Virtual Reality Supported Therapy: Technologies and Ethics · Juan et. al. (2005). Using augmented...

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INFORMATION SCIENCE Brian Dixon & Holger Regenbrecht

Virtual Reality Supported Therapy:Technologies and Ethics

c.ott

(Modified version of talk given at Bioethics 2008)

dixon / regenbrechtapril 2008 cs/is 2008

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(Thanks to Chris Slane)


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Outline

1. Who we are2. What is Virtual Supported Therapy? 3. Selected International Projects4. Example Project: cMRET5. Discussion of Pros and Cons 6. The Issues 7. Developing and applying standards 8. Conclusion and Discussion

(c) CyberMind


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Who we are

Holger RegenbrechtComputer Scientist

Academic and industrial research in: Virtual and Augmented Reality

Teleconferencing Presence in Virtual Environments

Brian DixonConsultant Clinical Psychologist

Clinical practitioner: Treatment provision (private practice) Clinical supervision and teaching Professional ethics consulting


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What is Virtual Supported Therapy?

We all experience fear and avoid certain situations This is usually a normal phenomenon, probably a result of

evolutionary survival strategies In some people the extent of the fear negatively affects

their social behaviour or daily functioning over an extended period or permanently

Treatment may be indicated or even essential Examples: Fear of heights, fear of flying, fear of public

speaking lead to significant disadvantages in private or business life

Clinical psychology has developed methods for the treatment of these phobias

Example - FEAR


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Clients (patients) are confronted with fear-evoking stimuli with the client imagining the situation (in imagino) in reality (in vivo) (e.g. taking client to bridge)

Level of exposure controlled by therapist, various approaches: direct confrontation of feared object (“flooding”,

“implosion”) careful, graduated exposure (“systematic

desensitisation”, “exposure therapy”) Goal: Client learns to cope with fear-evoking situation by

habituating to the anxiety and experiencing personal control of the approach/avoidance behaviour

Developments in Virtual Reality technology lead to a third, supplemental method: in virtu therapy

THERAPY


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Virtual therapy environment should provoke the same physiological and psychological reactions as in the real-world situation (see North et al., 1996)

Empirical evidence for this - Rothbaum et al. (1995) in treatment of fear of heights. virtual lifts and bridges 20 students suffering from acrophobia treatment group and waiting list condition patients showed effects equivalent to the feared real-

world situations study laid foundations for the treatment of other

psychological disorders with Virtual Reality

Virtual Reality Exposure Therapy (VRET)

IN VIRTU THERAPY


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Selected International Projects


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Selected International Projects::Overview

Specific Phobias Fear of Flying Fear of small animals (spiders, cockroaches …) Fear of Heights

Social Phobias Fear of Public Speaking

Post Traumatic Stress Disorder (PTSD) War Veterans Survivors of catastrophes

Pain Treatments Burn Pain Distraction

Slater et. al. (1999)Hodges et. al. (2001)


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Selected International Projects::Example

www.vrphobia.com


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Selected International Projects::Fear of Flying

Hodges et. al. (1996). A virtual airplane for fear of flying therapy. Proceedings of the 1996 Virtual Reality Annual International Symposium

• First case study - one subject

• Subjective Units of Distress (SUDs) & Questionnaires

• self-reported fear decreased from “8” to “4”


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Selected International Projects::Fear of Spiders

Juan et. al. (2005). Using augmented reality to treat phobias. IEEE ComputerGraphics and Applications, 25:31–37

• Augmented Reality approach (video-see-through real-world display with overlaid, animated spiders in kitchen environment)

• SUDs, interviews and questionnaires


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Selected International Projects::Fear of Heights 1/2

Hodges et. al., (1995) Virtual environments for treating the fear of heights. IEEE Computer, 28(7):27–34


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Selected International Projects::Fear of Heights 2/2

Hodges et. al (1995):• 178 students were screened, 17 completed the study (10 % !)• Treatment group and control group• “Feel weak in the knees . . wanting to hold on for dear life.”• SUDs, Questionnaires and Number and Type of Symptoms• significant decrease of anxiety and avoidance for the

treatment group• Sample size too small

Regenbrecht et. al (1998):• no actual treatment, measuring presence• real world symptoms observed, like sweating, avoidance

behaviour, even crawling on the floor• high spatial presence (sense of being in the virtual

environment) measured in fear evoking environment.


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Selected International Projects::Fear of Public Speaking

Slater et. al. (1999). Public speaking in virtual reality: Facing an audience of avatars. IEEE Computer Graphics and Applications, 19:6–9


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Selected International Projects::PTSD

Hodges et. al. (2001). Treating Psychological and Physical Disorders with VR. IEEE Computer Graphics and Applications, 21(6):25–33

• uncontrolled treatment study• 10 Vietnam Veterans completed the study• clinicians rated that 7 of 8 patients were improved (6 months after

treatment)• symptoms decreased from severe to moderate and from moderately

to mildly depressed.


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Selected International Projects::Burn Pain Distraction


• Standard : opiates• Side effects : tolerance, dependence, nausea, delirium …• excruciating pain during daily bandage changes• patients are young : 40% are 22 years old or younger• Solution : Videogames !


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Example Project cMRET


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Example Project: cMRET

Virtual Reality (and with this VRET) depends on sense of presence (defining property)

Therapist present in real world Client present in virtual world

Whenever the therapist communicates with the client, a break in the sense of presence for the client occurs

A Solution:collaborative

Virtual Reality

Exposure Therapy


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Virtual World

Client

Therapist

Therapist and Client meet in one virtual space


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CMRET.mp4


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(Thanks Chris Slane)

So, now psychology can get realistic-looking spiders AND put them on the Web!


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Internet-based remote services

Increasing use of computer links for the provision of services to remote areas where such services are otherwise inaccessible or only limited in scope.

Prototype example: ISLANDS project • collaboration between researchers and practitioners in several

EU countries • implemented mainly in the Czech Republic, Austria and remote

island territories of France, Spain and Greece

Sulzenbacher et al. (2005) De las Cuevas, (2005) Amditis, Lentziou, Bekiaris, Cabrera and Bullinger (2005).


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Psychology, technology and service delivery

Virtual reality technologies are being used to support and enhance therapies;

Internet communication enables widespread delivery of services to remote points;


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VR – supported treatment is a reality

Norcross, Hedges, & Prochaska (2002)

62 psychotherapy experts produced rankings of therapeutic techniques in terms of impact on psychotherapy, psychologists, and patients

1. homework assignments 2. relapse prevention 3. use of VR4. problem-solving 5. computerised therapies6.…..

It is clear that building new virtual environments and developing standardised protocols are crucial if therapists are going to be able to adapt these tools to their day-to-day clinical practice. Giuseppe Riva (2003)


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Pros and Cons of VR supported therapy


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Advantages of Virtual Reality Supported Therapy

V.R. ... is not a substitute for – but is a supportive method for

clinical psychology

can increase treatment efficiency (eg shorter duration)

enables easy distribution and delivery of standardised programmes

is enabling for some clients

permits experiences that may be otherwise unattainable

is increasingly economical (after initial outlay)


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research is easily and exactly replicable

can provide a controlled, safe environment

reduces travel demands on clients/therapists

can be collaborative between client and therapist

....

Advantages ctd.


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Problems with Virtual Reality Supported Therapy

BUT …

development costs are high

potential risks in wrong hands (e.g. internet distribution of treatment packages)

possible entrepreneurial “capture and control” of treatment methods

military applications are attracting much of the funding (US military is investing $$$$$$$)

professional regulation issues


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ctd..

simulator sickness syndromes

unknown long term human side effects

alienation of some clients

risk of dehumanising psychological therapies

may be inappropriate for some clients/conditions

cultural issues and implications seldom considered

…..


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ISSUES


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Ethical, Practice and Professional concerns

Rizzo, Schultheis and Rothbaum (2003)

Important review of ethical issues in the use of VR, describe:

“looming ethical challenges” side effects, exclusionary criteria, professional practice issues concerns regarding general societal impact

They conclude: those involved in using the technology have a professional responsibility “to consider and address incumbent ethical concerns that surround this emerging technology”.


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Rizzo, Schultheis and Rothbaum (2003)Ten issues

1. Potential for VE-related side effects

2. Use of VR applications with people with altered awareness or reality-testing.

3. Using VR out side area of expertise

4. Effect of VR on the therapist/client relationship.

5. Risk that therapists will rely on VR as a substitute for good clinical skills or to mask shoddy service.


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Ten issues ctd ..

6. Risk of advances in VR access leading to cases of faulty self-diagnosis and self-treatment.

7. Risks of overstated claims in the application of VR to medical research

8. Dependence on virtual vs. "real" world interactions and relationships with "real" people

9. Potential misuse (eg violent or dehumanizing content)

10.“Universal Access” vs. “Digital Divide” in the availability of VR assessment and treatment


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Selected Rizzo et al. issues

1. Potential for VE-related side effects

“a significant concern as the occurrence of side effects could limit the applicability of virtual environments for certain clinical populations.”

identify cybersickness and exposure after-effects as the two main types of VR side effects,

Those with disabilities may be more vulnerable or susceptible.


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2. Use of VR applications with people with altered awareness or reality-testing.

caution required with those with psychiatric conditions resulting in distorted reality testing or individuals with cognitive impairments who may have altered awareness.


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4. Effect of VR on the therapist/client relationship

5. Risk that therapists will rely on VR as a substitute for good clinical skills or to mask poor services.

“therapists should be cautioned not to … let the technology dominate …”. “… should use VR to enhance therapy rather than substitute for it.”


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Rizzo et al. 10 issues (ctd)

7. Risks of overstated claims in the application of VR to medical research


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9. Potential misuse (eg violent or dehumanizing content)


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10. “Universal Access” vs. “Digital Divide” in the availability of VR assessment and treatment

This refers to the accessibility of technology and computer-assisted treatment.


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Developing and applying standards


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Are existing Codes/guidelines adequate?

Fisher and Fried (2003). “ongoing technological advances produce new methods

of providing services that continually outpace specific guidelines pertaining to these new methods”

conclude American Psychological Association code of ethics recognises the evolving nature of the field and provides standards that are applicable for: competence conflicts of interest informed consent privacy/confidentiality public statements/advertising test selection/scoring.


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New Zealand/Australian codes, guidelines

Most codes/guidelines provide general guidance that can be applied to new developments but specific relevance to VR and internet technologies is missing.

eg. the NZ Psychologists’ Code of Ethics has relevant standards (as noted by Fisher and Fried 2003 for the APA Code). The four overarching principles of that code also allow practitioners to make decisions on new technology:

Respect for the dignity of persons and peoples Responsible caring (includes promotion of wellbeing) Integrity in relationships Social justice and responsibility to society

Code of Ethics for Psychologists Working in Aotearoa/New Zealand, 2002


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BUT are the codes/guidelines applied?

Heinlen et al., 2003Re: American Psychological Association (2002) Ethical

Principles and guidelines of the International Society for Mental Health Online (2000).

“troubling levels of noncompliance with APA and ISMHO principles and an uninformed approach to the ethical and legal dilemmas unique to Web-based service”.

Areas of concern include: confidentiality, information on alternative treatments, provision of services to minors, informed consent, promotional statements and claims, and responses to emergencies.


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AND regulation/enforcement is difficult

Traditional state-based professional regulation of services is inadequate.

No clear geographical boundaries to limit provision of services by health practitioners; internet allows international accessibility.

Trend for treatments to be offered by organisations without identifiable individual practitioners.

Regulatory bodies need to consider whether they can and they could respond to these issues.

Need more international collaboration and development of international codes - otherwise authorities will be powerless and irrelevant.


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Rizzo et al (2003) propose VR treatment Guidelines

Conduct ethical analysis. • Clear description of the protocol …. list of potential affected parties and stakeholders.

• Thorough evaluation of each step …, identifying both the risks and the benefits for all parties involved

Consider the unique risks of VR exposure.

Plan for the unexpected. • Thoroughly evaluate all possible negative reactions prior to initiation of protocol

Integrate safeguards into protocol. • The most recent screening procedures (e.g. Simulator Sickness Questionnaire) should be standard in all VR protocols.

Identify more vulnerable groups. • Identify those who may be at a higher risk for negative experiences … identify (ways) to minimize risks among these individuals.


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Guidelines ctd

Clearly define the need for VR.

Explain the protocol.

Defining data. • Variables to be measured in the VE should be clearly identified …

hypothesis driven and based on prior research or knowledge.

Identify responsibility, liability and accountability. • procedures to address any significant complications should be clearly

identified in the early stages of the protocol development.

Source: Rizzo, Schultheis and Rothbaum (2003).


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Conclusions and Discussion


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Ethical use of VR – Some challenges

• Need a unified code of ethics or guidelines to provide agreed compliance standards for VR and internet based services.

• Development of “cyber-therapy ethics” needs to be parallel to development of the technology (each informed by the other).

• Major awareness gaps (eg cultural factors are largely unaddressed; equity and social justice implications)

• Imperative that professional bodies and regulatory authorities consider what mechanisms might be viable to promote standards and monitor those.

• Agreement on (New Zealand or Australasian) practice guidelines is overdue.


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Summary

• Advances in VR and internet delivery systems are promising technologies and are able to augment a wide range of “traditional” treatment services

• More prototypes and laboratory studies are needed but these are often not considered as rapid technological changes lead the development of treatment services (longitudinal field studies would be useful).

• A multi-disciplinary approach is essential

• There needs to be parallel, collaborative development of an applicable code of ethics.

• Professional bodies and regulatory authorities must consider their role (if any).

• Need practice guidelines (for New Zealand/Australasia)


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References

Amditis, A., Lentziou, Z., Bekiaris, E., Cabrera, M., and Bullinger, A. (2005).The overall architecture of the ISLANDS system: towards a modular non-conventional telepsychiatry system. Presentation to 10th Annual CyberTherapy Conference, Basel, Switzerland, June 2005.

De las Cuevas, Carlos (2005). Telepsychiatry: Psychiatric Consultation through Videoconference Clinical Results. Presentationto 10th Annual CyberTherapy Conference, Basel, Switzerland, June 2005.

Code of Ethics for Psychologists Working in Aotearoa/New Zealand, 2002. NZ Psychological Society, NZ College of Clinical Psychologists, NZ Psychologists Board

Fisher, C.B. & Fried, A.L. (2003). Internet-mediated psychological services and the American Psychological Association ethics code. Psychotherapy: Theory, Research, Practice, Training, 40, 103-111.

Heinlen, K., Welfel, E., Richmond, E., et al (2003) The nature, scope, and ethics of psychologists’ e-therapy web sites: what consumers find when surfing the web. Psychotherapy Theory, Research, Practice, Training, 40, 112–124.

Hodges et. al., (1995) Virtual environments for treating the fear of heights. IEEE Computer, 28(7):27–34


Hodges et. al. (1996). A virtual airplane for fear of flying therapy. Proceedings of the 1996 Virtual Reality Annual International Symposium

Juan et. al. (2005). Using augmented reality to treat phobias. IEEE Computer Graphics and Applications, 25:31–37


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References ctd

Norcross, J. C., Hedges, M., & Prochaska, J. O. (2002). The face of 2010: A Delphi poll on the future of psychotherapy. Professional Psychology: Research and Practice, 33, 316-322.

North, M.M., North, S.M., & Coble, J.R. (1996). Virtual Reality Therapy: An innovative paradigm. Colorado Springs, CO: IPI Press.

Regenbrecht, H.T., Schubert, T.W., & Friedmann, F. (1998). Measuring the Sense of Presence and its relations to Fear of Heights in Virtual Environments. International Journal of Human-Computer Interaction 10(3), 233-249.

Riva, Giuseppe (2003), Virtual Environments. Clinical Psychology IN Psychotherapy: Theory, Research, Practice, Training, Vol. 40, No. 1/2, 68–76

Rizzo, A. A., Schultheis, M. T., & Rothbaum, B. (2002). Ethical issues for the use of virtual reality in the psychological sciences. In S. Bush & M. Drexler (Eds.), Ethical issues in clinical neuropsychology(pp. 243-280). Lisse, NL: Swets & Zeitlinger.

Rothbaum, B.O.,Hodges, L.F.,Kooper, R.. Effectiveness of Virtual Reality Graded Exposure in the Treatment of Acrophobia. (1995). Behavior Therapy vol. 26, 547-554.

Sulzenbacher Hubert & Members of the ISLANDS Consortium Medical University Innsbruck (2005).Telecommunication in Psychiatry: A Needs Assessment of Different Potential User Groups in the ISLANDS Project. Presentation to 10th Annual CyberTherapy Conference, Basel, Switzerland, June 2005.

Slater et. al. (1999). Public speaking in virtual reality: Facing an audience of avatars. IEEE Computer Graphics and Applications, 19:6–9


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To contact us:

Brian [email protected]

Holger [email protected]

Slides download (as pdf): http://www.hci.otago.ac.nz


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“JUST LIE BACK AND I’LL GET A FEW PHOTOS TO LIVEN UP MY NEXT POWERPOINT PRESENTATION”

(Thanks to Chris Slane)

Virtual Reality Supported Therapy: Technologies and Ethics · Juan et. al. (2005). Using augmented...

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