Elements of social presence for a psychosocial approach to VR based CBT Gloria Belloni, MA Matteo Cantamesse, PhD candidate Cybertherapy 2007, Washington DC, June 13 Centre of Study and Research on Communication Psychology

2 Content: Research framework: -ECT for Panic Disorder and Agoraphobia -Social Presence and VR-based ECT -Psychosocial perspective Object of analysis, method and data Key aspects and results Conclusions

3 ECT for Panic Disorder and Agoraphobia 1 From CBT (Cognitive Behavioural Therapy) TO ECT - Experiential Cognitive Therapy (Vincelli, F., Riva, G., 2001) A multicomponent approach The use of VR for exposure therapy, interoceptive exposure, cognitive restructuring An experiential approach The duration of the CBT-VRA (ECT) is 8 sessions

4 ECT for Panic Disorder and Agoraphobia 2 Main advantages of ECT protocol for PDA Shorter Therapy (8 sessions vs. 15) Stymuli can be controlled by the therapist Number of patients and characteristics AgeSexEducation 51 patients seeking treatment in one of the institutions involved in the study - They met DSM IV critera for panic disorder for a minimum of 6 months SCID model) (mean: 42,8) F: 36 M: years (mean: 11)

5 ECT for Panic Disorder and Agoraphobia 3 Main advantages A person’s experience of a situation in a virtual environment may evoke the same reactions as the experience of a similar real world situation A person may experience a sense of virtual presence similar to the real world even when the VE does not represent perfectly the real-world situation Each person brings his/her own background into a virtual reality experience Virtual environments can be personalised

6 Social presence and VR based ECT 1 Mehrabian’s concept of immediacy (1969): “The directedness and intensity of interaction between two entities” Short et al. (1976): Social Presence as: “The salience of the other in a mediated communication and the consequent salience of their interpersonal interactions” Biocca et al. (2001): -co-presence and mutual awareness -Experience of psychological involvement -Behavioral interaction Where does the concept of Social Presence come from?

7 Social presence and VR based ECT 2 Which are the terms of the question today? Concept still unclear and used in different ways without specific distinction: with reference both to the medium in CMC and to perceptions, behaviours or attitudes of the participants Research methods: Generally based on questionnaires and/or on psycho- physiological measures Psychosocial approach: Recognizes the reciprocal contribution of both environment and its inhabitants in configuring each other and the central role of local action in shaping presence (Spagnolli, 2003)

8 Social presence and VR based ECT 3 VR based ECT protocol used by our research unit recognises in ‘other’ presence an important therapeutic and functional element. Intervention on 2 fronts: Ergonomic (VR environments design process) Clinical - therapeutical (ECT protocol)

9 Psychosocial framework Qualitative methods applied in our study are strongly based on perspectives that consider the action as focus of analysis Situated Action Theory (SAT): “cognition in practice” “Instead of separating actions from circustances…(SAT) tries to study how people use circumstances to develop an intelligent course of actions” (Suchman,1987)

10 Deductive category definition process Research question, Object Theoretical based definition of the aspects of analysis, main categories, subcategories Examples and coding rules Coding agenda Revision Final working through the texts Interpretation of results, ev. quantitative steps (e.g. frequencies) Formative check of reliability Summative check of reliability

11 Specific object of analysis Object of analysis is to verify some key aspects connected to social presence and their relevance for therapy Phase 1: analysis of occurences in quantitative terms Phase 2:in context evaluation = specific situation in which a verbal exchange occurs, a thought is expressed, or an action is done

12 Categories

13 Data AgeSexVR tool 9 patients = 3 patients for each of the 3 therapists involved in the project 54 VR based ECT sessions - patients seeking treatment in one of the institutions involved in the study - They met DSM IV critera for panic disorder for a minimum of 6 months SCID model) 18-55M: 5 F: 4 VEPDA (Virtual Environments for Panic Disorder and Agoraphobia) The town square

14 Key aspects and example of results 1 When does the patient focus on social environment? It seems to emerge that when the anxiety level increases, patients’ answers and descriptions are more focused on social elements of the environment than on objects, even if the therapist’s request specifically refers to the description of objects. In which specific phases of the session this happens? Possible connections with the therapist’s interaction style

15 Key aspects and example of results 2 It is possible to identify a ‘therapeutic style’? How to use VR stimuli Some therapists tend to keep the patient immersed in the VE, while other therapists use some cues of the VE to invite the patient “what would happen in the real world if…”. It is possible to identify a proper ‘style’ when the number of occurences of one type is considerably frequent for a specific therapist independently by the patient

16 Key aspects and example of results 3 Perception of Self in VR and social environment When the patient describes the environment focusing on social elements, he is inclined to describe himself as effectively present in VR (referring other actions or intentions to himself (higher level) or simply including himself in the social space (lower level), more than when he describes inanimated objects) This element can be connected to the ‘activation level’: when the patient recognizes other’s presence he is inclined to consider himself as reference point.

17 Key aspects and example of results 4 Narration as ‘sense making’ Therapists rarely feel the need to create a story to facilitate the immersion. Detailed descriptions of elements existing in the environment and support actions towards the patients (scaffolding actions with reference to the immersion) are enough to “give sense” to the immersion

18 Conclusions 1 Therapist-patient interaction with a VE and with ‘other’ emerging in VE even when no interaction, for example with other avatars is foreseen VR based sessions can be considered a social context that can be analysed with psychosocial methods Researchers can better get aware of the dynamics emerging during the therapeutic interaction in a correct process ecology perspective Considerations emerged will be used to improve both VR environments and clinical procedures

19 Conclusions 2 1Focus on social environment ‘Social situations’ will be improved and better characterized. Social dimension will have to be immediately perceived by the patient (queues at the supermarket, more people in front of shop-windows…) 2Self-perception The presence of the patient must affect the environment, especially the social environment (the patient can have the possibility to push his way through the crowd and see the people change their place) VR ENVIRONMENT AND ERGONOMIC ISSUES

20 Conclusions 3 3Therapeutic style Each VR environment can be better structured in different zones to facilitate the therapist in his ‘sense making’ purposes. Possible strategies can be suggested and formally included in the protocol 4Narration as sense making New useful elements that the therapist can autonomously activate to focus patient’s attention can be included. These new possibilities can be formalized in the protocol (as for point 3) THERAPEUTIC PROTOCOL

21 Future steps Development of the: -Final version of VEPDA (2.0) -Updated clinical protocol Small scale clinical trial

22 Future steps In-depth analysis of possible connections of elements found with specific and progressive phases of the therapeutic sessions Better monitoring of responses generated by the patient through integration with other social presence measurement tools

23 Present work was carried out in the framework of the NeuroTIV Project, funded by the Italian Ministry of University and Research (MIUR- FIRB 2001) Project duration: