VIRTUAL ENVIRONMENTS

IN CLINICAL PSYCHOLOGY AND NEUROSCIENCE

Methods and techniques in advances patient-therapist interaction

NOW indexed by PsycLIT® and MedLine (as "Studies in Health Technology and Informatics", 58)

PREFACE

Scientific discovery is a form of problem solving,
and… the processes whereby science is carried on
can be explained in the terms that have been used
to explain the processes of problem solving.
Simon, 1966

We are entering the second wave of virtual reality (VR) applications in medicine. Surgical simulations and training, three-dimensional anatomy, and the new field of real-time three- dimensional physiological imaging are some of the more notable uses and applications of VR in the first wave in clinical medicine. Because first wave applications required and continue to require significant computing power, many of the Silicon Graphics and workstation-based technologies were well-suited to meet these demands. Until recently, the application of VR technology in mental health was severely limited by the lack of inexpensive, easy-to-maintain and easy-to-use personal-computer (PC) based systems. The very expensive and high- powered computational systems are out of the reach of most practicing mental health professionals. The development of PC-based VR platforms with more user-friendly programming software is helping to launch this great second wave.

Two successful areas of VR application in psychology include treatment of specific phobias (such as fear of heights, fear of flying, fear of driving, fear of public speaking, and claustrophobia, etc.) and neuro-psychological evaluation and testing. Well over one hundred publications from at least fifteen centers around the world addressing these two areas are in the literature. Early results seem to indicate that virtual environments are not only effective but have multiple advantages over conventional therapies in the treatment of specific phobias. In addition it seems to make intuitive sense that this application will work. Before a wider acceptance of this new technology occurs however it is crucial that clinical trials and comparison of outcomes are published and are evaluated by peer-reviewed groups.

Neuro-psychological evaluation and testing is another area that can easily be transitioned to a virtual environment. Again, multiple advantages seen by performing these tasks in virtual environments are suggested. Clearly the three-dimensional testing would seem a better predictor of function in our three-dimensional world. Smaller numbers of studies are seen in a
much wider area of mental health testing, evaluation, and delivery as demonstrated by the excellent work in this current volume. It is now the time to continue exploring additional applications of this exciting technology.

Several barriers remain however. The PC-based system, while inexpensive and easy-to-use, still suffers from a lack of flexibility and capabilities necessary to individualize environments for each patient. There is a question as to whether the admittedly more cartoonish graphics have wide acceptance by patients. On the other hand, in those circumstances the clinical skills of the therapist remain the most important factor in the successful use of VR systems. It is clear that building new and additional virtual environments is important so therapists will continue to investigate applying these in their day-to-day clinical practice.

Possible scenarios for success could involve multi-disciplinary teams of engineers, computer programmers, and therapists working in concert to attack specific clinical problems. Information on advances in VR technology must be made available to the mental health community in a format that is easy-to-understand and invites participation. For example, an inexpensive system that would allow the therapist and patient to enter the VR world together provides a basis for a number of interesting potential therapeutic interactions.

It is important that the technical-oriented members of the team understand the aims, requirements, and scope of the therapeutic intervention so they may effectively bringadvanced computing tools that specifically address the problem. Future potential applications of VR are really only limited by the imaginations of talented individuals. The second wave is expanding rapidly, and the international community has already provided the basis upon which continued growth and development will occur. It is hoped that by bringing together this community of experts further stimulation of interest from granting agencies is accelerated.

Mark, D. Wiederhold, M.D., Ph.D.
Editor-in-Chief
CyberPsychology and Behavior
La Jolla, CA, USA

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INTRODUCTION

This volume represents the work of a distinguished international group of investigators who are pushing the frontiers of using virtual reality (VR) in the diagnosis and treatment of mental health disorders.  Many aspects of psychology and psychiatry are represented as well as neuro-psychology, neuro-physiology, occupational and physical therapy, and rehabilitation medicine.  The integration of these disciplines into a multimodal approach for improving the delivery of mental health care services offers exciting possibilities for the future.

The main goal of the volume is to provide rationales for virtual reality’s applicability in these fields. We reviewed the relevant literature regarding theoretical and pragmatic issues for these applications, and provided a description of ongoing work developed worldwide. The topics directly involve critical issues for clinicians, designers and users, and are presented with scientific competence with suggestions for actual use.

To create successful health care applications with today's virtual environments, we must begin by asking: what are they good at? This book offers an answer to its possible readers - physicians, psychologists and health care providers - by presenting an overview of the current research in this field. Infact the book, whose idea comes from the work made within the EC funded Virtual Reality Environments for Psycho-neuro-physiological Assessment and Rehabilitation VREPAR - projects, (HC 1053 - HC 1055 - http://www.psicologia.net), is a collection of chapters from researchers who have pioneered the ideas and the technology associated with virtual reality. More in particular, the book discusses the clinical principles, human factors, and technological issues associated with the use of virtual reality for assessment and treatment.

Obviously, the technical characteristics of virtual environments change very rapidly; but what will not change is the user of a virtual environment. Thus, to ensure that the contents of this book are not quickly updated, all the contributors did a great effort to identify possible constraints in the use of VR technology and to indicate how they can be faced and solved. The key issue was to integrate knowledge of clinical therapy and neuro-psychological principles related to human factors into the design of virtual environments.

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CONTENTS

The book is divided in three main sections comprising 24 chapters overall: Technology and Human Issues in Virtual Reality, Virtual Reality in Clinical Psychology and Virtual Reality in Neuroscience:

Section I: Technology and Human Issues in Virtual Reality

The first section of the book contains four chapters that discuss the technology of VR and the related human issues: Gobbetti & Scateni present a survey of the field of VR, covering both technical and practical issues. Rizzo, Wiederhold, & Buckwalter provide some thought-provoking issues to consider in using virtual reality in mental health and Bangay & Preston study the influences on immersion in VR environments. Finally, Wiederhold, Davis, & Wiederhold evaluate how immersion and presence effect physiology.

Virtual Reality: Past, Present and Future - E. Gobbetti, R. Scateni

Basic Issues in the Use of Virtual Environments for Mental Health Applications - A. A. Rizzo, M. Wiederhold, J. G. Buckwalter

An Investigation into Factors influencing Immersion in Interactive Virtual Reality Environments - S. Bangay, L. Preston

The Effects of Immersiveness on Physiology - B. K. Wiederhold, R. Davis, M. D. Wiederhold

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Section II: Virtual Reality in Clinical Psychology

The second section of the book provides examples of how virtual reality is being used in the area of clinical assessment and therapy. Huang & Alessi discuss the current limitations in the application of VR to mental health research. Vincelli & Molinari outline the possible links between VR and imaginative techniques. Botella, Perpina, Banos, & Garcia-Palacios analyze VR and its applications in clinical psychology, and Alessi & Huang assess attachment theory as it applies to virtual humans. McComas, Pivik, & LaFlamme study the use of virtual reality for children with varied disabilities. Brown, Standen, & Cobb also detail a special education VR environment for learning disabled children. Two chapters, one by North, North, & Coble and one by Bullinger, Roessler, & Mueller-Spahn outline the use of virtual environments in the treatment of phobias. Riva, Bacchetta, Baruffi, Rinaldi & Molinari present the Experiential Cognitive Therapy, a VR based treatment for eating disorders, and Optale, Munari, Nasta, Pianon, Baldaro Verde & Viggiano, present the results coming from their VR based therapy for the treatment of impotence and premature ejaculation. The last part of this section contains three chapters that assess the possibility of using virtual reality to enhance the quality of life in patents with cancer. Greene discusses three CD-Rom interactive software programs available for persons with cancer. Two articles, one by Oyama and one by Ohsuga & Oyama detail the “Bedside Wellness System” for cancer patients and discuss how this works with existing palliative care techniques. Rogers also details VR environments which may be used to allow clients personal expression and exploration of personal myth.

Current Limitations into the Application of Virtual Reality to Mental Health Research - M. P. Huang, N. E. Alessi

Virtual Reality and Imaginative Techniques in Clinical Psychology - F. Vincelli, E. Molinari

Virtual Reality: a New Clinical Setting Lab. - C. Botella, C. Perpiñá, R. M. Baños, A. García-Palacios

Possibility of Virtual Reality for Mental Care - M. Ohsuga, H. Oyama

Virtual Environments Special Needs and Evaluative Methods - D.J. Brown, P.J. Standen, S.V.Cobb

From Toy to Tool: the Development of Immersive Virtual Reality Environments for Psychotherapy of Specific Phobias - A. H. Bullinger, A. Roessler, F. Mueller-Spahn

Virtual Reality Therapy: An Effective Treatment for Phobias - M. M. North, S. M. North, J. R. Coble

Experiential Cognitive Therapy: a VR Based Approach for the Assessment and Treatment of Eating Disorders - G. Riva, M. Bacchetta, M. Baruffi, S. Rinaldi, E. Molinari

A VR Based Therapy for the Treatment of Impotence and Premature Ejaculation - G. Optale, A. Munari, A. Nasta, C. Pianon, J. Baldaro Verde, G. Viggiano

Virtual Reality for Palliative Medicine - H. Oyama

Personal Stories within Virtual Environments: Creating three Experiences in Cancer Information Software - D. Drew Greene

Current Uses of Virtual Reality for Children with Disabilities - J. McComas, J. Pivik, M. Laflamme

Virtual Reality in Psychotherapy: the Mythseeker Software - M. B. Rogers, II

The Potential Relevance of Attachment Theory in Assessing Relatedness with Virtual Humans - N. E. Alessi, M. P. Huang

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Part III: Virtual Reality in Neuroscience

In the final section, devoted to VR applications in Neuroscience, Riva highlights the uses of virtual reality in several neuroscience applications while Rose, Attree, Brooks, & Johnson provide a rationale for using virtual environments in neurological rehabilitation. Reiss evaluates an augmented-reality device for use with Parkinson's patients while Stanton, Foreman, & Wilson provide a review of how children with mobility impairments may transfer skills from virtual environments to the real world. Finally, Pugnetti, Mendozzi, Barbieri & Motta, starting from their personal experience in the field, analyze the basic cost/benefit issues of VR applications, while Riva describes a VR- enhanced orthopaedic appliance to be used in stroke disorders' rehabilitation.

Virtual Reality in Neuroscience: a Survey - G. Riva

Gait and Parkinson’s Disease: a Conceptual Model for an Augmented-Reality Based Therapeutic Device - T. J. Riess

Virtual Reality in Paraplegia: a VR-Enhanced Orthopaedic Appliance for Walking and Rehabilitation - G. Riva

Uses of Virtual Reality in Clinical Training: Developing the Spatial Skills of Children with Mobility Impairments - D. Stanton, N. Foreman, P. N. Wilson

Virtual Environments in Brain Damage Rehabilitation: A Rationale from Basic Neuroscience - F. D. Rose, E. A. Attree, B. M. Brooks, D. A.Johnson

VR Experience with Neurological Patients: Basic Cost/Benefit Issues - L. Pugnetti, L. Mendozzi, E. Barbieri, A. Motta

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ABSTRACTS

• Virtual Reality: Past, Present and Future

  ENRICO GOBBETTI, RICCARDO SCATENI
  

  CRS4 - Center for Advanced Studies, Research and Development in Sardinia
  Cagliari, Italy
  

  Abstract: This report provides a short survey of the field of virtual reality,
  highlighting application domains, technological requirements, and currently available
  solutions. The report is organized as follows: section 1 presents the background and
  motivation of virtual environment research and identifies typical application domain,
  section 2 discusses the characteristics a virtual reality system must have in order to
  exploit the perceptual and spatial skills of users, section 3 surveys current
  input/output devices for virtual reality, section 4 surveys current software approaches
  to support the creation of virtual reality systems, and section 5 summarizes the
  report.

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• Basic Issues in the Use of Virtual Environments for Mental Health Applications

  ALBERT A. RIZZO (1),
  MARK WIEDERHOLD (2),
  GALEN BUCKWALTER (1)
  

  (1) Andrus Gerontology Center
  University of Southern California, Los Angeles, CA, USA
  (2) Scripps Clinic
  La Jolla, CA, USA
  

  Abstract: In order for Virtual Environments (VE) to be efficiently developed in the areas
  of clinical psychology and neuropsychology, a number of basic theoretical and pragmatic
  issues need to be considered. The current status of VE’s in these fields, while provocative,
  is limited by the small number of controlled studies that have been reported which apply
  this technology to clinical populations. This is to be expected considering it’s relatively
  recent development, expense, and the lack of familiarity with the technology by
  mainstream researchers in these fields. In spite of this, some work has emerged which can
  begin to provide a basic foundation of knowledge which could be useful for guiding future
  research efforts. Although much of the work does not involve the use of fully immersive
  head mounted displays (HMD’s), studies reporting PC-based flatscreen approaches are
  providing valuable information on issues necessary for the reasonable and measured
  development of VE/mental health applications. In light of this, the following review will
  focus on basic issues that we see as important for the development of both HMD and non-
  HMD VE applications for clinical psychology, neuropsychological assessment, and
  cognitive rehabilitation. These basic issues are discussed in terms of decision-making for
  choosing to develop and apply a VE for a mental health application. The chapter covers
  the issues involved with choosing a VE approach over already existing methods, deciding
  on the “fit” between a VE approach and the clinical population, level of presence,
  navigation factors, side effects, generalization, and general methodological and data
  analysis concerns.

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• An Investigation into Factors influencing Immersion in Interactive Virtual Reality Environments

  SHAUN BANGAY, LOUISE PRESTON
  

  Department of Computer Science
  Rhodes University
  Grahamstown, South Africa
  

  Abstract: Two interactive virtual reality environments were used to identify factors that
  may affect, or be affected by, the degree of immersion in a virtual world. In particular,
  the level of stress in a “swimming with dolphins” simulation is measured, as is the
  degree of simulator sickness resulting form a virtual roller coaster.
  Analysis of the results indicates that a relationship between the degree of immersion and
  the following factors: excitement, comfort, quality and age. The following factors are
  found to depend on the degree of immersion: simulator sickness, control, excitement and
  desire to repeat the experience.

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• The Effects of Immersiveness on Physiology

  BRENDA K. WIEDERHOLD (1)
  RENEE DAVIS (2)
  MARK D. WIEDERHOLD (3)

  (1)Center for Advanced Multimedia Psychotherapy
  California School of Professional Psychology
  San Diego, CA, USA
  (2) California School of Professional Psychology
  San Diego, CA, USA
  (3) Scripps Clinic Medical Group, Inc.
  La Jolla, CA, USA
  

  Abstract: The effects of varying levels of immersion in virtual reality environments on
  participant’s heart rate, respiration rate, peripheral skin temperature, and skin resistance
  levels were examined. Subjective reports of presence were also noted. Participants were
  presented with a virtual environment of an airplane flight both as seen from a two-
  dimensional computer screen and as seen from within a head-mounted display. Subjects
  were randomly assigned to different order of conditions presented, but all subjects
  received both conditions. Differences between the non-phobics’ physiological responses
  and the phobic’s response when placed in a virtual environment related to the phobia
  were noted. Also noted were changes in physiology based on degree of immersion.

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• Current Limitations into the Application of Virtual Reality to Mental Health Research

  MILTON P. HUANG, NORMAN E. ALESSI
  

  University of Michigan Department of Psychiatry
  Ann Arbor, MI, USA
  

  Abstract: Virtual Reality (VR) environments have significant potential as a tool
  in mental health research, but are limited by technical factors and by mental health
  research factors. Technical difficulties include cost and complexity of virtual
  environment creation. Mental health research difficulties include current
  inadequacy of standards to specify needed details for virtual environment design.
  Technical difficulties are disappearing with technological advances, but the mental
  health research difficulties will take a concerted effort to overcome. Some of this
  effort will need to be directed at the formation of collaborative projects and
  standards for how such collaborations should proceed.

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• Virtual Reality and Imaginative Techniques in Clinical Psychology

  FRANCESCO VINCELLI (1)
  ENRICO MOLINARI (1-2)

  (1) Laboratorio di Ricerche Psicologiche
  Istituto Auxologico Italiano, Verbania, Italy
  (2)Dipartimento di Psicologia
  Università Cattolica del Sacro Cuore, Milan, Italy
  

  Abstract: The great potential offered by Virtual Reality (VR) derives prevalently from
  the central role, in psychotherapy, occupied by the imagination and by memory. These
  two elements, which are fundamental in the life of every one of us, present absolute and
  relative limits to individual potential. Thanks to virtual experiences, it is possible to
  transcend these limits. The re-created world may at times be more vivid and real than
  the one that most subjects are able to describe through their own imagination and
  through their own memory. This chapter focuses on imaginative techniques to find new
  ways of applications in therapy. In particular the chapter analyses in which way VR can
  be used to improve the efficacy of current techniques. VR produces a change with
  respect to the traditional relationship between client and therapist. The new
  configuration of this relationship is based on the awareness of being more skilled in the
  difficult operations of recovery of past experiences, through the memory, and of
  foreseeing of future experiences, through the imagination. At the same time, the subject
  undergoing treatment perceives the advantage of being able to re-create and use a real
  experiential world within the walls of the clinical office of his own therapist.

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• Virtual Reality: a New Clinical Setting Lab.

  C. BOTELLA (1)
  C. PERPIÑÁ (2)
  R. M. BAÑOS (2)
  A. GARCÍA-PALACIOS (1)
  

  (1) Universitat Jaume I, Spain
  (2) University of Valencia, Spain
  

  Abstract. Virtual Reality (VR) is a new technology halfway between television and
  computer. It constitutes another step in the evolution of our use of a tool that allows us
  to see, to hear and to feel in a world created graphically in three dimensions, and to
  interact with it. VR is, mainly, a mental experience which makes the user believe that
  “he is there”, that he is present in the virtual world. With this new tool, the user is no
  longer a mere observer of that which is happening on a screen, but he “feels” that he is
  immersed in that world and participates in it, in spite of the fact that they are spaces and
  objects that only exist in the memory of the computer and in the user’s mind.
  This chapter seeks to carry out different reflections at different levels. First, we will
  analyze the relationships between VR and Psychology, one of the disciplines that has
  made more efforts in order to understand how we obtain knowledge from the world and
  from ourselves. We will also analyze the impact VR can have in one of the applied
  disciplines of Psychology, which is Clinical Psychology. With regard to this application
  environment, VR becomes a tool which can generate useful models for Psychology
  (both normal and abnormal), and it is offered as a research context for Clinical
  Psychology; as a “realistic” laboratory where we can study behaviours, emotions,
  thoughts, etc.; and a new means to develop psychological treatments.

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• Possibility of Virtual Reality for Mental Care

  MIEKO OHSUGA (1)
  HIROSHI OYAMA (2)
  

  (1) Mitsubishi Electric Corp. Advanced Technology R&D Center
  Tsukaguchi-Honmachi, Amagasaki, Hyogo, JAPAN
  (2)National Cancer Center Hospital
  Tsukiji, Chuo-ku, Tokyo, JAPAN
  

  Abstract: The possibility of applying Virtual Reality (VR) techniques to the mental care
  of patients is discussed in this chapter. VR technology holds much promise for
  providing supportive activities and promoting cooperation among caregivers.
  Interactivity with media may give the feeling of control to patients and thus provide a
  greater joy than passively watching television. Immersion in VR is expected to reduce
  pain and relieve anxieties for a while. Some kinds of VR content would make patients
  relaxed or encourage them in their fight against disease. Moreover, networked VR could
  offer a virtual space where patients meet, communicate, organize activities, and share
  experiences with other people - other patients, friends, family members, medical
  doctors, social workers, and so on. A basic study and trials to evaluate our developed
  VR system, called the ‘Bedside Wellness System,’ provide evidence for the
  effectiveness of this approach. Future research tasks are also discussed.

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• Virtual Environments Special Needs and Evaluative Methods

  D.J. BROWN (1)
  P.J. STANDEN (2)
  S.V.COBB (1)
  

  (1) VIRART, Virtual Reality Applications Research Team
  Department of Manufacturing Engineering and
  Operations Management
  University of Nottingham, UK
  (2)Department of Learning Disabilities
  University of Nottingham Medical School, UK
  

  Abstract: This paper presents an overview of the development of the Learning in
  Virtual Environments programme (LIVE), carried out in special education over the
  last four years. It is more precisely a project chronology, so that the reader can
  sense the historical development of the programme rather than giving emphasis to
  any one particular feature or breakthrough, which are covered in other papers and
  available through the authors.
  The project conception in a special school in Nottingham is followed by a
  description of the development of experiential and communicational virtual
  learning environments. These are followed, in turn, by the results of our testing
  programmes which show that experience gained in a virtual environment can
  transfer to the real world and that their use can encourage self-directed activity in
  students with severe learning difficulties. Also included is a discussion of the role
  of virtual learning environments (VLEs) in special education and of its attributes
  in the context of contemporary educational theory.

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• From Toy to Tool: the Development of Immersive Virtual Reality Environments for Psychotherapy of Specific Phobias

  ALEX H. BULLINGER (1)
  ANDREAS ROESSLER (2)
  FRANZ MUELLER-SPAHN (3)
  

  (1) Competence Center Communications,
  University of Basel, Department of Clinical Psychiatry, Basel, Switzerland
  (2) Competence Center Virtual Reality
  Fraunhofer Institute for Labor Economy and Organisation (IAO), Stuttgart, Germany
  (3) Department of Clinical Psychiatry
  University of Basel, Basel, Switzerland
  

  Abstract: Virtual Reality (VR) entered the mental health field some years ago. While
  the technology itself has been available for more than ten years now, there is still a
  certain amount of uncertainty among researchers and users as to whether VR will one
  day fulfill all it’s promises.
  In this chapter we are giving an overview of the implementation of the technology in
  our mental health research facility in Basel, Switzerland. The development of two
  applications for use with claustrophobic and acrophobic patients perspectively serves
  just as an example within this context. Some may say, the chapter is too much based
  on technical considerations. Strictly speaking, VR is pure technology, even knowing
  that this special form of technology has sensory, psychological and even philosophical
  implications not known from other human computer interfaces so far. As far as we are
  concerned, the development of the technology for use within the mental health sector
  has merely just begun. As today’s mostly used immersive output devices (Head-
  mounted Displays, shutter glasses) do not have a satisfactory resolution, do restrict
  movements and prevent multi-user-capabilities, there will be a soar of mental health
  applications the day some or at least the most important of these obstacles have been
  overcome.

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• Virtual Reality Therapy: An Effective Treatment for Phobias

  MAX M. NORTH, SARAH M. NORTH, JOSEPH R. COBLE
  

  Virtual Reality Technology Laboratory
  Clark Atlanta University, Atlanta, Georgia, USA
  

  Abstract: Behavioral therapy techniques for treating phobias often includes graded
  exposure of the patient to anxiety-producing stimuli (Systematic Desensitization).
  However, in utilizing systematic desensitization, research reviews demonstrate that
  many patients appear to have difficulty in applying imaginative techniques.
  This chapter describes the Virtual Reality Therapy (VRT), a new therapeutical
  approach that can be used to overcome some of the difficulties inherent in the
  traditional treatment of phobias. VRT, like current imaginal and in vivo
  modalities, can generate stimuli that could be utilized in desensitization therapy.
  Like systematic desensitization therapy, VRT can provide stimuli for patients who
  have difficulty in imagining scenes and/or are too phobic to experience real
  situations.
  As far as we know, the idea of using virtual reality technology to combat
  psychological disorders was first conceived within the Human-Computer
  Interaction Group at Clark Atlanta University in November 1992. Since then, we
  have successfully conducted the first known pilot experiments in the use of virtual
  reality technologies in the treatment of specific phobias: fear of flying, fear of
  heights, fear of being in certain situations (such as a dark barn, an enclosed bridge
  over a river, and in the presence of an animal [a black cat] in a dark room), and fear
  of public speaking. The results of these experiments are described.

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• Experiential Cognitive Therapy: a VR Based Approach for the Assessment and Treatment of Eating Disorders

  GIUSEPPE RIVA (1-4)
  MONICA BACCHETTA (1)
  MARGHERITA BARUFFI (1)
  SILVIA RINALDI (2)
  ENRICO MOLINARI (3-4)
  

  (1) Applied Technology for Neuro-Psychology Lab.
  Istituto Auxologico Italiano, Verbania, Italy
  (2) Servizio di Psicologia Clinica
  Istituto Auxologico Italiano, Verbania, Italy
  (3) Laboratorio di Ricerche Psicologiche
  Istituto Auxologico Italiano, Verbania, Italy
  (4)Dipartimento di Psicologia
  Università Cattolica del Sacro Cuore, Milan, Italy
  

  Abstract. Even if there has been significant progress in research on eating disorders,
  little empirical work has been done yet to specify the content of clinical guidelines and
  to validate their efficacy in treatment. In particular there are at least three themes that
  are somehow neglected by current guidelines: body experience disturbances, motivation
  for change and the integration between the different approaches used.
  This chapter details the characteristics of the Experiential Cognitive Therapy (ECT), an
  integrated approach ranging from cogni t i ve-behavioral therapy to virt ual realit y (VR)
  sessions. In particular, using VR, ECT is able to address both body experience dis turbances
  and motivation for change. In the chapter a description of all the phases of this approach
  are offered by using an actual clinical case: a 22-year old female anorectic patient.

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• A VR Based Therapy for the Treatment of Impotence and Premature Ejaculation

  GABRIELE OPTALE (1)
  ADRIANO MUNARI (2)
  ALBERTO NASTA (2)
  CARLO PIANON (2)
  JOLE BALDARO VERDE (3)
  GIUSEPPE VIGGIANO (2)
  

  (1) Member of the Association for Research in Sexology, Venice, Italy
  (2) Public Hospital, Venice-Mestre, Italy
  (3) University of Genoa, Genoa, Italy
  

  Abstract: The use of psycho-dynamic psychotherapy integrating virtual reality
  (VR) dealt with in this study on the treatment of erection dysfunctions and premature
  ejaculation started several years ago, after having seen the scarce results we obtained
  using exclusively a psycho-dynamic approach (accompanied by pre-recorded sound
  and music). Considering the particular way that full-immersion VR involves the
  subject who experiences it, we hypothesized that better results could be obtained
  during therapy for these sexual disorders and in particular regarding the nature of
  erection dysfunction, commonly referred to as impotence “a persistent or recurrent
  inability to attain, or to maintain until completion of the sexual activity, an adequate
  erection.” The plan for therapy consisted of 12 hour-long sessions over a 25-week
  period, and the methods involved the use of a VR helmet, joystick and miniature
  television screens that projected specially-designed CD-ROM programs on
  psychological development.

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• Virtual Reality for Palliative Medicine

  HIROSHI OYAMA
  

  Medical Virtual Reality Development Lab
  National Cancer Center Hospital
  5-1-1, Tsukiji, Chuo-ku, 104 Tokyo, Japan
  

  Abstract: The technology of virtual reality (VR) offers several advantages in the
  field of medicine because it enables us to practice medical procedures repeatedly,
  and can provide a variety of experiences by using virtual organs in different
  patients. It also aids in learning about a clinical procedure and facilitates objective
  evaluation by a supervisor.
  In the field of clinical oncology, a virtual environment can be useful for simulating
  surgery, diagnosing cancer invasion, obtaining informed consent or enhancing
  patient education, and for clinical communication using network-based VR. This
  technology can also be used to improve a patient’s living conditions and to treat the
  psychological problems and/or stress of cancer patients. In the present chapter
  advanced VR research for palliative medicine at the National Cancer Center
  Hospital Japan is described and discussed.

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• Personal Stories within Virtual Environments: Creating three Experiences in Cancer Information Software

  DARCY DREW GREENE
  

  Communication Technology Laboratory
  School of Journalism, Michigan State University
  East Lansing, MI, USA
  

  Abstract: Virtual environments can create a relaxed mood, increasing a patient’s receptivity to
  learning. Personal stories and an individual approach to the content, rather than abstract facts,
  make the CD-generated experience vivid and informative. With the user in control, selecting
  content and interacting constantly with the program, the virtual experience is more meaningful
  than the one created by simply retrieving information. This chapter explains how three CD-ROMs
  containing cancer information - Breast Cancer Lighthouse, Easing Cancer Pain and Cancer
  Prevention Park - embody personal stories and medical information in virtual environments.

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• Current Uses of Virtual Reality for Children with Disabilities

  JOAN MCCOMAS, JAYNE PIVIK, MARC LAFLAMME
  

  Rehabilitation Sciences Virtual Reality Lab,
  University of Ottawa, Ottawa, Ontario, Canada
  

  Abs tract: Technological advances, including the use of virtual reality, have contributed
  enormously to improving the treatment, training, and quality of life of children with
  disabilities. This paper describes the advantages of VR for children with disabilities, how
  VR can minimize the effects of a disability, the role of VR in training and skills
  enhancement, and how social participation and the child’s quality of life may be improved
  through the use of VR.
  Examples from published literature and Internet sites are given of current and completed
  projects which focus on improving the lives of children with disabilities. The research
  describing the efficacy of knowledge and skills transfer from a virtual environment to the
  real world are examined in relation to children with disabilities. Finally, the current
  limitations and future directions of VR for children with disabilities are considered.

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• Virtual Reality in Psychotherapy: the Mythseeker Software

  MCCAGIE BROOKS ROGERS, II
  

  The MYTHSEEKER Institute
  Eagle Rock, California, USA
  

  Abstract: This chapter outlines the use in psychotherapy and medical diagnosis of an
  intelligent software system that helps clients to explore Personal Myth within virtual
  reality environments. Patented MYTHSEEKER software will allow clients to work with
  mythic analogues of lifeshapes and aspirations. This can help to focus therapy directions,
  find ways to participate with the person's world, and allow a kind of personal expression not
  previously possible. The software phases of assessment, facilitation, and enaction are
  described by which the client is assisted to explore systems of mythology or spirituality
  (called Depth Systems) that are traditional, ancient or newly-arising. The client builds a
  Personal Depth System representing Personal Myth, based on experiencing other Depth
  Systems, which can itself be experienced in the virtual environment This paper outlines
  our methodology and technology to realize these operations. Space limitations prevent
  further description in the present chapter of MYTHSEEKER software technology or
  psychotherapy scenarios of involvement.

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• The Potential Relevance of Attachment Theory in Assessing Relatedness with Virtual Humans

  NORMAN E. ALESSI, MILTON P. HUANG
  

  University of Michigan Department of Psychiatry
  East Medical Center Drive
  Ann Arbor, Michigan, USA
  

  Abstract. Primary efforts to create virtual humans have been in the production of
  computer generated ergonomically correct objects that look like humans. Although
  there has been concern with essential human factors, absent are the metrics of human
  relatedness, or the ability to assess the degree to which a virtual human elicits human
  emotions. We discuss the potential application of attachment theory as a context for
  the development of such an assessment paradigm, and specifically the application of
  the Ainsworth Strange Situation in the evaluation of a “Virtual Mom”. Virtual
  relatedness fidelity is discussed as a macrometric to define relatedness that would
  occur with virtual humans. Potential lessons learned are discussed as they apply to
  the selection of those to develop the model, and its impact on the introduction of
  virtual humans into clinical psychiatry and psychology.

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• Virtual Reality in Neuroscience: a Survey

  GIUSEPPE RIVA
  

  Applied Technology for Neuro-Psychology Lab.
  Istituto Auxologico Italiano, IRCCS
  Verbania, Italy
  

  Abstract: Some research projects have begun to test the possibility of using Virtual
  Environments (VEs) for research in neuroscience, neurosurgery and for the study and
  rehabilitation of human cognitive and functional activities. In fact, VEs let users
  navigate and interact with computer-generated 3-D environments in real time,
  allowing for the control of complex stimulus presentations. VEs enable the
  neuroscientist to present a wide variety of controlled stimuli and to measure and
  monitor a wide variety of responses made by the user.
  This paper highlights recent and ongoing research related to the applications of VEs in
  the neuroscience arena. In particular it focuses on the European and US applications in
  this field.

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• Gait and Parkinson’s Disease: a Conceptual Model for an Augmented-Reality Based Therapeutic Device

  THOMAS J. RIESS
  

  176 Morningside Dr.
  San Anselmo, CA, USA
  

  Abstract. This chapter presents an augmented-reality based therapeutic device designed to
  overcome gait problems associated with Parkinson’s Disease (PD). A normal model of
  gait is proposed followed by a model of Parkinsonian gait with the goal of construction of
  a gait enabling therapeutic device. The fundamental underlying tenet of the model is that
  vision pathology is responsible for the majority of Parkinsonian gait pathology. The
  basis for such a claim is the well documented phenomenon known as Kinesia Paradoxa,
  whereby in the presence of certain so-called visual cues a PD subject can be transformed
  from a totally immobile, helpless victim of this disease into a near normal walking
  individual. Several gait-enabling devices are also described.

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• Virtual Reality in Paraplegia: a VR-Enhanced Orthopaedic Appliance for Walking and Rehabilitation

  GIUSEPPE RIVA
  

  Applied Technology for Neuro-Psychology Lab.
  Istituto Auxologico Italiano, IRCCS
  Verbania, Italy
  

  Abstract: Spinal cord injuries (SCIs) have a profound physical, social and emotional
  cost to patients and their families. Obviously SCIs severely disrupt normal patterns of
  interaction with the environment. Firstly, the opportunities for active interaction are
  inevitably diminished due to motor or sensory impairment. Moreover, such problems
  may increase as the time since injury lengthens and the patient becomes more
  withdrawn and isolated in all spheres of activity. However, advances in Information
  Technology are providing new opportunities for rehabilitation technology. These
  advances are helping people to overcome the physical limitations affecting their
  mobility or their ability to hear, see or speak.
  In this chapter an overview is given of the design issues of a VR-enhanced
  orthopaedic appliance to be used in SCI rehabilitation. The basis for this approach is
  that physical therapy and motivation are crucial for maintaining flexibility and muscle
  strength and for reorganizing the nervous system after SCIs. First some design
  considerations are described and an outline of aims which the tool should pursue
  given. Finally, the design issues are described focusing both on the development of a
  test-bed rehabilitation device and on the description of a preliminary study detailing
  the use of the device with a long-term SCI patient.

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• Uses of Virtual Reality in Clinical Training: Developing the Spatial Skills of Children with Mobility Impairments

  DANAË STANTON (1)
  NIGEL FOREMAN (2)
  PAUL N. WILSON (2)

  (1) Dept. of Psychology, University of Reading, 3
  Earley Gate, Whiteknights, Reading, UK
  (2) Dept. of Psychology, University of Leicester
  University Road, Leicester, UK
  

  Abstract: In this chapter we review some of the ways in which the skills learned
  in virtual environments (VEs) transfer to real situations, and in particular how
  information about the spatial layouts of virtual buildings acquired from the
  exploration of three-dimensional computer-simulations transfers to their real
  equivalents. Four experiments are briefly described which examined VR use by
  disabled children. We conclude that spatial information of the kind required for
  navigation transfers effectively from virtual to real situations. Spatial skills in
  disabled children showed progressive improvement with repeated exploration of
  virtual environments. The results are discussed in relation to the potential future
  benefits of VR in special needs education and training.

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• Virtual Environments in Brain Damage Rehabilitation: A Rationale from Basic Neuroscience

  F. D. ROSE, E. A. ATTREE, B. M. BROOKS, D. A.JOHNSON
  

  Department of Psychology
  University of East London, London, UK
  

  Abstract. The potential of virtual environments in assessment and training of
  cognitive function is a more than adequate reason for their application to
  neurorehabilitation. However, there is a more fundamental justification, and one
  which is firmly rooted in the neuroscience literature. Over the last half century
  there has been a wealth of published evidence that enriching the environments of
  laboratory rats stimulates neuroplastic change in the cerebral cortex, enhances
  learning and problem solving in normal rats and reduces cognitive impairment in
  brain damaged rats. Central to all three effects of enrichment are the increased
  levels of interaction with the physical environment engendered by enrichment.
  Placing humans who have damaged brains in virtual environments is one way of
  enhancing their levels of environmental interaction which, because of cognitive
  impairments and sensory and motor disabilities, is otherwise difficult to achieve.
  In this chapter we explore the potential of virtual environments as enriched
  environments within the rehabilitation regime. The underlying assumption, that
  interaction with a virtual environment is functionally equivalent to interaction
  with a real environment, is examined. Three lines of relevant evidence are
  reviewed, neuroimaging studies and psychophysiological studies of people in
  virtual environments and studies of transfer of training from virtual to real tasks.
  An agenda for future research in this area is proposed.

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• VR Experience with Neurological Patients: Basic Cost/Benefit Issues

  LUIGI PUGNETTI (1)
  LAURA MENDOZZI (1)
  ELENA BARBIERI (1)
  ACHILLE MOTTA (2)
  

  (1) Scientific Institute S. Maria Nascente, Don Gnocchi Foundation
  Milan, Italy
  (2) Psychiatric Unit, Policlinico “Città di Monza”
  Monza, Italy
  

  Abstract: The future of VR applications for mental health is currently regarded as
  depending on the rational development of ideas and systems. Criteria to guide this
  development have been suggested that are both clear and agreeable.
  Their application, however, may not be easy at this stage. While we may already be
  able to predict costs of specific VR applications, a period of more extensive clinical
  research is needed in order to assess adequately any benefit. In our still limited
  experience, the development of VR applications to increase the diagnostic sensitivity
  of traditional tests to strategy application disorders is worthwhile, but the uniqueness
  of VR assets may make the adherence to some of the proposed criteria somewhat
  problematic.

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LIST OF CONTRIBUTORS

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N. E. ALESSI, M. D.: University of Michigan Department of Psychiatry
East Medical Center Drive, Ann Arbor, MI, USA

E. A. ATTREE, B. SC.: Department of Psychology
University of East London, London, UK

M. BACCHETTA, M. S.: Applied Technology for Neuro-Psychology Lab.
Istituto Auxologico Italiano, Verbania, Italy

J. BALDARO VERDE, M. S.:University of Genoa, Genoa, Italy

S. BANGAY, PH. D.: Department of Computer Science
Rhodes University, Grahamstown, South Africa

R. M. BAÑOS, M. S.:University of Valencia, Spain

E. BARBIERI, M. D.: Scientific Institute S. Maria Nascente
Don Gnocchi Foundation, Milan, Italy

M. BARUFFI, M. S.: Applied Technology for Neuro-Psychology Lab.
Istituto Auxologico Italiano, Verbania, Italy

C. BOTELLA, M. S.: Universitat Jaume I, Spain

B. M. BROOKS, PH. D.: Department of Psychology
University of East London, London, UK

D.J. BROWN, PH. D.: Department of Manufacturing Engineering and Operations Management
University of Nottingham, UK

J. G. BUCKWALTER, PH. D.: Andrus Gerontology Center
University of Southern California, Los Angeles, CA, USA

A. H. BULLINGER, PH. D.: Competence Center Communications
University of Basel, Departement of Clinical Psychiatry, Basel, Switzerland

S.V.COBB, PH. D.: Department of Manufacturing Engineering and Operations Management
University of Nottingham, UK

J. R. COBLE, Ph. D.: Virtual Reality Technology Laboratory
Clark Atlanta University, Atlanta Georgia, USA

R. DAVIS, M. S.: California School of Professional Psychology
San Diego, CA, USA

D. DREW GREENE, M. F. A.: Communication Technology Laboratory
School of Journalism, Michigan State University, East Lansing, MI, USA

N. FOREMAN, M. S.: Dept. of Psychology
University of Leicester, University Road, Leicester, UK

E. GOBBETTI, PH. D.: CRS4
Center for Advanced Studies, Research and Development in Sardinia

A. GARCÍA-PALACIOS, M. S.: Universitat Jaume I, Spain

M. P. HUANG, M. D.: University of Michigan Department of Psychiatry
East Medical Center Drive, Ann Arbor, MI, USA

D. A. JOHNSON, B. SC.: Department of Psychology
University of East London, London, UK

M. LAFLAMME, B. SC.: Rehabilitation Sciences Virtual Reality Lab,
University of Ottawa, Ottawa, Ontario, Canada

J. MCCOMAS, PH. D.: Rehabilitation Sciences Virtual Reality Lab,
University of Ottawa, Ottawa,Ontario, Canada

L. MENDOZZI, M. D.: Scientific Institute S. Maria Nascente
Don Gnocchi Foundation, Milan, Italy

E. MOLINARI, PH. D.: Dipartimento di Psicologia
UNIVERSITÀ CATTOLICA DEL SACRO CUORE, MILAN, ITALY

A. MOTTA, M. D.: Psychiatric Unit
Policlinico “Città di Monza”, Monza, MI, Italy

F. MUELLER-SPAHN, PH. D.: Departement of Clinical Psychiatry
University of Basel, Basel, Switzerland

A. MUNARI, M. D.:Public Hospital, Venice-Mestre, Italy

A. NASTA, M. D.:Public Hospital, Venice-Mestre, Italy

M. M. NORTH, PH. D.: Virtual Reality Technology Laboratory
Clark Atlanta University, Atlanta Georgia, USA

S. M. NORTH, ED. D. : Virtual Reality Technology Laboratory
Clark Atlanta University, Atlanta Georgia, USA

M. OHSUGA, DR. ENG.: Mitsubishi Electric Corp. Advanced Technology R&D Center
Tsukaguchi-Honmachi, Amagasaki, Hyogo, Japan

G. OPTALE, M. D.:Member of the Association for Research in Sexology, Venice, Italy

H. OYAMA, M. D.: Medical Virtual Reality Development Lab
National Cancer Center Hospital, Tsukiji, Chuo-ku, Tokyo, Japan

C. PERPIÑÁ, M. S.: University of Valencia, Spain

C. PIANON, M. D.: Public Hospital, Venice-Mestre, Italy

J. PIVIK, M. A.: Rehabilitation Sciences Virtual Reality Lab,
University of Ottawa, Ottawa, Ontario, Canada

L. PRESTON, PH. D.: Department of Computer Science
Rhodes University, Grahamstown, South Africa

L. PUGNETTI, M. D.: Scientific Institute S. Maria Nascente
Don Gnocchi Foundation, Milan, Italy

T. J. RIESS, San Anselmo, CA, USA

S. RINALDI, M. D.: Servizio di Psicologia Clinica
Istituto Auxologico Italiano, Verbania, Italy

G. RIVA, PH. D.: Applied Technology for Neuro-Psychology Lab.
Istituto Auxologico Italiano, Verbania, Italy

A. A. RIZZO, PH. D.: Andrus Gerontology Center
University of Southern California, Los Angeles, CA, USA

M. B. ROGERS II, M. A.: The MYTHSEEKER Institute
Eagle Rock, California, USA

F. D. ROSE, PH. D.: Department of Psychology
University of East London, London, UK

A. ROESSLER, PH. D.: Competence Center Virtual Reality
Fraunhofer Institute for Labor Economy and Organisation (IAO), Stuttgart, Germany

R. SCATENI, PH. D.: CRS4
Center for Advanced Studies, Research and Development in Sardinia

P.J. STANDEN, PH. D.: Department of Learning Disabilities
University of Nottingham Medical School, UK

D. STANTON, M. S.: Dept. of Psychology
University of Reading, Whiteknights, Reading, UK

G. VIGGIANO, M. D.:Public Hospital, Venice-Mestre, Italy

F. VINCELLI, M. S.: Laboratorio di Ricerche Psicologiche
Istituto Auxologico Italiano, Verbania, Italy

B. K. WIEDERHOLD, M. S., MBA: Center for Advanced Multimedia Psychotherapy
California School of Professional Psychology, San Diego, CA, USA

M. WIEDERHOLD, M. D., PH. D.: Scripps Clinic Medical Group
La Jolla, CA, USA

P. N. WILSON, Dept. of Psychology
UNIVERSITY OF LEICESTER, UNIVERSITY ROAD, LEICESTER, UK

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