the current state of virtual reality research in the treatment of mental health problems.

METHODS

PubMed and PsycINFO were searched for all articles containing the words "virtual reality". In addition a manual search of the references contained in the papers resulting from this search was conducted and relevant periodicals were searched. Studies reporting the results of treatment utilizing VR in the mental health field and involving at least one patient were identified.

RESULTS

More than 50 studies using VR were identified, the majority of which were case studies. Seventeen employed a between groups design: 4 involved patients with fear of flying; 3 involved patients with fear of heights; 3 involved patients with social phobia/public speaking anxiety; 2 involved people with spider phobia; 2 involved patients with agoraphobia; 2 involved patients with body image disturbance and 1 involved obese patients. There are both advantages in terms of delivery and disadvantages in terms of side effects to using VR. Although virtual reality based therapy appears to be superior to no treatment the effectiveness of VR therapy over traditional therapeutic approaches is not supported by the research currently available.

CONCLUSIONS

There is a lack of good quality research on the effectiveness of VR therapy. Before clinicians will be able to make effective use of this emerging technology greater emphasis must be placed on controlled trials with clinically identified populations.

Vicarious trauma and first responders: a case study utilizing eye movement desensitization and reprocessing (EMDR) as the primary treatment modality

Traumatic events can occur and adversely affect people during their lifetime. Natural disasters such as the earthquake in Pakistan in 2005 or the Tsunami in Asia in 2004, terrorist atrocities around the world, or personal events such as physical or sexual assault, can result in psychological difficulties for those people directly affected by these events. The diagnostic term Posttraumatic Stress Disorder (PTSD; Diagnostic and Statistical Manual of Mental Disorders, 4th edition, DSM IV 1994) is generally used to explain the often-severe psychological sequalae (van der Kolk, 1996; Servan-Schreiber 2004; Shapiro, 1995) that people may exhibit when directly affected by trauma. However, what of those people not directly involved in the trauma, but those who have borne witness to it, either by listening to the stories of survivors, or in the case of the helping professionals (such as police officers, nurses, doctors, psychotherapists, fire-fighters), actively working with survivors in psychological distress? This paper examines the potential psychological consequences for those in helping professions who are working with traumatized clients. This paper then focuses on a specific treatment intervention, EMDR, utilizing a case study by way of explanation.

Assessing personality change in psychotherapy with the SWAP-200: a case study

Many studies document the efficacy of psychotherapy for acute syndromes such as depression, but less is known about personality change in patients treated for personality pathology. The Shedler-Westen Assessment Procedure (SWAP-200; Westen & Shedler, 1999a, 1999b) is an assessment tool that measures a broad spectrum of personality constructs and is designed to bridge the gap between the clinical and empirical traditions in personality assessment. In this article, we demonstrate the use of the SWAP-200 as a measure of change in a case study of a patient diagnosed with borderline personality disorder. We collected assessment data at the start of treatment and after 2 years of psychotherapy. The findings illustrate the personality processes targeted in intensive psychotherapy for borderline personality.

Online therapy for addictive behaviors

Clinicians working in the field of addictive behaviors cannot afford to ignore the Internet. Psychological advice, help, and treatment for addicts are no exceptions, with both counseling and psychotherapy entering the computer age. This paper reviews the main issues in the area and approaches the discussion acknowledging that online therapy has to be incorporated within the overall framework of the need for clinical assistance. The paper also provides brief overviews of some websites as illustrative examples of what types of online therapy are available.

Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying

This controlled clinical trial tested virtual reality exposure (VRE) therapy for the fear of flying (FOF), a relatively new and innovative way to do exposure therapy, and compared it to standard (in vivo) exposure therapy (SE) and a wait list (WL) control with a 6- and 12-month follow-up. Eighty-three participants with FOF were randomly assigned to VRE, SE, or WL. Seventy-five participants, 25 per group, completed the study. Twenty-three WL participants completed randomly assigned treatment following the waiting period. Treatment consisted of 4 sessions of anxiety management training followed either by exposure to a virtual airplane (VRE) or an actual airplane at the airport (SE) conducted over 6 weeks. Results indicate that VRE was superior to WL on all measures, including willingness to fly on the posttreatment flight (76% for VRE and SE; 20% for WL). VRE and SE were essentially equivalent on standardized questionnaires, willingness to fly, anxiety ratings during the flight, self-ratings of improvement, and patient satisfaction with treatment. Follow-up assessments at 6 and 12 months indicated that treatment gains were maintained, with more than 70% of respondents from both groups reporting continued flying at follow-up. Based on these findings, the use of VRE in the treatment of FOF was supported in this controlled study, suggesting that experiences in the virtual world can change experiences in the real world.

Comparison of internet and face-to-face delivery of a group body image and disordered eating intervention for women: a pilot study

Increased access to therapy for body dissatisfaction and disordered eating is required. This pilot study compared a group intervention delivered face-to-face or synchronously over the Internet. Women with body dissatisfaction and disordered eating were randomly assigned to a face-to-face (N = 19) or Internet (N = 21) group. Body dissatisfaction, disordered eating, and psychological variables were assessed at baseline, post-intervention, and two months follow-up. Significant improvements on all outcome variables were observed and maintained at follow-up in both groups. There were no significant differences between delivery modes. This program shows promise, and the Internet mode of delivery has potential to overcome geographical distance.

Visual search improvement in hemianopic patients after audio-visual stimulation

One of the most effective techniques in the rehabilitation of visual field defects is based on implementation of oculomotor strategies to compensate for visual field loss. In the present study we develop a new rehabilitation approach based on the audio-visual stimulation of the visual field. Since it has been demonstrated that audio-visual interaction in multisensory neurons can improve temporally visual perception in patients with hemianopia, the aim of the present study was to verify whether a systematic audio-visual stimulation might induce a long-lasting amelioration of visual field disorders. Eight patients with chronic visual field defects were trained to detect the presence of visual targets. During the training, the visual stimulus could be presented alone, i.e. unimodal condition, or together with an acoustic stimulus, i.e. crossmodal conditions. In the crossmodal conditions, the spatial disparity between the visual and the acoustic stimuli were systematically varied (0, 16 and 32 degrees of disparity). Furthermore, the temporal interval between the acoustic stimulus and the visual target in the crossmodal conditions was gradually reduced from 500 to 0 ms. Patients underwent the treatment for 4 h daily, over a period of nearly 2 weeks. The results showed a progressive improvement of visual detections during the training and an improvement of visual oculomotor exploration that allowed patients to efficiently compensate for the loss of vision. More interesting, there was a transfer of treatment gains to functional measures assessing visual field exploration and to daily-life activities, which was found stable at the 1 month follow-up control session. These findings are very promising with respect to the possibility of taking advantage of human multisensory capabilities to recover from unimodal sensory impairments.

Virtual Reality in Psychotherapy: Review

Virtual reality (VR) has recently emerged as a potentially effective way to provide general and specialty health care services, and appears poised to enter mainstream psychotherapy delivery. Because VR could be part of the future of clinical psychology, it is critical to all psychotherapists that it be defined broadly. To ensure appropriate development of VR applications, clinicians must have a clear understanding of the opportunities and challenges it will provide in professional practice. This review outlines the current state of clinical research relevant to the development of virtual environments for use in psychotherapy. In particular, the paper focuses its analysis on both actual applications of VR in clinical psychology and how different clinical perspectives can use this approach to improve the process of therapeutic change.

Telephone-based treatment for family practice patients with mild depression

The need for treating milder forms of depression has recently been of increased interest. This was a randomized, controlled study to evaluate the effects of telephone-based problem-solving therapy for mild depression. Comparison groups were a treatment-as-usual group and another group receiving stress-management training by telephone. From 1,742 family practice patients screened for depression, 54 with mild depression entered the study. Treatment was provided by experienced family practice nurses, trained and supervised in the treatments. The Hamilton Rating Scale for Depression was administered before and after the intervention period, and the Beck Depression Inventory and Duke Health Profile were administered at the end of the intervention period. Of the 36 subjects assigned to the problem-solving and stress-management groups, half dropped out early in the study. Five from the treatment-as-usual group were lost to follow-up. In the remaining subjects, there was a significant decrease in depression scores. There were no significant differences in the amount of decrease between the groups on any scores. The small sample and high dropout rate limit the interpretation of the findings. However, since all subjects tended to improve, regardless of treatment received, mild levels of depression may generally remit even without focal intervention, and watchful waiting may be a reasonable alternative for management.

Technology in psychotherapy: an introduction

All indicators suggest that technology may be an inherent part of psychotherapy delivery in the next decade. This article serves as an introduction to a special issue of Journal of Clinical Psychology: In Session devoted to technology in psychotherapy. Articles in this series feature self-help Internet sites, computer-administered psychotherapy, adjunctive palmtop computer psychotherapy, virtual reality psychotherapy, interactive voice messaging systems, biofeedback via ambulatory physiological monitoring, synchronous and asynchronous online support groups, and use of electronic mail by psychotherapists. As illustrated by many of the articles in this issue, technological advances may extend psychotherapy beyond the therapy hour and increase psychotherapy dissemination, client motivation, and compliance.

Improving the effectiveness of adjuvant psychological treatment for women with breast cancer: The feasibility of providing online support

Many well-designed studies have shown psychosocial treatments for cancer to be efficacious for improving patients' quality of life, but the actual impact of these treatments may be limited by low rates of participation. Web-based treatment formats could improve effectiveness by increasing availability and accessibility. Two phases of a feasibility study are reported in this article. In the first phase, we sought to assess internet access and perceived interest in online support among 136 women with breast cancer (June-October, 1999). Levels of interest in participating in an online psychosocial treatment were associated with age, outcome expectancy, and barriers to using the internet but not stage or time since diagnosis. In the second phase, we document accrual rates among several methods of recruitment during a randomized trial (February-December, 2001) and report changes over time in internet access. Recruitment rates were substantially higher when a study representative was available in clinic to provide information about the treatment than for all other methods of recruitment. Access to the internet increased between 1999 (63%) and 2001 (70%) and varied across age groups. These results suggest that internet-based psychosocial treatments, with notable limitations, are feasible for increasing the impact of psychosocial care.

The VEPSY UPDATED Project: clinical rationale and technical approach

More than 10 years ago, Tart (1990) described virtual reality (VR) as a technological model of consciousness offering intriguing possibilities for developing diagnostic, inductive, psychotherapeutic, and training techniques that can extend and supplement current ones. To exploit and understand this potential is the overall goal of the "Telemedicine and Portable Virtual Environment in Clinical Psychology"--VEPSY UPDATED--a European Community-funded research project (IST-2000-25323, www.cybertherapy.info). Particularly, its specific goal is the development of different PC-based virtual reality modules to be used in clinical assessment and treatment of social phobia, panic disorders, male sexual disorders, obesity, and eating disorders. The paper describes the clinical and technical rationale behind the clinical applications developed by the project. Moreover, the paper focuses its analysis on the possible role of VR in clinical psychology and how it can be used for therapeutic change.

From psychotherapy to e-therapy: the integration of traditional techniques and new communication tools in clinical settings

Technology is starting to influence psychological fields. In particular, computer-mediated communication (CMC) is providing new tools that can be fruitfully applied in psychotherapy. These new technologies do not substitute for traditional techniques and approaches but they could be used as integration in the clinical process, enhancing or making easier particular steps of it. This paper focuses on the concept of e-therapy as a new modality of helping people resolve life and relationship issues. It utilizes the power and convenience of the Internet to allow synchronous and asynchronous communication between patient and therapist. It is important to underline that e-therapy is not an alternative treatment, but a resource that can be added to traditional psychotherapy. The paper also discusses how different forms of CMC can be fruitfully applied in psychology and psychotherapy, by evaluating the effectiveness of them in the clinical practice. To enhance the diffusion of e-therapy, further research is needed to evaluate all the pros and cons.

Emotional Prosody Measurement (EPM): a voice-based evaluation method for psychological therapy effectiveness

The voice embodies three sources of information: speech, the identity, and the emotional state of the speaker (i.e., emotional prosody). The latter feature is resembled by the variability of the F0 (also named fundamental frequency of pitch) (SD F0). To extract this feature, Emotional Prosody Measurement (EPM) was developed, which consists of 1) speech recording, 2) removal of speckle noise, 3) a Fourier Transform to extract the F0-signal, and 4) the determination of SD F0. After a pilot study in which six participants mimicked emotions by their voice, the core experiment was conducted to see whether EPM is successful. Twenty-five patients suffering from a panic disorder with agoraphobia participated. Two methods (story-telling and reliving) were used to trigger anxiety and were compared with comparable but more relaxed conditions. This resulted in a unique database of speech samples that was used to compare the EPM with the Subjective Unit of Distress to validate it as measure for anxiety/stress. The experimental manipulation of anxiety proved to be successful and EPM proved to be a successful evaluation method for psychological therapy effectiveness.

Computer and Internet applications for psychological treatment: Update for clinicians

Computers and the Internet have the potential to be used to deliver psychological treatments. This article provides a selective review of applications involving little or no therapist contact, applications involving asynchronous and synchronous communication with providers, and applications that have been used as adjuncts to standard psychotherapy. Data on the efficacy of these applications most strongly support using the Internet to complete and submit behavioral assignments, to obtain social support from peers, and to receive education, feedback, and support from therapists in the form of e-mail or chatroom communications. General practice recommendations are given with an emphasis on ways to encourage use of the Internet as an information and communication tool as an adjunct to regular psychotherapy.

New Diagnostic Tool for Robotic Psychology and Robotherapy Studies

Robotic psychology and robotherapy as a new research area employs a systematic approach in studying psycho-physiological, psychological, and social aspects of person-robot communication. An analysis of the mechanisms underlying different forms of computer-mediated behavior requires both an adequate methodology and research tools. In the proposed article we discuss the concept, basic principles, structure, and contents of the newly designed Person-Robot Complex Interactive Scale (PRCIS), proposed for the purpose of investigating psychological specifics and therapeutic potentials of multilevel person-robot interactions. Assuming that human-robot communication has symbolic meaning, each interactive pattern evaluated via the newly developed scale is assigned certain psychological value associated with the person's past life experiences, likes and dislikes, emotional, cognitive, and behavioral traits or states. PRCIS includes (1) assessment of a person's individual style of communication with the robotic creature based on direct observations; (2) the participant's evaluation of his/her new experiences with an interactive robot and evaluation of its features, advantages and disadvantages, as well as past experiences with modern technology; and (3) the instructor's overall evaluation of the session.

Internet-Based Telehealth System for the Treatment of Agoraphobia

In this work that is being validated within the VEPSY project, we present a system that allows the patient to continue a psychological virtual reality treatment from his or her home PC as complementary therapy. In the consulting room, we have been using virtual therapy for panic disorder and agoraphobia treatment to expose the patient to several situations. For the complementary therapy, a structured treatment via the Internet has been prepared, which consists of several parts: an assessment protocol; a structured treatment protocol organized in several blocks (such as psychoeducation and exposure); and an outcome protocol. The same situations as in the consulting room have been selected for the exposure, but each of them has been divided into several virtual environments with specific characteristics that limit its difficulty level. The stimuli that are used at each level are controlled automatically by the system. The information of the patient is stored in a database, which is placed in a remote server using XML format and used to control which stages of the treatment he or she can access. The psychologist can limit the evolution of the patient. The virtual environments are installed in the patient's PC, and they are implemented with a mechanism that ensures that they can only be run when the patient connects to the web. The user should not have any special virtual reality hardware at home, so head rotations have been simulated with the navigation system.

Avatars in clinical psychology: a framework for the clinical use of virtual humans

Early applications of virtual reality (VR) technology in psychological assessment, treatment, and research have yielded promising results. In particular, an increasing number of studies analyze the unique features of the experience made by patients during their exposure to virtual environments. However, the majority of these studies explore how patients navigate in the virtual spaces and interact with virtual objects. Only a few of them investigate the features of inhabited virtual environments, where real people and autonomous virtual humans are able to interact and to cooperate. In particular, there is a lack of discussion of the role that such autonomous virtual humans could have in VR-aided psychotherapy. The main goal of this paper is to identify a framework for future research in this area. Three levels of analysis are identified. The purpose of the first two levels is the identification of the key "physical" features (e.g., appearance, structure) and "internal" characteristics (e.g., behavior, degree of autonomy, perceptual capabilities) needed by an effective simulation. The third level is concerned with the evaluation of the interaction characteristics required for a successful relationship between the patient and the virtual human.

Virtual reality exposure therapy for World Trade Center Post-traumatic Stress Disorder: a case report

Done properly by experienced therapists, re-exposure to memories of traumatic events via imaginal exposure therapy can lead to a reduction of Post-traumatic Stress Disorder (PTSD) symptoms. Exposure helps the patient process and habituate to memories and strong emotions associated with the traumatic event: memories and emotions they have been carefully avoiding. But many patients are unwilling or unable to self-generate and re-experience painful emotional images. The present case study describes the treatment of a survivor of the World Trade Center (WTC) attack of 9-11-01 who had developed acute PTSD. After she failed to improve with traditional imaginal exposure therapy, we sought to increase emotional engagement and treatment success using virtual reality (VR) exposure therapy. Over the course of six 1-h VR exposure therapy sessions, we gradually and systematically exposed the PTSD patient to virtual planes flying over the World Trade Center, jets crashing into the World Trade Center with animated explosions and sound effects, virtual people jumping to their deaths from the burning buildings, towers collapsing, and dust clouds. VR graded exposure therapy was successful for reducing acute PTSD symptoms. Depression and PTSD symptoms as measured by the Beck Depression Inventory and the Clinician Administered PTSD Scale indicated a large (83%) reduction in depression, and large (90%) reduction in PTSD symptoms after completing VR exposure therapy. Although case reports are scientifically inconclusive by nature, these strong preliminary results suggest that VR exposure therapy is a promising new medium for treating acute PTSD. This study may be examined in more detail at www.vrpain.com.

Brief virtual reality therapy for public speaking anxiety

The primary goal of this research program was to investigate the effectiveness of virtual reality therapy (VRT) in reducing public speaking anxiety of university students. The prevalence and impact of public speaking anxiety as a type of Social Phobia are discussed. Studies of VRT as an emerging treatment for psychological problems are reviewed. In the present study, eight students completed VRT individual treatment and post-testing, and six students in a Wait-List control group completed post-testing. Assessment measures included four self-report inventories, self-report of Subjective Units of Discomfort during exposure to VRT and physiological measurements of heart rate during speaking tasks. Four weekly individual exposure treatment sessions of approximately 15 min each were conducted by the author serving as therapist. Results on self-report and physiological measures appear to indicate that four virtual reality treatment sessions were effective in reducing public speaking anxiety in university students, corroborating earlier studies of VRT's effectiveness as a psychotherapeutic modality. Future research directions are discussed, primarily the need for research on younger populations, to assess the effectiveness of VRT for earlier intervention with public speaking anxiety.

Physiological monitoring as an objective tool in virtual reality therapy

The goals of this study were twofold: (1) to investigate nonphobics' and phobics' physiological response in virtual environments, and (2) to analyze the trend of phobics' physiology during virtual reality (VR) treatment. As a measure of physiology, heart rate, skin resistance, and skin temperature were acquired. The data for two groups of participants were analyzed: 22 nonphobic participants (mean = 32 +/- 9.4 years) and 36 subjects with fear of flying (mean = 40 +/- 12.1 years) who met the DSM-IV criteria for fear of flying. As a result, skin resistance showed significant differences between nonphobics and phobics, T(56) = 2.978 and p < 0.01, respectively. The physiological response of 33 phobic participants, who were able to fly without medicine after VR treatment, showed a gradual trend toward the nonphobics' physiological responses as therapy sessions progressed. In this study, physiological monitoring, in particular skin resistance, appeared to be useful both in understanding the physiological state of phobic individuals and in evaluating the results of treatment in VR psychotherapy.

E-therapy: practical, ethical, and legal issues

E-therapy is a term that has been coined to describe the process of interacting with a therapist online in ongoing conversations over time when the client and counselor are in separate or remote locations and utilize electronic means to communicate with each other. It is a relatively new modality of assisting individuals resolve life and relationship issues. E-therapy utilizes the power and convenience of the internet to allow simultaneous (synchronous) and time-delayed (asynchronous) communication between an individual and a professional. For the purposes of this paper, e-therapy is defined as a licensed mental health care professional providing mental health services via e-mail, video conferencing, virtual reality technology, chat technology, or any combination of these. It does not include self-help methods such as public bulletin boards or private listservs. E-therapy is not psychotherapy or psychological counseling per se since it does to presume to diagnose or treat mental or medical disorders. However, e-therapy is flexible enough to also address many difficulties which clients present to the online therapist. As in other types of therapy, such as bibliotherapy, occupational therapy, and rehabilitation therapy), e-therapy does assist a person in addressing specific concerns with specific skills. This article examines the following issues of e-therapy. First, the types of e-therapy and related services are described to provide a background for the article. Second, the ethical codes which have been adopted by three major professional organizations (American Counseling Association, National Board for Certified Counselors, and the International Society for Mental Health Online) pertaining to e-therapy are summarized for professional and consumer use. Finally, the practical, ethical, and legal issues of e-therapy services are discussed fully.

Interapy, treatment of posttraumatic stress through the Internet: a controlled trial

On-line therapy offers many advantages over face-to-face settings. Interapy includes psycho-education, screening, effect measures and protocol-driven treatment via the Internet for clients. The present paper reports the results of a controlled trial on the Interapy treatment of posttraumatic stress and grief in students, gaining course credits. The participants in the experimental condition (n = 13) improved significantly than the participants in the waiting-list control condition (n = 12), on trauma-related symptoms and general psychopathology. The effect sizes were large. Eighty percent of the treated participants showed clinically significant improvement after treatment. The possibilities for future research with Interapy, including studies into moderating variables, are discussed.

Virtual reality in psychotherapy: the MYTHSEEKER software

This chapter outlines the use in psychotherapy and medical diagnosis of an intelligent software system that helps clients to explore Personal Myth within virtual reality environments. Patented MYTHSEEKER software will allow clients to work with mythic analogues of lifeshapes and aspirations. This can help to focus therapy directions, find ways to participate with the person's world, and allow a kind of personal expression not previously possible. The software phases of assessment, facilitation, and enaction are described by which the client is assisted to explore systems of mythology or spirituality (called Depth Systems) that are traditional, ancient or newly-arising. The client builds a Personal Depth System representing Personal Myth, based on experiencing other Depth Systems, which can itself be experienced in the virtual environment. This paper outlines our methodology and technology to realize these operations. Space limitations prevent further description in the present chapter of MYTHSEEKER software technology or psychotherapy scenarios of involvement.

Current limitations into the application of virtual reality to mental health research

Virtual Reality (VR) environments have significant potential as a tool in mental health research, but are limited by technical factors and by mental health research factors. Technical difficulties include cost and complexity of virtual environment creation. Mental health research difficulties include current inadequacy of standards to specify needed details for virtual environment design. Technical difficulties are disappearing with technological advances, but the mental health research difficulties will take a concerted effort to overcome. Some of this effort will need to be directed at the formation of collaborative projects and standards for how such collaborations should proceed.

Virtual reality and imaginative techniques in clinical psychology

The great potential offered by Virtual Reality (VR) derives prevalently from the central role, in psychotherapy, occupied by the imagination and by memory. These two elements, which are fundamental in the life of every one of us, present absolute and relative limits to individual potential. Thanks to virtual experiences, it is possible to transcend these limits. The re-created world may at times be more vivid and real than the one that most subjects are able to describe through their own imagination and through their own memory. This chapter focuses on imaginative techniques to find new ways of applications in therapy. In particular the chapter analyses in which way VR can be used to improve the efficacy of current techniques. VR produces a change with respect to the traditional relationship between client and therapist. The new configuration of this relationship is based on the awareness of being more skilled in the difficult operations of recovery of past experiences, through the memory, and of foreseeing of future experiences, through the imagination. At the same time, the subject undergoing treatment perceives the advantage of being able to re-create and use a real experiential world within the walls of the clinical office of his own therapist.