Avatars and online psychotherapy: what contributions can they make to telemental health?

20 Feb

Avatar and online psychotherapy They represent a constantly growing area of investigation in the field of telemental health. Two seemingly irreconcilable worlds whose goals and objectives seem very distant from each other..

In fact, the online virtual environments are increasingly populated by the so-called avatar, that is, digital characters that are customized by users with the aim of representing their identity.

Other Characteristic of Avatars is to allow users to interact and communicate with each other synchronously within a digital environment.

According to Gorini and colleagues (2008) Avatars can be used in the virtual world in two ways:

as a computer-based application in which the user interacts with a single Avatar;
in multi-user mode within a three-dimensional environment such as Second Life.

From the studies conducted within this disciplinary field, the hypothesis and possibility of thinking of Avatars and virtual rooms as environments that could potentially facilitate online interventions for mental health problems has emerged.

In the seminal work of Gorini and colleagues (ibidem) it was hypothesized that theusing a digital avatar in online psychotherapy could generate:

a form of technology other than simply using Augmented Reality Headsets to provide exposure-based therapy for anxiety disorders and substance abuse problems;
structuring online peer support communities.

Therefore, this article, published in the journal “Frontiers in Psychiatry”, aimed to consider the applications of computer-based psychotherapy and online Avatar technology, in order to understand the ways in which avatars have been used to replace or augment patterns of interaction between psychotherapist and client

The Role of Avatars in Mental Health

It is well known that social networks have the potential to promote and create cohesion among people. This characteristic within a virtual world becomes a strength that pushes users to use this type of technology, because they have the opportunity to adopt and create your own avatar.

Scientific research has often focused its attention on the program Second Life, in which users can create a realistic, human-looking avatar that moves around a virtual environment and interacts remotely with other avatars – other users – through audio and/or text communication.

What has emerged from some studies (Beard et al., 2009) is that Many health-related activities were carried out within Second Life, of which 20% are characterized primarily by providing support to their peers.

Many support communities born within Second Life have, for example, focused on sensitive topics such as sexual health or addictions, or have been organized for and by groups of vulnerable people, often marginalized and discriminated against in real life.

Some scholars believe that this success is linked to the fact that Second Life provides an environment where users can collaborate, interact, and consult with other avatars in real time while maintaining anonymity..

Avatar and psychotherapy

The Second Life platform has been the subject of numerous studies precisely because it allows the replication of individual and group psychological treatment models entirely online.. Client and therapist interact with each other within the virtual environment through their Avatar.

To date, this model has been tested in two uncontrolled studies using individual (Yuen et al., 2013) and group (Hock et al., 2012) treatments. Let’s look at them in more detail.

Avatar, Second Life and individual treatment

In the study by Yuen and colleagues (2013) a Online behavioral treatment entirely in Second Life for adults with social anxiety disorder.

The group, consisting of 14 participants and 3 psychotherapists, met in a private, secure virtual room for a 1-hour individual treatment session every week for 12 weeks.

During the exposure and role-playing exercises, therapeutic sessions took place in other virtual spaces relevant to the specific anxiety symptom—for example, a presentation in a virtual conference room.

Psychotherapists, making use of a custom avatar facilitated the various exercises proposed.

The results showed that aspects of anxiety, mood, and psychosocial components improved, and these improvements were confirmed at a 12-week follow-up. Obviously, future research needs to conduct a comparison using a control condition.

Avatar, Second Life and group treatment

The study by Hoch and colleagues (2012) instead gave rise to a group psychotherapeutic treatment within the Second Life platform. The treatment, based on relaxation and mindfulness, lasted 8 weeks, with two meetings per week for groups of 10 participants.

The first session of each week involved teaching specific relaxation strategies. In the second weekly session, the avatar, led by the participants, met in one virtual teaching space designed to feel relaxing – for example, a virtual forest – where they were asked to implement what they had learned in the first lesson.

Overall, mental health symptoms measured with the Symptom Checklist 90 decreased from pre-treatment to post-treatment. Participants reported appreciating the convenience of being able to participate remotely in a virtual group program and they underlined that the possibility of remaining anonymous facilitated the desire to get involved.

Avatar-mediated and -assisted psychotherapy

Several studies have used various forms of avatar technology to facilitate or increase patient engagement in psychotherapy.

The models that have been implemented for these forms of Avatar-assisted psychotherapy there are two:

applications that require the client to “represent” themselves as an avatar to participate in therapy;
applications that require the client to interact with another avatar, be it the therapist or someone else.

Now we will see them in more detail.

The customer represents himself as an avatar

Kandalaft and colleagues (2013) conducted a study using the Second Life platform. Within the virtual platform they delivered a Social skills education program for children with high-functioning autism spectrum disorder.

During the 5 weeks of treatment, 10 online sessions were carried out. During the different sessions, the therapist physically sat next to the patient and instructed him through scenarios. virtual role-playing games.

During each session, the therapist, represented as an avatar, directed participants to various virtual spaces—for example, a cafe, a park, a store. Within these social settings, the children’s avatars met with another psychologist/psychotherapist, also represented as an avatar, with whom they engaged in social interaction.

Neurocognitive measures related to verbal and nonverbal emotional recognition were significantly improved from pre- to post-treatment. More specifically, the researchers suggest that a An educational program developed entirely online can improve elements of social communication typically compromised in people with autism.

In another study (Van Rijn et al., 2015) another method was used Avatar platform which takes the name of ProReal. In this case, the avatar had the role of mediating communication within an online group therapy session in a prison environment.

Unlike the Second Life Avatars, The Avatar ProReal They appear as androgynous, featureless human forms, which users can manipulate in terms of color, size, and expressive gestures.

Another feature of these Avatars is that users can also equip them with virtual props that can facilitate symbolic emotional expression. online group therapy sessions They lasted 90 minutes over a period of six weeks and were guided by a psychotherapist.

At the end of the treatment, the discomfort ratings had significantly reduced. From a qualitative point of view, the researchers believe that theuse of avatars in group psychotherapy specific help participants express emotions that are difficult to communicate verbally and develop empathy for other group members.

Avatar-Mediated Psychotherapy

The software Avatar in the field of online psychotherapy can offer clients a unique purpose to address their distress, in a Personalized and secure setting, with the support of a therapist.

Leff and colleagues (Leff et al., 2013) used the Avatars to test a new form of treatment for persecutory auditory hallucinations.

The 26 participants were asked to create an Avatar that resembled the entity they believed was speaking to them.Therapist avatar introduced the patient to exercises specifically designed to help him respond more adaptively to the voice.

Very promising results were reported in another pilot study (ibidem) with significant reductions in the severity of hallucinations compared to the control group, and some participants reported a remission of their voices.

The Avatar technology for learning and practicing new social skills in this new field of studies it has been recognized by numerous authors (Rus-Calafell et al., 2014; Peyroux & Franck, 2014).

Avatars, online psychotherapy, and psychotic conditions

In their respective studies, the researchers used avatars to simulate social situations as part of social cognitive rehabilitation programs for people with psychotic disorders.

In the Soskitrain program, with biweekly sessions over a 2-month period, the 12 participants practiced social skills with a variety of avatar characters in different situational environments.

In Rus-Calafell’s (2014) study, participants reported significant improvements in negative symptoms such as apathy, flat affect, and social functioning. Errors in facial emotion recognition recorded by the system and the time spent in conversations with avatars also improved. These results were maintained at a 4-month follow-up.

Using a different avatar-based simulation program (RC2S), Peyroux and Franck (2014) reported two single-case experimental studies with significant improvements in theory of mind abilities, facial emotion recognition, social competence, self-esteem, and attributional style.

Using RC2S, participants learned to analyze the mental state, emotions, and intentions of avatar Tom while guiding him through different social situations.

As in Soskitrain, the therapist’s role was to provide social skills training and feedback to support the patient interactions with the scanner.from

The Avatar's Contribution to Online Psychotherapy

As can be seen from what has been said so far, the Avatar technology It allows for the development of a therapeutic relationship precisely because both parties – psychotherapist and client – develop a sense of social presence within a remotely accessible online environment.

The characteristics of the online environment can, in fact, encourage people to engage in greater self-disclosure than in face-to-face interactions (Joinson, 2001). The virtual world also has the potential to engage all those users who, out of shame or stigma, would otherwise be unlikely to seek mental health support.

We will now examine, more specifically, how Avatar technology contributes to online psychotherapy.

Avatar reduces communication barriers

The ability to use audio and/or text-based communication on virtual platforms gives customers the ability to choose which communication method to adopt to feel most comfortable.

In a study by Stendal and Balandin (2015) it was observed how text-based communication in the platform Second Life reduced communication barriers in some participants with autism spectrum disorder., reducing the ambiguity of social and emotional signals during interactions with peers online.

Similarly, in the study by Kandalaft and colleagues (2013) participants with Autism Spectrum Disorder reported feeling comfortable with computer-mediated communication and this encouraged them to participate in the social situations simulated by the avatar.

Along with its advantages, online communication also presents some technical challenges that can create new communication barriers. First and foremost, customers must feel confident using the technology or learn how to use it.

Another problem is that the lack of visual cues can reduce the sense of responsibility towards one’s interlocutor, since both parties may simultaneously be performing other tasks without the other being able to see them.

Even for the psychologist and/or psychotherapist, this can foster a sense of disconnection, which in itself can inhibit the development of communicative and emotional attunement (Quackenbush & Krasner, 2012).

Avatar as a representation of one's identity

A particularly significant component in theuse of avatars during online psychotherapy interventions It is the possibility that these provide to customers to express, experiment, explore and build the virtual representation of one’s self.

In a study conducted on the Second Life platform (Gilbert et al., 2014) they were identified three functions of avatars as an expression of the individual’s “real world” identity:

Avatars can be used as a faithful representation of physical characteristics, job occupation, interests and so on;
Avatars can be used to enhance one’s real-world self by embodying characteristics perceived by the individual as positive. For example, avatars express personality traits that the individual normally suppresses;
Avatars can be used to diversify one’s self-representation by adopting a completely new identity in the virtual world. For example, having a different name and gender, and therefore a new “life story” that doesn’t reflect one’s own.

Participants in this study reported, regardless of improvement, diversity, and consistency with avatars, that their experiences within Second Life generated positive emotional, cognitive, and social outcomes in the real world.

This then leads the authors to argue that all identity-based functions could have significant implications for thetherapeutic use of avatars.

Conclusions

LUse of Avatars in e-mental-health interventions represents a constantly growing area of investigation. As demonstrated in this article, the psychotherapeutic applications of online avatar technologies and computer-based ones are many and varied.

Several studies presented were uncontrolled studies with small sample sizes; diversity in study objectives, methodologies, participant sample sizes, intervention types, and treatment delivery models precludes drawing generalizable conclusions about the effectiveness of avatars in the context of telemental health.

However, the possibility of using a flexible and creative platform in which to provide individual and group services, and peer support makes the Avatar technology: a potentially significant psychological tool. One of its strengths is its ability to engage a wide range of clients who need psychological support but are reluctant to seek it in the real world.

I Advantages of avatar technology in online psychotherapy are therefore the following:

overcoming communication barriers typical of some disabilities and mental disorders;
guarantees anonymity for those seeking treatment;
supports clients in exploring and representing their identity;
It provides psychologists and psychotherapists with greater control over the stimuli they introduce and submit to their patients.

The challenge is very difficult, especially from an ethical point of view. For future research, the researchers conclude, it will be important to outline feasible and appropriate models.use of the avatar for psychotherapeutic purposes.

It is therefore central to investigate the attitudes and preferences of both consumers and clinicians towards technology.

By Doctor Georgia Lauro

Bibliography

Beard L, Wilson K, Morra D, Keelan J. A survey of health-related activities in second life. J Med Internet Res (2009) 11(2):e17.
Gilbert R, Thadani V, Handy C, Andrews H, Sguigna T, Sasso A, et al. The psychological functions of avatars and alt(s): a qualitative study. Comput Human Behav (2014) 32:1.
Gorini A, Gaggioli A, Vigna C, Riva G. A second life for eHealth: prospects for the use of 3-D virtual worlds in clinical psychology. J Med Internet Res (2008) 10(3)
Hoch DB, Watson AJ, Linton DA, Bellow HE, Senelly M, Milik MT, et al. The feasibility and impact of delivering a mind-body intervention in a virtual world. PLoS One (2012) 7(3):E33843.
Joinson AM. Self-disclosure in computer-mediated communication: the role of self-awareness and visual anonymity. Eur J Soc Psych (2001) 31:177–92.
Kandalaft MR, Didehbani N, Krawczyk DC, Allen TT, Chapman SB. Virtual reality social cognition training for young adults with high-functioning autism. J Autism Dev Disord (2013) 43:34–44.
Leff J, Williams G, Huckvale M, Arbuthnot M, Leff AP. Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study. Br J Psychiatry (2013) 202:428–33.
Peyroux E, Franck N. RC2S: a cognitive remediation program to improve social cognition in schizophrenia and related disorders. Front Human Neurosci (2014) 8:400
Powers MB, Briceno NF, Gresham R, Jouriles EN, Emmelkamp PMG, Smits JAJ. Do conversations with virtual avatars increase feelings of social anxiety? J Anxiety Disord (2013) 27:398–403
Quackenbush DM, Krasner A. Avatar therapy: where technology, symbols, culture, and connection collide. J Psychiatr Pract (2012) 18(6):451–9.
Rus-Calafell M, Gutierrez-Maldonado J, Ribas-Sabate J. A virtual reality-integrated program for improving social skills in patients with schizophrenia: a pilot study. J Behav Ther Exp Psychiatry (2014) 45:81–9
Stendal K, Balandin S. Virtual worlds for people with autism spectrum disorder: a case study in second life. Disabil Rehabil (2015) 37(17):1591–8.
Van Rijn B, Cooper M, Jackson A, Wild C. Avatar-based therapy within prison settings: pilot evaluation. Br J Guid Couns (2015) 1–16.
Yuen EK, Herbert JD, Forman EM, Goetter EM, Comer R, Bradley J. Treatment of social anxiety using online virtual environments in second life. Behav Ther (2013) 44:51