Acceptability of an Online Emotional Therapy System to Apply Homework Assignments in Adjustment Disorder:

A Case Study

III Workshop on Technology for Healthcare and Healthy Lifestyle Valencia, December 2011

S. Quero1, M.A. Pérez-Ara1, C. Botella1, R. Herrero1, M. Molés1, S. Andreu-Mateu1 & R.M. Baños2

1Universitat Jaume I

2 Universidad de Valencia

INTRODUCTION • People cope with diverse stressful and difficult

situations and, most of them, do this in a more o less successful way.

• However, in some cases coping is not adequate. This maladaptive, more intense and prolonged than expected reaction is the base of Adjustment Disorders (AD).

• AD are an important mental health problem.

• However, there is no agreement concerning its diagnosis and no evidence-based assessment or treatment protocols are available.

Neurotic disorders, Secondary to stressful situations and somatoforms: • Phobic anxiety disorders • Other anxiety disorders • Obsessive-compulsive disorder • Reactions to severe stress and adjustment disorders

– Acute stress reaction – Posttraumatic stress disorder (PTSD) – Adjustment disorders – Other reactions to severe stress – Non otherwise specified severe stress reactions

• Dissociative disorders (conversion disorder) • Somatoform disorders

ICD-10 Adjustment Disorders

• The essential feature of Adjustment Disorder (AD) is the development of clinically significant emotional or behavioural symptoms in response to an identifiable stressor (APA, 2000).

Adjustment Disorders DSM-IV-TR

• A debilitating reaction to a stressful event or situation.

• When a person can't cope with a stressful event and develops emotional or behavioural symptoms

• The stressful event can be anything

• People with AD may have a wide variety of symptoms

• Symptoms must be developed within 3 months after the onset of the stressor.

Adjustment Disorders DSM-IV-TR

Proposals:

• To include the AD in the wider category of disorders related to trauma and stress.

• To add 2 new subtypes: AD with symptoms similar to PTSD

Complicated grief

(http://www.dsm5.org/Pages/Default.aspx).

Adjustment Disorders DSM-V

AD as an important health problem

• Very common disorders, that can affect anyone, regardless of gender, age, or lifestyle. Incidence from 5 to 21% (APA, 2000; Despland, Monod & Ferrero,

1995; Fabrega, Mezzich & Mezzich, 1987) The most common diagnosis in primary care.

• Very frequent in people who suffer from medical

conditions (Strain et al., 1998) especially if they are serious diseases (e.g., approx. 35% of

oncologic patients).

• Associated with: significant impairment in social or occupational functioning Causing a high percentage of sick leaves (Van der Klink et al.,

2003).

• In last 25 years, less than 30 articles (Casey, Dowrick y Wilkinson, 2001)

• No present in major part of great epidemiological studies

• Almost absents in handbooks and psychological guides

• Leading article and 2 articles in Comprehensive Psychiatry (2008)

AD: “Forgotten” disorders

Psychological treatment of AD

• In the literature we have found few studies which matched different therapeutic approaches to different types of patients (Barraza, 2004; Jojic & Leposari, 2005).

• Only 4 out of 10 of these studies were published in prestigious journals with impact factor; two of them are cases studies and the other two include experimental groups.

• No specific protocol exists for AD, and the majority of the studies about this issue have significant methodological problems (Casey & Bailey, 2011).

The use of ICTs for the treatment of AD

• AD: treatment protocol based on CBT procedures and supported by the use of ICTs (specifically EMMA VR system) (Botella, Baños & Guillén, 2008).

• EMMA’s World is an adaptive VR display whose content is adapted to every patient’s needs.

It is a Sophisticated ICT-based system that helps to produce emotional changes in individuals who have suffered traumatic, disturbing or stressful experiences.

EMMA uses objects and symbols to represent the negative experience that the individual needs to process:

• ... In order to enhance and facilitate the process of change.

• … Creating, at the same time, a protected and safe environment.

EMMA’s World

EMMA’s “world" : 5 landscapes around the architectonic structure

EMMA’s “room": An architectonic structure

EMMA’s World

Retro projected Big screen

Joystick

No HMD

The use of ICTs for the treatment of AD

• This treatment protocol has already showed its efficacy in several preliminary studies with participants diagnosed of stress related disorders (including AD) (Andreu-Mateu, Botella, Quero, Guillén,& Baños, in press; Baños et al., 2008; Baños et al., 2011) and in a controlled study that compared 3 experimental conditions (Andreu-Mateu, 2011):

1. EMMA treatment condition 2. Traditional treatment condition 3. Waiting list condition

• One way to enhance the efficiency of AD treatment outcomes

could be by using ICTs to apply homework assignments in order to consolidate learning between therapy sessions.

Homework Assignments in CBT • Since the beginning of CBT the homework assignments are

considered very relevant: As a treatment component.

It’s included in the Agenda of practically all treatment sessions at the

beginning and at the end: the homework assigned last week is reviewed and new homework is assigned for the next week.

They are assigned for each therapeutic component that is being introduced in the treatment program.

Traditionally they have included reading materials and writing tasks to carry out between sessions, as well as practicing in real life the different strategies that have been learned in session (e.g., exposure tasks, social skills practice).

The use of ICTs for the treatment of AD

• Studies that examine the utility of the application

of ICTs for the treatment of AD are needed.

So far, the studies that use ICTs for psychological treatments have been centred on how to use these technologies to apply the therapy.

Use of ICTs to apply homework

assignments

• The present work pretends to go one step beyond and join: the use of VR EMMA system within the therapy sessions and The use of other ICTs to apply homework assignments.

• To transfer the ICTs to the patient’s home: what the patient has

to do in the meantime between session is also important.

• First time that a homework assignments component that ca be completely self-administered over the Internet is developed:

EMOTIONAL THERAPY SYSTEM ONLINE (TEO)

What is TEO?

• It is a completely open system based on Web technology which permits in an easy and effective way to create personalized therapeutic material and to offer and present this material to the patients though the Internet.

https://www.teo.uji.es • It is possible to cover different therapy needs and to optimize it.

• Allows the therapist to support the patient throughout the whole

therapeutic process, facilitating learning.

• To use TEO system an Internet connection and a Web browser are needed.

What is TEO?

• The use of ICTs in order to carry out therapeutic homework provides the patient and the therapist a more active role, more involvement and a higher degree of control throughout the whole treatment process

• TEO system includes 2 platforms:

1. Therapist platform (administrator) 2. Patient platform (user)

Therapist platform • Manage and administer the database and treatment results.

• Manage, organize and label the therapeutic contents based on

multimedia materials (texts, videos, images and audios).

• Create personalized treatment sessions and protocols with multimedia material, which can be assigned to one or several patients who will be able to visualize them online in the patient’s platform.

• Assign assessment protocols that allow the monitoring or supervision of each patient.

TEO: Log in portal

Therapist platform menu

Therapist platform menu • Users: adding a new patient, viewing patients and users list.

• Multimedia: Administer the multimedia contents (texts, videos, images and audio) He can add multimedia elements and view the list of elements

available in the database

• Sessions: Build up by a set of multimedia contents (organized in an strategic way

by the therapist) and the patient can view in his/her platform. He can add a new session, view the list of sessions available and

assign a session to a user or several users.

• Treatment protocol: Build up by a set of sessions grouped and ordered strategically

according to the specific psychological problems of the patients. He can add a new protocol, view the list of protocols and add a

protocol to a user or several users.

Therapist platform menu • Assessment: Build up by several predetermined instruments that assess the

main clinical variables concerning AD. 2 moments of use: Pre-post session made by the user. The therapist can view the existing assessment protocols and

assign them to a patient.

• Reports: the therapist has access to the download of the reports derived from all activity carried out with the following data: List of users and sessions Protocols contents Sessions contents Sessions made by the users.

Patient platform (user)

• Main function: to receive the sessions assigned

and sent by the therapist from the therapist platform.

• The user access with a user an a password received by e-mail once he/she is logged in by the therapist.

• The user advances in a lineal way and the system offers the different options with tutorials.

Patient platform (user): Pre-assessment

Patient platform: select the virtual environment

Patient platform: Select the session to visualize

Patient platform: Visualizing the session

Patient platform: walk through the virtual environment

Patient platform: ending the session

Patient platform: post assessment

Objective

The aim of the present work is to present preliminary data about the acceptability of TEO system in a case study with AD

Participant

• 35 year old woman, divorced with Colombian Nationality who was living in Spain for the last 2 years.

• She was doing her doctorate.

• She met DSM-IV-TR (2000) criteria for AD with mixed anxiety and depression mood subtype.

• Stressful event: work problems.

Measures: pre-treatment Homework Assignments Preferences Questionnaire

1. “If you could choose between the two ways of

applying the homework assignments, which one would you choose?”;

2. “Which of these two ways do you consider more effective to help you overcome your problem?”;

3. “Which of these two ways do you consider more aversive?” and;

4. “Which of these two ways would you recommend to a friend in case that he/she had the same problem?

• .

Measures: post-treatment Homework Assignments Assessment Questionnaire • 2 parts:

1. Traditional method assessment: • Level of agreement from 1 (totally agree) to 5

(totally disagree) with 3 items about her opinion: – the reading materials were useful to overcome her problem – the audio recorded sessions were useful to process the

negative event and, – other persons with similar problems should use this

material. • An additional item assessed how often she

implemented the assignments per week.

Measures: post-treatment Homework Assignments Assessment Questionnaire • 2 parts:

2. TEO method assessment: • Level of agreement from 1 (totally agree) to 5 (totally disagree)

with 3 items about her opinion: – the multimedia contents were useful to overcome her problem – Having available at home the symbols and lanscapes of EMMA’s

World were useful to process the negative event and, – other persons with similar problems should use the system.

• 5 additional usability items (e.g., easy to use, comfortable, …)

• Also include an item to assess how often she implemented the assignments per week.

Measures: post-treatment Comparison Questionnaire of the two methods: • Assessed the participant’s preferences (TEO

system versus Traditional) after treatment with 4 questions:

1. “What type of application would you rather use?” 2. “Which one of them was more useful to overcome

your problem?” 3. “Which one was more useful to process the

negative event”, and 4. “Which one seemed more attractive to you?”. The response scale was multiple choice with 3

alternatives: TEO, Traditional or No difference

Design

• Case study with two treatment conditions:

1. Homework assignments using TEO: • 3 therapy sessions where homework

assignments were applied with TEO.

2. Homework assignments in the traditional way: • 3 therapy sessions where the homework

assignments were applied in the traditional way (reading materials, writing tasks and session audio records)

Treatment

• CBT program for AD (Botella, Baños & Guillén, 2008).

• Components: Educational Elaboration/processing of the stressful event

• In vivo exposure • Positive strategies • Applied with VR (EMMA system)

Relapse prevention

Procedure

• Screening interview

• Evaluation phase: Pre-treatment: 2 sessions (1 and a half hour

each) • Homework Assignments Questionnaire

Post-treatment: • Homework Assignments Assessment Questionnaire • Comparison Questionnaire of the two Methods

(Traditional versus TEO system).

Questions Responses

If you could choose between the two ways of implementing homework assignments, which

one would you choose? TEO

Which of these two ways do you consider was more effective to overcome your problem? TEO

Which of these two ways do you consider more aversive? Traditional

Which of these two treatments would you recommend to a friend in the case that he/she

had the same problem? TEO

Results obtained from the homework assignments preferences questionnaire at pre-treatment

Results obtained from the homework assignments assessment questionnaire at post-treatment

Item TEO Traditional

It is useful to overcome the problem Totally agree (1) Agree (2)

It helps to process the negative event Totally agree (1) Agree (2)

Other people with similar problems should use this method Totally agree (1) Agree (2)

Days of the week the homework assignments were implemented 4-5 times per week 4-5 times per week

Easy to use Normal (3) Easy to learn Agree (2)

Easy to follow the instructions Nor agree neither disagree (3)

Comfortable Very comfortable (5)

It is very attractive Totally agree (1)

Results obtained from the comparison questionnaire of the two methods at post-treatment

Items Chosen option

I prefer to use it TEO

It is more useful to overcome the problem No difference

It is more useful to process the negative event TEO

It is more attractive TEO

CONCLUSIONS

• Results obtained showed positive expectations towards TEO system • Participant’s opinion after treatment was, in general, very positive for

both methods. • However, she reported a more positive opinion about TEO than the

traditional method. • She also answered positively to the items referred to the usability of the

system. • When she compared both methods, she continued to prefer the TEO

system over the traditional method.

• TEO is the first program developed that permits to apply the homework assignments component using a computer and in a self-applied way.

TEO ADVANTAGES • TEO offers a great adaptability and flexibility to adjust

the therapeutic homework on every patient’s characteristics and needs, attending to the specific meaning of his/her problem.

• Each session will be adapted to the patient’s needs. Furthermore, because it is based on Web it will increase the possibilities for therapy: it can be used in blended mode (complementing the therapy),

or in tele-assistance mode (being the own self-administered therapy).

It might also facilitate the patient’s treatment adherence and the therapist’s work in designing homework assignments.

LIMITATIONS

• Uncontrolled case study

• External validity is compromised

• Future research with larger samples and controlled studies are needed

CLOSING REMARKS

• The advantages and versatility of a system like TEO opens new possibilities to the clinicians:

1. to design personalized homework assignments to practice at home what they have worked in the therapy sessions in a self-applied way using a computer.

2. To design entire therapeutic sessions or parts of

sessions that can be self-applied with a consequence of a reduction of the costs and, as a result, an improvement in the efficiency of the treatment.

Thank you very much for your attention!

CONCLUSIONS

• La realidad virtual en la psicología. La realidad virtual en la psicología. • La realidad virtual en la psicología. • La realidad virtual en la psicología. La realidad virtual en la psicología. • La realidad virtual en la psicología. • La realidad virtual en la psicología. • La realidad virtual en la psicología. • La realidad virtual en la psicología. • La realidad virtual en la psicología. • La realidad virtual en la psicología.

TEO • Sistema dirigido a las emociones, algo central en el enfoque actual

del tratamiento transdiagnóstico de Barlow (Barlow, Allen y Choate, 2004; Ehrenreich, Goldstein, Wrighty Barlow, 2009; Ellard, Fairholme, Boisseau, Farchione y Barlow, 2010; Brown y Barlow, 2009).

• Vulnerabilidad psicológica generalizada de base que comparten grupos de trastornos como los trastornos emocionales: TCC centrado en la regulación emocional Uso de músicas para exponer a los pacientes a las emociones.

• TEO es más potente ya que utiliza otros recursos multimedia para evocar, reflejar emociones positivas y negativas.

TEO • TEO puede ser de utilidad a distintos niveles:

como un laboratorio de investigación (inducción de emociones

en la línea de los parques de EMMA)

para trabajar en distintos trastornos emocionales los componentes de aceptación y mindfulness y aprender a manejar las emociones y,

para desarrollar protocolos de sesiones de recordatorio de tareas para casa (aquí es por donde hemos empezado y en TA, pero también se están preparando estos protocolos para fibromialgia y para psicooncología)

• EN SUMA, Con TEO podemos crear contextos emocionales

relevantes desde un punto de vista de psicopatología y de tratamiento.

TEO • Sistema dirigido a las emociones, algo central en el enfoque actual

del tratamiento transdiagnóstico de Barlow (Barlow, Allen y Choate, 2004; Ehrenreich, Goldstein, Wrighty Barlow, 2009; Ellard, Fairholme, Boisseau, Farchione y Barlow, 2010; Brown y Barlow, 2009).

• Vulnerabilidad psicológica generalizada de base que comparten grupos de trastornos como los trastornos emocionales: TCC centrado en la regulación emocional Uso de músicas para exponer a los pacientes a las emociones.

• TEO es más potente ya que utiliza otros recursos multimedia para evocar, reflejar emociones positivas y negativas.

Advantages and disadvantages of the two methods

TEO TRAD

ADVANTAGES

Interactive

More attractive

More immersive

Don’t need computer

Easy to remember

DISADVANTAGES Unclear interface Monotone