METANOMICS: IN COUNSELING

BEHAVIORAL THERAPY IN VIRTUAL WORLDS

OCTOBER 28, 2009

ANNOUNCER: Metanomics is brought to you by Remedy Communications and Dusan Writer’s Metaverse.

ROBERT BLOOMFIELD: Hi. I’m Robert Bloomfield, professor at Cornell University’s Johnson Graduate School of Management. Today we continue exploring Virtual Worlds in the larger sphere, social media, culture, enterprise and policy. Naturally, our discussion about Virtual Worlds takes place in a Virtual World. So join us. This is Metanomics.

ANNOUNCER: Metanomics is filmed today in front of a live audience at our studios in Second Life. We are pleased to broadcast weekly to our event partners and to welcome discussion. We use ChatBridge technology to allow viewers to comment during the show. Metanomics is sponsored by the Johnson Graduate School of Management at Cornell University and Immersive Workspaces. Welcome. This is Metanomics.

ROBERT BLOOMFIELD: Welcome to Metanomics. When we think about serious uses of Virtual Worlds, we often get stymied by some shortcomings: Virtual Worlds are anonymous. They’re game-like. They don’t provide as rich an interaction as meeting face to face. Today we are going to look at two projects that turn these shortcomings into strengths. Dick Dillon of Preferred Family Healthcare is using Virtual Worlds to provide effective behavioral therapies for adolescents with substance use disorders.

And Dan Krawczyk and Michelle Kandalaft, of the Center for Brain Health at the University of Texas Dallas, they’re doing something similar with children and adults on the autism spectrum disorder, or with schizophrenia or brain trauma. It turns out anonymity and a game-like environment can be useful tools. We’re going to kick off today’s session with Dick Dillon and get to Drs. Krawczyk and Kandalaft right after the break. Dick, Welcome to Metanomics.

DICK DILLON: Thanks. Glad to be here.

ROBERT BLOOMFIELD: It’s great to have you, and it’s great to have everyone else who is watching us on the web or in Second Life at our Metanomics Sim or at any of our event partners. We’ll be tracking the text chat so please keep those questions and comments coming. Now, Dick, I understand that Preferred Family Healthcare is the largest provider of publicly-funded substance-abuse treatment for youth in Missouri. Just for background, what is the traditional treatment for youth who are struggling with substance abuse?

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DICK DILLON: Rob, there’s a variety of levels of treatment, and we try to set up our system so that anybody can enter at any point of intensity, depending on what’s going on with them. But we offer residential care, where youth will come and actually live in one of our centers for normally an average of 25 to 35 days and then outpatient care which could be as often as daily and tends to be dialed down to three times a week, two times a week, you try to taper off your involvement, in an ideal situation with a client. Again, people can enter as outpatients, and, if their situation doesn’t improve as we would hope it would, they might end up in a residential center. They might be outpatients through the entire course of their treatment.

At whatever level they’re in and whether they’re living with us or not, we offer a wide range of group and individual counseling activities, education on issues that are relevant to recovery, motivational counseling, creative arts therapy; it’s quite a broad range. We keep our clients busy.

ROBERT BLOOMFIELD: I guess that’s part of the treatment. You got a grant from the Missouri Foundation for Health, their Innovative Funding Initiative, and, of course, the reason you’re here on Metanomics today is that you’re bringing your clients into a Virtual World for part of their treatment. When in the course of that treatment you’ve described did the Virtual Worlds come in?

DICK DILLON: That’s right, Rob. We’ve actually, with the help of the Reaction Grid people, we’ve set up our own private Sim on a server. Preferred Family Healthcare has a pretty big presence in the Second Life main grid. But we do all of our counseling behind our own firewall, on our own server, for confidentiality. What we have done is, because we have received this grant, it’s enabled us to identify clients in two of our residential centers in the central part of Missouri, which is our headquarter state, and we find clients that we believe might have difficulty coming back to our offices once they’ve left residential care because of distance, transportation, time, money, etcetera. And, while they’re still in residential care, we actually give them laptops that are capable of running Second Life, and we orient them to the Second Life program. And then, when they go home, they attend their follow-up counseling just by logging in from home.

ROBERT BLOOMFIELD: So I see people are giving shout-outs to Reaction Grid, and my guess is, there are many listeners, viewers who aren’t familiar with them. Can you just clarify who they are?

DICK DILLON: Well, Reaction Grid is one of the, I think, richest open grid projects that’s going on. Kyle Gomboy and his wife, Robin, and Chris, who have put Reaction Grid together, have been incredibly helpful to us in building our own sort of mini-world that is rich and useful and allows us to deliver virtually all the services that we would do in real life to our clients who are coming in.

ROBERT BLOOMFIELD: But not that early phase of treatment, right? This is a later part?

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DICK DILLON: We do see down the road very much a potential for delivering every level of service from the initial meetings and interventions to throughout all the counseling in a Virtual World, but we’re at the proof-of-concept stage, I think, with this grant. So we’re trying to work specifically with young people that we believe that we have the best opportunity to orient them to the program and measure whether we’re going to be able to be successful or not. ROBERT BLOOMFIELD: And so how do you select children for this project?

DICK DILLON: What we’re looking for when we talk to the kids, unfortunately, I think, because we hope this will change over time, is people who have internet access, other than dialup, that becomes a selective factor. So we want to know can they get internet into their house, or do they have a local community resource, like a café or a library that they can go, and they can log in. That becomes one of the criteria that we have to consider. We’re also looking for young people whose parents are interested in being involved in their treatment because we think that that’s an important factor in developing the responsibility that they need to have, to take our computers home and work with them.

It’s interesting, we’ve been seeing kids for nine months now, and, although we built in a 25 percent loss factor on our hardware, we so far haven’t had to replace any computers. None of them have been dropped or had soda spilled on top of them or got broken or damaged or lost in any way so that’s been a real positive thing. Other than that, we try not to do any further screening. We want these kids to be as representative of the general population as they possibly can so that, as we look at follow-up statistics, we can feel that there is some validity behind any conclusions we draw about using Virtual World counseling.

ROBERT BLOOMFIELD: So already the questions are rolling in so let me just jump to some of these. DagnyT Gabilondo asks whether you see in the future a Virtual World venue in which you could do diagnosis and prescriptions.

DICK DILLON: I think that there’s some very real possibility for that. An interesting thing that’s occurred amongst our clientele is, and I have to admit that the number is small; we’ve only enrolled 15 clients so far. We plan to enroll approximately 100 over the three-year period of the grant. But, in two instances already, through the interaction just in the Virtual World between our online counselor and clients, we have diagnosed their need for more intensive treatment.

We’ve made referrals. In one case, brought a client back into our residential program. In another case, referred a client to a psychiatric facility. And we’re able to do that without face-to-face intervention between our staff and the client. And I’ll add also that, in both cases, the clients accepted the recommendation and got more intensive treatment. ROBERT BLOOMFIELD: We also have a question from Douglas Rishmal, “How would you enforce compliance at the early stages with a fully virtualized treatment?”

DICK DILLON: Well, we are not completely separate at this point in time from our clientele so the counselor does make some rounds and drives out to their houses, so we can do things like

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urinalysis on clients, things that could also conceivably be done if you had some local assistance of someone you could trust if you needed to see a client on a face-to-face basis. For the most part, what we found in both real life and in virtual life is, clients tend to be a lot more honest about what’s going on in their lives, once they’ve engaged in treatment than they might have been in their lives prior to getting into treatment. So we feel pretty comfortable that, when we’re having conversations in the Virtual World with clients, that they’re telling us the truth about what’s going on.

ROBERT BLOOMFIELD: That gets us to a point I’m very interested in, which is, honesty and anonymity in Virtual Worlds so I’m wondering are you finding that, on the one hand, people who are anonymous can say whatever they want and feel like they don’t have to be honest at all; they can make it up. On the other hand, they may feel more free to be honest. What are you finding with your clients?

DICK DILLON: I should point out that the way that we’ve structured our grid is that staff members who come into our private area use their real life names, and clients are forbidden to use their real life names. So we require every client to create an avatar name. Of course, we have a database so that, when we’re dealing with the clients, we know who they really are. But none of the other clients needs to know who you are unless you choose personally to give them that information.

One of the most universal responses we’ve had from the clients to date is that they say that they believe that that additional layer of protection between themselves and the rest of the people involved has allowed them to feel like they can be considerably more honest in their discussions. We do a lot of our activity in group settings in the Virtual World, and the clients constantly tell us that they feel that it’s easier to talk about what’s going on with them, both their feelings and their behaviors because they don’t feel that sense that someone that they know or who knows them personally might be sitting there across the table from them and judging them.

ROBERT BLOOMFIELD: Knoh Oh is asking, “How does your work differ from teleconferencing? Are you utilizing the 3D space?

DICK DILLON: Oh, yeah, we utilize the 3D space a lot. One of the nice things, of course, about Second Life and Virtual Worlds of this type is that you’re able to create a lot of interesting settings that put a little bit of an entertainment element possibly into the entire process of working with others. So we have a group setting that’s high up in a tree house. We have a group setting that’s built inside a Campbell Soup can. We have one whole Sim that we encourage our clients to come into the Virtual World even when staff aren’t online, and they have building privileges so they can come in and play around. A couple of our clients are actually building a skateboard park right now, that we think is going to be fun for everybody when it’s completed.

So how I see it differing from teleconferencing is that ability to use a 3D world of your own creation, be a little bit more fantasy-like. It’s also, I think, much easier to do group counseling in

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a 3D setting. Unless you have some pretty high-end products, it’s hard to look at seven webcams on your TV screen and have any kind of a perception that you’re all in the same room together.

ROBERT BLOOMFIELD: And I should mention the vast majority of our viewers actually watch this show on the web. I’m sure many of them have been in Second Life, but, if you haven’t, spatial voice has got to be a big help. You can actually have everyone sitting in a circle, you hear the voice of the person on your right or on your left. So I can imagine that--

DICK DILLON: Spatial sound is really a very cool effect.

ROBERT BLOOMFIELD: Now you also mentioned a couple other things; I guess they’re related: role play and putting people in the face of temptation and teaching them coping strategies. Could you talk about that?

DICK DILLON: Yeah, absolutely. One of the nice things about having even some basic building skills is that you can build a setting whether it’s the kitchen table where you’re having an argument with your parents or the school yard or walking down the street in a neighborhood, where you’re exposed to temptation, where we can not only talk through the situation with the client and help them deal with high-risk situations, but we can walk them through it. We have about a dozen staff members who are pretty familiar with Second Life and use it regularly enough that they can actually come in and play other parts, if that’s called for, or we can enlist other clients to take the roles.

It’s very common in a traditional setting to do role-play scripting, but, again, you have people standing in a group therapy room, holding a piece of paper, reading off of the script. And there’s much more ability to develop a more realistic situation by not only having the appropriate scripting, but also changing the environment to match what it would be like in real life.

ROBERT BLOOMFIELD: There are a couple other things you have on your land that--we sent our staff “jack of all trades,” JenzZa Misfit, who’s also a photographer, and she took a number of pictures of some of your builds. You’ve got a coconut tree and a bridge. I’m wondering if you can talk about the role those play in treatment.

DICK DILLON: Our full time in-world counselor, whose name in Second Life is Brena Benoir, did a tremendous job in September, which is nationally considered to be recovery month around the country every year. And she put those two particular builds in specifically for that, and this is on our Preferred Family HC island here in the main grid. It’s not where we do our counseling. But the coconut tree has a basically inspirational messages and things for you to think about so you can wander through the coconut grove and pick up a coconut, and it’ll give you something to think about--a message.

And then she built a bridge to recovery that’s basically made out of large-scale models of hands

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that are holding the bridge up, to represent the fact that, for just about everybody, recovery is not a singular personal job, but it takes the help of a lot of other people supporting you and your hard work, to get better from substance-use disorders.

ROBERT BLOOMFIELD: You’ve talked about some of the advantages of using a Virtual World, benefits of anonymity, the ability to have these creative builds and so on. What do you feel you lose by not having face-to-face contact?

DICK DILLON: We’ve taken the position really from the beginning and from when I got into Second Life and tried to figure out how our organization could best utilize it to do some good. But we’ve always taken the position that, all things being equal, interaction face-to-face is the best of all possible worlds. The problem is that face-to-face [AUDIO GLITCH] is also one of the most challenging things to arrange. When you start taking into account factors that affect people’s ability to come in to your office, which not only include things like--I’ve mentioned time, gas money, distance, physical handicaps--but also the more psychological things like do you really want to drive your car and park it in the parking lot of the drug abuse treatment center if you’re living in a town where people might drive by and see you walking in there. So there’s stigma that still has to be dealt with and the like. Even for people who have access to our bricks and mortar facilities, from time to time things come up that interfere with their ability to get there: They’re physically ill. They have to travel out of town on some important piece of business. We have a snow day. All of those things become inconsequential when you’re dealing with Virtual Worlds.

In a perfect world, everybody would have easy access to face-to-face contact with their therapist, but it’s not a perfect world. And what we believe is that Virtual Worlds offer tremendous opportunity to reach most anybody some of the time and some people all of the time, in ways that they could never get help today.

ROBERT BLOOMFIELD: I know that one of the biggest problems with substance abuse programs is the dropout rate. So can you give us a sense of how the dropout rate in your program compares to what you would expect with a traditional program?

DICK DILLON: So far, and we really haven’t been into this long enough to feel like we want to publish any data, but we’ve been incredibly amazed by the retention rate of clients in this program. One of our hypothesis was that, because we are resolving some significant access issues, that we would have a better retention rate of clients as compared with our general population. What we’ve found is that, whereas, in the general population, usually between 50 and 60 percent of our clients drop out of follow-up care within the first three to six months. We’ve been running this program now for nine months, and, so far, we’ve had zero dropout rate. Everybody who’s gotten into the program is continuing to receive services. It’s been actually an awesome result, much better than we expected.

ROBERT BLOOMFIELD: You mentioned you’re not yet ready to publish your data, but I’m wondering, what types of data are you collecting? I’m assuming you want to demonstrate that

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type of retention more formally, effectiveness and so on. What are you collecting?

DICK DILLON: Sure. We look at obvious things with clients: relapse rates. If they do return to chemical use, are they able to halt that quickly and get back on the recovery track? Things that you might expect also, other behavioral issues: How are they doing in school, both attendance-wise and grade-wise? How is their home life? Do they and do their parents report better relationships with one another? Are they getting along better? Are they fighting less? We look at involvement with the legal system. And these are things we measure with all of our clients. So our basic premise is that, if, in fact, use of Virtual Worlds increases the retention of clients and increases their attendance in our programming and we have results that are at least equal to what we have with our clients who are coming into our office, in terms of these other social factors, that we think this is going to be an unqualified success.

And, so far, everything we’ve seen is that the statistics on things like family involvement, school involvement, grades, legal system involvement, have been as good or better than the rest of our clientele.

ROBERT BLOOMFIELD: You mentioned legal system involvement, and I’m just wondering, the clients that you get, are they being referred by the criminal justice system, by their schools?

DICK DILLON: Yeah, a certain percentage of our clients come in because they’ve had involvement with the juvenile authorities. This is true for adults too. They come in because of court orders and things like that. Many of our clients are being identified in schools. We have a very robust school intervention program that is in place in many of the school districts in the areas where we have centers and allows us to work with the faculty and the staff of the schools to do some early intervention on kids so that perhaps the work we do with them doesn’t have to be quite as intense as if we waited until their problems got to be incredibly critical. And we get family referrals.

We’ve also been around for over 30 years now in Missouri and have established a presence also in Kansas and Texas, and a lot of our referrals just come through our reputation. People know who we are, and they know what we do. And when there’s a child or an adult that has a problem with substance-use disorders, we’re often the first place they call.

ROBERT BLOOMFIELD: There are so many questions here, makes it easy for me to do my job. I know that you were in Second Life before you started this program because I read a news article where you basically said, “I noticed next door to me in Second Life was a professional organization that I was a member of.” But let’s see, now I’ve lost whose question this is, but someone is asking--oh, Devon Alderton, “Do your therapists have Second Life experience before they start providing services through the program?”

DICK DILLON: Yeah, we boast and perhaps incorrectly--somebody can correct me if I’m wrong--that we have the first full time in-world counselor who I mentioned earlier, Brena, and Brena has spent a lot of time in Second Life before we ever initiated this project. I think it was

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one of the things that really drew her to want to be the person who applied for the job when that job became available. I got involved in Second Life in February of 2007, and very early on looked for people who were of like mind because I thought this was an interesting tool for my organization and our mission, and came across the TechSoup people who’ve developed the Nonprofit Commons, which is now a multi-Sim area that hosts about 85 nonprofits of various types. That was where I ran into the National Council for Community Behavioral Healthcare which actually had a building two doors down from the Preferred Family Healthcare building at Nonprofit Commons. Very interesting.

ROBERT BLOOMFIELD: You’ll never know who you’ll meet in Second Life.

DICK DILLON: Or who you’ll never meet. I always tell people when I first came in, the average concurrent usage was about 14,000 residents at a time. You’d log in, and you’d see 14,000, “Wow! What a market.” And, of course, today when I logged in, it was about 60,000 people, but I also read recently that the land mass on the main grid now is about the size of Rhode Island, which has a population of over a million so the population density compared to Rhode Island is about one-twentieth.

I always tell people that our initial idea of actually marketing our services directly to Second Life residents is sort of like selling vacuum cleaners door to door in Montana. It’s not that there’s nobody there, it’s just that the drives are really long in between houses. So what we ended up deciding to do was start this out and, hopefully, get good at it with our current clientele. As time go on, who knows. We may get some people from Montana.

ROBERT BLOOMFIELD: Great! Well, we’re just hitting the halfway point of the show so we’re going to take a break. Dick, thanks so much for telling us about what you’re doing, and we will actually bring you back at the very end of the show to talk about future directions, with our other guests. They are conducting also behavioral therapy though for people with autism spectrum disorder, schizophrenia and brain trauma. So I’d like to ask everyone to stick with us after we spend a moment looking back to hear Alice Krueger tell us how helpful Virtual Worlds can be for those who face challenges in getting to and from support group meetings and other events. So we’ll be back in a second.

[VIDIO]

ROBERT BLOOMFIELD: With Metanomics now in its third season we thought it would be fun to take a look back at some of our past shows and guests since September of 2007. With over 80 episodes to choose from we chose some of the most interesting, engaging and occasionally contentious discussions. As always you can see the complete episodes at metanomics.net or on our iTunes channel.

ARCHIVE SEGMENT:METANOMICS: VIRTUAL ABILITY

FEBRUARY 23, 2009

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ROBERT BLOOMFIELD: And as an example of information sources that people could be seeking out coming into Virtual Worlds, we’ve got Health Info Island and the Path of Support. Can you tell us about that?

ALICE KRUEGER: Certainly. There’s a number of good resources for people on Health Info Island, and one of those is the Path of Support, which is a series of posters that are about the peer support groups here in Second Life, for people with disabilities. We were really pleased. We found over 70 different peer support groups that are in English, and we know that there are others in other languages as well. So a Second Life resident walking down the Path of Support can get information about these support groups and learn how to access them for information. And so it’s so much better to be part of a peer support group in Second Life. I belong to both real life and Second Life peer support groups for multiple sclerosis.

To get to my real life group meeting every month, I have to arrange para-transit. I spend an hour on a rattling old bus, to get to a place that is 20 minutes from my home. I am told when I will pick up the bus. I can’t go when I want to. When I get to my real life support group meeting, then I have to figure out how to get into the building. It’s not totally accessible where we’re meeting. And then, after the meeting, I again have to catch the para-transit bus when they decide to pick me up, not on my schedule, and it’s another hour rattling back.

In Second Life, to go to my monthly peer support group, I teleport, and there I am.

[END OF VIDEO]

ROBERT BLOOMFIELD: Welcome back. We are joined now by Drs. Dan Krawczyk and Michelle Kandalaft from the Center for Brain Health at the University of Texas Dallas, and they’re going to be telling us about a collaborative effort to provide behavioral therapy in a Virtual World for people with a range of conditions, including autism spectrum disorder, traumatic brain injury and schizophrenia. Dan is an assistant professor, and Michelle is a clinical psychologist. Their work is overseen by the director of the Center for Brain Health, Dr. Sandra Chapman. So, Dan, Michelle, welcome to Metanomics.

DAN KRAWCZYK: Thank you.

MICHELLE KANDALAFT: Thank you for having us.

ROBERT BLOOMFIELD: Michelle, since you’re the clinician working directly with your clients, I’d like to start with you. And could you just paint a picture for us about some patient? Give us a sense of what issues they’re coming to you with and what type of behavioral therapy you’re providing.

MICHELLE KANDALAFT: Sure. One of our most memorable participants is a 19-year-old young

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man, and he had just started college and was having significant deficits and doing well in college. After he and his mother had heard about the Center for Brain Health through the news story that we had, his mom contacted us, and he came in, and he told us about some of the social impairments that he was having, especially in his relationship with his roommate for example, and how difficult it was for him to speak with his teachers and really grasp a great college learning experience because of that. Also, he was working at a nearby Wal-Mart and wasn’t sure why he wasn’t succeeding as much as he thought he should be.

So we felt like he was a really good match for our program, and he came in for some initial pre-testing, and that included some EEG and FMRI that Dan will talk about later. Then we put him through our intervention, virtual reality intervention, which consists of ten sessions of beautiful storyline of adult-related scenarios. What we do in these scenarios is myself and another therapist will work together to pose a situation in which the participant has to work through, and these, like I said, are adult-related. So they have to work for a difficult roommate, for example. They have to earn money to live in the apartment that they’re living in on the island. And, to do that, they have to go and find a job. So all of these issues are very relatable to real life.

So this young man completed our intervention and went through a post-testing, and he was so thankful for all of the help that we were able to give him, and he still calls us to this day, to tell us about how improved his relationships have been, with his roommate for example, and how he’s able to go to teachers and talk to them and negotiate through a lot of issues at work.

ROBERT BLOOMFIELD: Now, Dan, this may be more a question for a researcher than a clinician, but feel free either of you to correct me on that. I guess I get a little confused. There are the neurological issues and sort of the underlying condition that someone may be struggling with, and then there are the behavioral treatments that you’re providing. Well, maybe, Michelle, if I could ask you: Do you know exactly what the physical or neurological condition was that this person was suffering from? And then what particular behaviors were they that were causing the problems? And how do you identify that?

MICHELLE KANDALAFT: Sure. We have criteria who is a good match for our study, and those people would have some social impairment and a diagnosis of one of the following: attention deficit hyperactivity disorder; Asperger’s, which is a high-form of functioning autism; traumatic brain injury or schizophrenia. For the young gentleman I just described, he has something called Asperger’s, and that’s a condition where someone has great impairment in social interactions, as well as restricted, repetitive patterns of behavior or interests, and that really impairs the ability to function socially and occupationally. So for that young man, those behaviors with the restricted interests, for example, really impacted his ability to make friends.

ROBERT BLOOMFIELD: You’re not just treating the symptoms rather than the cause. Is that right? Well, I guess it’s a question maybe more: Is it changing the underlying condition or just helping them address it more?

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MICHELLE KANDALAFT: Well, the underlying condition is manifested by these behaviors. And what we’re trying to do is improve their ability for success in their lives. So yes, we’re helping them improve their behaviors and not the underlying condition per se.

ROBERT BLOOMFIELD: Oh, sure. Dan.

DAN KRAWCZYK: I would add, as part of the research, we really are trying to get at what are the underlying reasons for the conditions. These aren’t extremely well known, even though these disorders have been diagnosed and studied for a number of years. It’s not totally clear, for instance, what about the brain of someone on the autism spectrum is different than someone who’s not on that spectrum. And, with brain injury, it’s very important to get clear information from brain imaging on what areas are showing impairments. That’s something we can actually look at. It differs, to some degree, between individuals so that’s one of the important phases of the project, on the research end, as actually trying to get sensitive measures that identify what may be the underlying causes.

ROBERT BLOOMFIELD: Okay. So I see there’s a little conversation going on in the chat. DagnyT Gabilondo is asking, “Asperger’s and ADHD are relatively mild. How do you deal with schizophrenic patients showing negative symptoms, like social withdrawal?” With the caveat that Ju Roussel says, “Asperger’s syndrome is not mild.” But that said, do you think this therapy really is only suited for the milder conditions?

MICHELLE KANDALAFT: Dan, would you like me to take this one?

DAN KRAWCZYK: Sure. I think we could probably both answer. We actually started on the relatively mild side. In terms of Asperger’s, whether or not it’s mild is sort of a subjective question. But compared to, for instance, highly autistic where there really isn’t much language being produced, you have to start somewhere, and it seemed as if Asperger’s was a good case because they can hold normal conversations, and they potentially could be more sensitive to the training. Not that it couldn’t be used for a wider range of people, we tried to identify individuals who might be more likely to benefit, to start with.

ROBERT BLOOMFIELD: And, Michelle, since, again, you’re the clinician right on the scene, can you talk about how what you are doing with the patients in the Virtual World differs from what you would do in a normal Real World situation?

MICHELLE KANDALAFT: Well, usually in therapy, when we’re trying to improve one’s ability to function socially, or the social skills training, we’ll do role-playing, just as Dick had mentioned before. And it’s basically you’re in the office together with your therapist, and you ask the patient to imagine that, “Forget I’m your therapist now. I’m an interviewer, and let me try to interview you.” And there’s some faults with this. I’ve noticed that a lot of patients don’t like to role-play in real life. I think that it makes them anxious to kind of remove that previous alliance with the therapist and now imagine that the therapist is someone else.

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And then also, I don’t feel like they feel as immersed in the situation, so we really appreciate what the Virtual World can provide in that immersion, in that suspension of disbelief. And we really find that our participants really are engaged and interact as if they were, in real life, in a real situation.

ROBERT BLOOMFIELD: You mentioned in one of the documents that I read that, in real life, people can only see the other person; whereas, if they’re role-playing in Second Life, they can actually see a replay of what they’ve done and see how they are responding to others. How do you integrate that into therapy?

MICHELLE KANDALAFT: Well, what we do, the way we structure every session is, we give them two opportunities to do a specific scenario, for example, the interview scenario. They start off, and they go into the office building, and they have an interview with a gentleman, let’s say. During that interview, the moderator therapist will interject and let them know in that exact moment things that are going well and things that may not be going as well. And then, after a break and a recap of some of those better coping skills, we allow them to do it again. The reason we record it is to give them one more piece of feedback, to show them, “See what we were talking about? See how you were saying this or that and how it could be improved the next time around?” So it’s just one more tool for us to give them feedback.

ROBERT BLOOMFIELD: G2 Proto has a question that you might anticipate from a Virtual World developer and programmer. He’s suggesting that AI, artificial intelligence, bots could help and separate that. Instead of a therapist, you could actually have a non-player character that’s computerized. Is that something that you do, or do you see advantages, disadvantages for that?

MICHELLE KANDALAFT: Definitely. We have a great tech team that works closely with us, and we’ve debated these issues and the effectiveness of having real avatars driven by real therapists versus AI or other avatars just walking around, for example. And we felt, to really have an immersive situation, you need to have a real human at this time in the technology, to have the emotional reactions that a person would have. Technology is not there to the point where the AI would be able to react on that cognitive emotional level that the human would be able to, to give that feedback that a person would need to change behavior.

DAN KRAWCZYK: One thing I would add, I think there are a few advantages that could come about with AI. One of the things we have difficulty with is the fact that the scenarios can be different, and they always are different because humans are playing all the roles. We have all the advantages of real humans interacting, but, in some cases, where we want to measure something, for instance, say we wanted to measure amount of time talking, it might be advantageous to actually have AI to where individuals could have exactly the same scenario or the same automated character that they’re interacting with. And that would allow it to be more controlled experimentally.

ROBERT BLOOMFIELD: Okay. Mercyblu Moorsider here is saying, “Maybe there’s a job opportunity in Second Life, acting in therapeutic role-plays.” I’d just like to mention that I know

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there are people who hire professional actors. For example, Language Lab teaches foreign languages in Second Life and hires actors who are native speakers of the language, being taught to act in ordinary roles. So I can see there may be licensing issues when you talk about therapy, but I can imagine that that would be useful.

Dan, I’d like to ask you a little bit about the data that you’re collecting, in addition to this project is providing care and treatment, I assume it also has a research element. So could you talk a little bit about what data you’re collecting, what questions you’re looking at?

DAN KRAWCZYK: Sure. One of the interesting areas that we can now work on through improvements in technology is really how the brain is involved in these different components of these disorders. We think that there are several common aspects. It’s an area called social neuroscience which enables us to look at how the brain is involved in things like reading emotion, recognizing faces and also predicting or interpreting what someone else is going to do. We use two technologies mainly for that. One is an MRI-based technique which allows us to see where is the brain active during a particular task. And so we have people, in an MRI scanner, doing things like reading emotion off of faces and also predicting what different individuals are doing within an animated scenario. The other technique is called EEG, which is an older technique, which allows us to get actual electrical recording off of the scalp. And what that enables you to do is look for basically brainwave signatures. For instance, in face recognition, there’s a very reliable drop in one of the tentials in the back of the head, which is a good marker for how you’re doing at recognizing faces. I think all three of these disorders tend to involve some kind of difference in face processing, which, of course, is a big gateway toward actual social understanding because, through face recognition and emotion recognition particularly, that’s how people really manage to figure out what’s going on.

In addition to those technological measures, we also take a lot of what are known are neuropsychological measures, which are standardized tests which try to get at similar sorts of things. So face recognition, ability to understand emotion, both in text as well as in pictures. We get a very rich dataset, and we try to gather all of these data before and after therapy, to see what might be sensitive to change.

ROBERT BLOOMFIELD: Okay. Fascinating. I have a question. This is, I guess, more on Second Life than about the treatment that you’re actually conducting. But I understand that there are a number of people on the autism spectrum disorder in Second Life, just as residents. It’s something they seem to find comfortable and engaging. I’m wondering if you have any insight into why that would be.

DAN KRAWCZYK: That’s an interesting question. It may be related in some ways to why we thought Second Life would be advantageous for therapy. Second Life provides, I think, a pretty realistic way of interacting with others, but perhaps it’s a bit less of a threatening situation that can happen in real life. That may be one of the reasons people may gravitate toward it. I think you could seek out social training in some ways, just on your own, by going into Second Life.

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ROBERT BLOOMFIELD: I see Riven Homewood is asking whether the limited facial expressions and limited body language cause problems in Virtual World therapies.

MICHELLE KANDALAFT: That’s a great question, Riven, and we believe that it really does inhibit a lot of the nonverbal communication that each person does, to communicate how they’re feeling. That’s something that we feel is a disadvantage with Second Life, and we hope that, with facial tracking and other types of physio measures, we can try to improve the ability to communicate. ROBERT BLOOMFIELD: Okay. Let’s see. I think what I’d like to do at this point, there are so many commonalities between what you two are doing at the Center for Brain Health and what Dick Dillon is doing with substance-abuse counseling, I’d like to bring Dick back into the conversation. Welcome back, Dick.

DICK DILLON: Thank you, Rob.

ROBERT BLOOMFIELD: Both of your groups, you know, this is medical care that comes under licensing, and we’ve had a number of questions where people are wondering about licensing issues in providing Virtual World care. Would any of you like to speak to that issue? How do you address that?

DICK DILLON: Yeah, I’d be happy to talk to that. Of course, in our project right now, we are both privately funded and delivering services within the borders of a single state. The counselor that we use has certification to do the work that she’s doing. The agency that oversees licensing for that type of work in our state is not only quite aware of what we’re doing, but actually I’ve demonstrated it to them, and they’re starting to talk about whether they’d be willing to pay for it with public funds. But licensure tends to be a state supported rather than a countrywide supported system, and that’s one of the things that’s going to have to be worked out.

If I’m in Missouri and I put a group of clients together, who come from Colorado and Idaho and New York state, what changes have to be made to the licensure laws and requirements that are going to allow me to do that type of practice. There is a lot of discussion going on about that. Within Second Life itself, there’s a group called the Online Therapy Institute that I certainly would recommend anybody who’s interested in this get in touch with because they’re both at a national and international level, are carrying the conversation on to address this head-on and deal with it in appropriate ways. We’re optimistic about it, and we believe that the overall potential benefits of using Virtual Worlds for counseling are going to overcome the insular thinking that might exist in some organizations that do licensing. But it remains to be seen.

ROBERT BLOOMFIELD: Related to this there are privacy issues. Dan or Michelle, do you have any thoughts? There are so many privacy guidelines in therapy and medical practice. How are you addressing those?

DAN KRAWCZYK: Well, we’ve always had confidentiality in place. We’re required to through

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our institutional agreements and regulation. I think one thing that’s important with any sort of new technology, like virtual reality or Second Life, is that things do remain very controlled, and anonymity is protected. What we do is really all within a controlled area of Second Life. We call it our island. Basically that enables only the people who are involved in the therapy to go on the island, and there’s no external way of accessing who’s on at a given time. Everyone also is on using new names. They’re de-identified, much like Dick said. So even if someone were to look at the Second Life therapy going on, it wouldn’t be involving anyone’s personal information.

ROBERT BLOOMFIELD: Changing gears, we had some people suggesting that--this was fairly early on in the first part of the show--people were suggesting that there might be a lot of other forms of therapy and medical treatment that could be done quite well in Virtual Worlds, including, for example, anxiety treatment. Could you just maybe share your thoughts on who you’d like to see join you in Virtual Worlds providing this kind of care?

MICHELLE KANDALAFT: Well, I think that the Virtual World is a perfect match for anxiety treatments because of the theory of systematic desensitization, in which you slowly expose participant to the feared stimuli. I think it’s a great platform for treating those types of disorders. However, I’m not sure if all mental disorders, coming from my field, if this would be a good match for other disorders, but definitely for anxiety.

DAN KRAWCZYK: I would add I think there’s a big potential for just general training for life skills. I could imagine training for job interviews would be a natural for this or training in international business situations. There’s a huge number of social situations in life I think all of us could use potentially some training in. And there are also some interesting military applications that are being worked on with the Department of Defense right now. I think the focus on disorders is interesting, but the potential is actually even greater, I think, for general skills training.

DICK DILLON: I would definitely have to agree with that as well, just public speaking skills, good interaction with other people, running meetings in appropriate ways where you can have a trainer sitting next to someone who’s working their avatar in Second Life and giving them advice on how to run an online meeting.

ROBERT BLOOMFIELD: And I’d just like to speak for a second to what Dan was talking about, with the Military. I know that, at USC, in cooperation with USC, the Military is doing research on post-traumatic stress disorder and essentially desensitization and various treatments that apparently are looking to be rather effective.

We only have a couple minutes left. I’d like to close by asking each of you just to tell us the people who will be following in your footsteps, maybe just what advice do you have for them? What do they really need to know, what’s maybe the biggest hurdle or biggest advantage they may not have thought of? And, Dan, why don’t we start with you?

MICHELLE KANDALAFT: The biggest hurdle, I would say, goes back to probably, in our case,

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emotional expression and also gesturing has been really challenging. And I think as technology improves, we’ll start to see that those problems go away, but you face some very strange challenges. So for instance unintuitively, as you get closer to perfect realism, things actually become less realistic for a short period of time until you actually have what would be considered like photorealism. And so that’s something that we deal with in trying to think about technology.

There’s a lot of strange barriers that we need to go through between what’s actually perfectly realistic and what’s virtual. So I think that’s one of the things that I would say we didn’t anticipate, but we have to think about all the time now.

ROBERT BLOOMFIELD: Michelle?

MICHELLE KANDALAFT: I definitely agree with what Dan said. Another thing in coming into this profession is, there may be some resistance from other therapists in using a platform as virtual reality and being able to explain clearly the limitations and benefits of such a platform. I think it’s really imperative for people coming into this field to be able to express that clearly to those who are interested.

ROBERT BLOOMFIELD: And, Dick, you get the last word.

DICK DILLON: I just encourage people to think creatively and expansively. There’s tons of historical references of people saying, “This is as much as we need. We only need one supercomputer. There will never be a reason for people to have a computer in their homes.” You can go back way before the computer age, and people have said, “We’re as far advanced as we possibly can.” And we’re just scratching the surface right now. The people that are up here with me and others that are working in the Virtual World on these issues are--we don’t have the answers to all of your questions because we haven’t figured them out yet, but I’m just delighted to be in the company of such intelligent, creative people that are finding really positive uses for this new technology, and I encourage people to keep working at it.

ROBERT BLOOMFIELD: Okay. Well, thank you very much. We had Dan Krawczyk and Michelle Kandalaft, from the Center for Brain health at the University of Texas Dallas, and Dick Dillon, of Preferred Family Healthcare. Thank you so much for joining us, all of you.

MICHELLE KANDALAFT: Thank you.

DAN KRAWCZYK: Thanks, Rob.

ROBERT BLOOMFIELD: Normally this would be the time that I would close with an opinion piece, but I knew that there would be so much to talk about today that we wouldn’t have a chance to get to that. So you’ll just have to live in suspense and see what I’m going to say next week. Now next week we’re going to be having Metanomics at a special time: 11:00 A.M. Pacific Time. We’re going to see a live presentation by Mark Kingdon on Linden Lab’s new

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enterprise solution, which, among other things, resides behind a firewall, allowing security that so many types of organizations require, particularly those that we listened to today in health care.

Don’t forget you can see now actually almost 90 hours of Metanomics in our archives at metanomics.net and on iTunes. See you next week. Bye bye.

Document: cor1070.docTranscribed by: http://www.hiredhand.comhttp://www.hiredhandtranscription.orgSecond Life Avatar: Transcriptionist Writer

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