Metaverse Health

Archive for the ‘Mental Health’ Category

It’s coming up to a year since we interviewed DeeAnna Nagel and Kate Anthony and discussed counselling in online environments broadly and in virtual environments more specifically. Over that time, the Online Therapy Institute has continued to grow. One example of this is the announcement of a five-hour course on online supervision.

Anyone who works in a counselling role will understand the importance of supervision as both a development and protective mechanism for a practitioner, let alone one working in an online environment. Additionally, a key plank of more widespread acceptance of online therapy is formalised governance mechanisms that provide peace of mind in regards to quality. Small steps like the ones taken here are helping to achieve just that.

The wider challenge is establishing e-health standards that ensure confidentiality, the ability to confirm practitioner credentials and good service navigation for face-to-face intervention when required. That sort of integration is potentially years off, but in the meantime counselling professionals are doing a great job of filling in the gaps.

If you’re involved in counselling in a virtual world environment, I’d love to hear from you to find out more about your work.

Update: an interview with the Online Therapy Institute in Second Life is now available:

Over the past few weeks, there’s been a spike in mainstream media interest around virtual environments and health. I thought it’d be worth showcasing three notable stories / issues that you may not be aware of.

Amputee Support

A press release from ADL Company Inc. and Virtual Ability, Inc. touts the launch of a project to provide peer-support to those who have undergone amputation of a limb. The project’s impetus has come about due to some sobering US-based facts:

Recent US military casualty figures for Operation Iraqi Freedom and Operation Enduring Freedom indicate that between September 2001 and mid-January 2009 over a thousand amputation injuries occurred. Of the 935 amputations considered major, one in five wounded warriors lost more than one limb. While the rehabilitation goal is for the soldier to return to active duty, many reintegrate into their civilian communities. In either case, military amputations are often accompanied by additional wounds, depression, fear, phantom limb pain, and post traumatic stress disorder.

Spouses and family members often become the caregivers of military amputees after they are released from military hospitals and rehabilitation programs. Family support members have their own grieving process to go through related to the amputation and to the change to family life.

The platform for the project is the recently released Second Life Enterprise product, meaning that users have a greater deal of privacy to explore issues in a group context. You can also read about the project from the perspective of ADL Inc’s President, and regular virtual worlds writer, Doug Thompson (SL: Dusan Writer).

Avatars: Perceptions of Self

New Scientist has a good article on a study looking at brain activity (as measured by MRI) when discussing perceptions of real self versus a heavily played World of Warcraft character. The methodology:

To probe what brain activity might underlie people’s virtual behaviour, Caudle’s team convinced 15 World of Warcraft players in their twenties – 14 men and 1 woman – who play the game an average of 23 hours a week, to drag themselves away from their computers and spend some time having their brains scanned using functional MRI.

While in the scanner, Caudle asked them to rate how well various adjectives such as innocent, competent, jealous and intelligent described themselves, their avatars, their best friend in the real world and their World of Warcraft guild leader.

For the early results, read the article, but essentially things aren’t black and white about how we perceive ourselves versus our avatars. No big surprise there. One particularly interesting signpost for future research is the idea that those who perceive themselves and their avatars in a similar way may be the individuals at higher risk for addictive behaviours in regards to their use of virtual environments.

Health Games Research

Health Games Research is a website well worth perusing. It’s a US-based organisation devoted to “research to advance the innovation and effectiveness of digital games and game technologies intended to improve health”. There are yearly grants for research into games and health, with the 2009 funding round announced last week.

It’d be great to hear from anyone interested in conducting their own research into the area, as I have an interest in undertaking some research myself and would love to discuss potential collaborations.

A new working group looking at the psychology of immersive environments is about to launch in Second Life. The inaugural get-together is occurring Wednesday July 15th at 4pm SL time. Click here for the exact location.

Thanks to Dusan Writer for the heads up.

Over the past couple of years I’ve had the opportunity to chat with Andrew Campbell on a couple of occasions. As Director of the Prometheus Research Team, Andrew is heavily involved in the area of mental health and technology. I’ve always been struck by Andrew’s objective view of gaming and virtual worlds, which he rightly sees as simultaneously providing significant opportunities and challenges.

I caught up with Andrew to discuss his work and perspectives on mental health, gaming and immersive virtual worlds.

DH: Can you describe the main focus of your clinical work?

AC: The main focus of my clinical work is divided into two categories. Firstly, research. My primary job is an academic researcher and teacher in the field of Psychology. I conduct research particularly in the area of Cyberpsychology, which is the study of how technology is impacting human behaviour, both in good and bad ways. Secondly, I am a general practice psychologist who specialises in child and adolescent mental health and behavioural problems. My clinical work to date has been focused on treating children with ADD/ADHD, anxiety and depression, conduct problems, as well as parental counselling and family therapy.

DH: What led your career to the stage it is at today – what got you into the issue of mental health and technology?

AC: In 1997 I was finishing my undergraduate degree in Psychology and Education at The University of Sydney and decided to spend some time in the United States working as a teaching assistant at a few universities. I became captivated with work being done by a handful of academic psychologists in the US at the time who were focusing on how the internet was going to be a revolution to impact human behaviour and society at large.

I read everything I could get my hands on at the time to do with online relationships, virtual societies and even gaming communities that were developing international reputations and new cultures in cyberspace. I asked myself at the time ‘could this be the start of a new movement in human enrichment?’ and set forth to find out the good and the bad (and the down-right terrible) aspects of spending a lot of time engrossed in an online world, be it chat, gaming, shopping, finance, politics etc. Thus, my interests turned toward career aspirations to develop psychological research and an applied track record in the use of information communication technology and the use of other technologies in helping the ‘human condition’.

DH: Arguably the number one and two areas of broader public interest with mental health and technology is gaming and violence and addiction. What percentage of your work is spent dealing with actual or perceived issues in those areas?

AC: To date, my clinical work as a generalist psychologist in child and adolescent mental health has only touched lightly on these issues. I have mainly dealt with traditional mental health concerns of parents over their children, but of those clients I have seen about gaming violence and addiction, I’ve noted that the parents themselves do not know anything about the games their children are playing. They tend to have a view that all games are violent or addictive. Given this, I normally direct parents to learn more about what their kids enjoy about their game in order to learn more about behaviours they may be modeling from the game. For example, two of my client’s parents had no idea that strategic games such as ‘Age of Empires’ actually have huge cognitive and historic learning benefits. The game is akin to modern day chess, with historical lessons of ages past. Other games that promote team play
increase problem solving skills in a collaborative environment, therefore promoting team work and clear communication strategies.

Adversely, some team playing games are based on a violent theme, such as the popular game ‘Counter Strike‘. Overall, through my work I’ve found that parents do have concerns about violence and addiction to games, but really do not have an understanding of games themselves. This is troubling in an age where gaming is increasing in popularity across generations and content is still not regulated well by Government or other ‘watchdog’ agencies. As such, parents need to be cognisant of the types of games out there – their pluses and minus points – and be involved in selecting and learning about the titles with their children in order to curtail negative behaviours related to certain genres.

DH: The issue of technology and its influence on behaviour has been around for decades, with the TV / Film and violence link being hotly debated for most of that time. Before we get onto gaming / virtual worlds, is there yet any empirical agreement on TV/Film and violent behaviour?

AC: As surprising as this may sound, no, there is not any empirical agreement on TV/Film and violent behaviour in contemporary society. Incidents such as the Columbine School Massacre and more recently, the Virginia Tech shooting have led psychologists to argue for renewed policies censuring violent films and TV shows from minors and suggestible personality types. Although games are becoming a popular target for connecting atrocious violent crimes to the perpetrator, TV and Film are still front runners in the causation of violent behaviour in, not just the younger population, but the population in general.

DH: The popular media perception of gaming is that there is at least an anecdotal link between the regular playing of violent games and violent real-life behaviour. From your work, have you seen any evidence of this?

AC: Unequivocally, no! To say that violent games or even violent TV/Film is causation for a violent crime is ludicrous. I won’t go so far to say that violent games, TV or Film have zero impact on violent crimes, but to look at it as a sole causation does not address the pathology of the individual to begin with, let alone motive to carry out the behaviour that may lead to a crime. Ergo, playing a violent game is no more likely to trigger someone’s violent behaviour than eating your favourite food is going to motivate you to become a chef! In my private practice, any child who has presented with conduct disorder or oppositional defiant disorder, or even anger management problems, may or may not have been a gamer – however – all have had pathology and environmental problems that
have led to their disorder that are more consistent and pervasive than just playing a violent video game a few hours a day.

DH: Is there actually an argument that gaming can have an ameliorating effect on real-world behaviour and if so, is there research supporting this?

AC: Yes, a number of studies have shown wonderful results helping people to ameliorate either behaviour or, in some cases, the management of pain. My own research has looked at how biofeedback video games that encourage the player to control a task on a screen using their breathing technique, has led to improved attention and relaxation strategies in ADD/ADHD children. Other research has shown that virtual reality games that are immersive can actually help in the treatment of PTSD. One of the best breakthroughs in serious games has been the treatment of burn victims from the current Iraq and Afghanistan wars. These patients have to undertake pain dressing changes and skin grafts. During these procedures, the patient plays a game called ‘Snow world’ which immerses them in an environment that triggers their subconscious into believing they are in a cool and calm environment that distracts them from the pain of the treatment they are receiving. The research in all these examples is very new, but compelling. It is beginning to influence the game developers in entertainment to consider the market for ’serious games’. This has already commenced with popular programs such as the Nintendo Wii releasing Wii fit and associated sports programs to tackle obesity.

DH: In regards to addiction and online gaming or virtual world environments, what’s your overall take?

AC: My overall take on addiction is that it is possible in either the virtual world or gaming environments online. What needs to be clarified is what aspects of these activities and functions are ‘addictive’. To say we are addicted to the Internet is like saying we are addicted to shopping – what items are we addicted to? The internet houses many areas of interest. It is obvious to posit that sex addiction offline could also be met online, as could be gambling. But gaming offline vs gaming online has different stimulus effects I would theorise.

Also, virtual worlds – what do we gain in socialising in these worlds that we don’t in our offline world? Is there such a thing as addiction to socialising?! Most likely not, because socialising is part of being human. Therefore, what is the attraction to these worlds that stimulates us highly enough to spend hours online engaging with strangers vs. meeting strangers in the offline world? The answer probably lies somewhere between the functions of pursuing anonymity, creativity, cerebral connections and/or reducing the chance of being socially awkward – all reasons one person may prefer the online world.

DH: If addiction is only quantifiable in a small component of the population, is that component larger or smaller than other behaviours such as substance use, gambling etc?

AC: I think if we look at gaming addiction in comparison to substance use, for example, we can quickly conclude that substance abuse is both physically and psychologically damaging and perhaps more wide spread globally across ages, genders and cultures. But the damage of gaming addiction is growing in certain cultures, such as in Asia where gaming is an accepted pasttime for all ages and genders and thus could be on the rise without society realising it since it is not an illegal behaviour or even an invasive or obviously destructive past time compared to drug taking.

However, it is psychologically damaging both in psychosocial relationships, employment responsibility and accountability and can even affect our general health to a large degree. You might therefore say that although substance abuse and gambling are faster and
harder-hitting addictions, gaming addiction is fast becoming a contemporary societal problem that is slow to build in destructiveness,
but easier to ignore.

DH: For those who do require actual treatment for addiction, what’s your take on the use of online treatment when the issue is related to online behaviour i.e. addressing the traditional view that you can’t use the mechanism for facilitating addiction to treat the addiction itself.

AC: One of the earliest therapies provided online by Psychologist, Dr Kimberly Young, was treatment for online addiction. She began this service, online, in the early 1990’s. Although it has been a growth industry for Dr Young and others who believe in her treatment modality, I personally find it to be flawed therapy and lacking in best-practice evidence. Addiction, be it to specific functions of the internet, gaming, substance abuse, gambling etc, is an extremely difficult pathology to treat, let alone treat well. Therefore, all scientific practice indicates that addiction therapy should be done in a face-to-face or group counselling environment. It requires ongoing resource support utilising mentors, friends and family. It is something that may (but only in very specifically suitable cases) use the internet as a support tool, but in all other regards addiction, especially to internet functions and gaming, should be done away from the primary stimulus.

DH: With growing immersiveness in gaming and in virtual worlds more broadly, what do you see as the mental health challenges and opportunities?

AC: Research right now is looking out how we can harness immersive environments, be they virtual worlds or games, for tackling problems in health, behaviour and education. The challenges we face at the moment are actually not to do with the quality of the environments being delivered to consumers over the internet or through off-the-shelf games, but more through the cost of developing serious games or health purpose virtual worlds by the commercial sector. In addition, we are facing a health professional vs tech industry challenge in trying to have these two expert bodies effectively harness the ideas that are scientifically based delivery of health interventions. In short – the health professionals need to learn more about the tech industry and vice versa. Once this bridge is finally built, I believe we will be entering a new error of technology consumerism – games for wellbeing and ICT for personal health management.

Australia’s ABC TV recently screened an interesting piece on the use of virtual reality in the treatment of Post-Traumatic Stress Disorder – you can view it here.

There’s also an extra 7-minute interview with a US Marine whose PTSD treatment was benefitted by the use of virtual reality.

DeeAnna Nagel and Kate Anthony are psychotherapists and founders of the Online Therapy Institute. The pair have only recently expanded their work to Second Life, but they have extensive experience in working with people therapeutically online. The pair now have a presence on Jokaydia in Second Life. I caught up with them to talk online counselling / therapy.

Lowell: Can you give a brief outline of your professional experience /qualifications pre-Second Life / online therapy?

DeeAnna: I have a Master of Education in Rehabilitation Counseling and a Bachelor of Science in Mental Health and Human Services. I have worked in the mental health field for nearly 20 years. About 10 years ago I discovered the power of the Internet and began providing online chat and email through a couple of e-clinics. Over the years I have always maintained a part-time practice online and have integrated technology in work settings working with interns, employees and clinical supervisees. I have been training therapists since 2001 about the ethical issues pertaining to technology and mental health. Now 100% of my work life is devoted to either providing online therapy or teaching others about online therapy.

Kate Anthony: I have a Master of Science in Therapeutic Counselling and a Bachelor of Science in Psychology, and am halfway through a PhD on the topic of Technology and Mental Health. At around the same time as I discovered how powerful relationships over the Internet can be and based my MSc thesis on that. From that, I co-authored the British Association for Counselling and Psychotherapy (BACP) Guidelines for Online work (including Supervision) through its 3 editions. I have trained mental health professionals to work online since 2002, have published widely including textbooks, and was recently made a Fellow of BACP for my work and DA and I are both past-Presidents of the International Society for Mental Health Online (ISMHO).

Lowell Cremorne: What was the event that led to you realising the potential of virtual worlds for counselling interventions

DeeAnna Nagel: There was no single event for me; just a realisation that virtual world settings offer another level of sensory experience that could enhance the therapeutic process.

Kate Anthony: I realised this in 2001 after speaking at a conference about Telephone Helplines. The Keynote speaker was head of BTExact Technologies, and he referred to the future of virtual worlds, and avatars specifically, being part of the future of health care. Most of the audience was laughing at the concept -– I wasn’t. I went on to work with him and his team to explore the concept and write a white paper on the topic (Anthony, K. and Lawson, M (2002). The Use of Innovative Avatar and Virtual Environment Technology for Counselling and Psychotherapy. Available online at www.kateanthony.co.uk/research).

Lowell Cremorne: Your Online Therapy Institute offers consultancy including advice on marketing counselling services online, but it seems you’ve carefully differentiated your SL consultancy to avatar familarisation etc. Would you agree that virtual worlds as an actual intervention mechanism are not evolved enough yet?

DeeAnna Nagel: The potential for therapeutic intervention in virtual world settings is already available – but not necessarily cost-effective for the private practitioner. Second Life is not encrypted and while we could offer therapy using secure methods such as a Sky Box, we have chosen not to. Proprietary software is being developed by companies and institutions for use in SL and other virtual worlds, and at some point private practitioners will be able to provide secure and encrypted services. Until that happens, we can, as you say, utilise our SL office as a way to meet people who want to provide an avatar representation and for other educational and consultancy opportunities.

Lowell Cremorne: What do you think needs to occur for people to be able to trust in-world therapy?

DeeAnna Nagel: Security including encryption is paramount. In addition, virtual world platforms need to be less cumbersome and be able to run on different platforms without the constant risk of technological breakdowns.

Lowell Cremorne: A common component of media coverage of virtual worlds is addiction – for the small percentage of people who may have a definable addiction, can the cause also play a role in the treatment? What I’m getting at here is whether in-world therapy for those addicted to virtual world interaction is a sensible treatment option or a damaging option.

DeeAnna Nagel: This should be taken on a case-by-case basis- I do offer online text-based therapy via chat and email to people who identify with Internet addiction. I think working with addicts inworld allows the client to experience a healthy relationship online and offers a way to model use of technology in appropriate ways. Technology is such a part of our social and vocational fabric now that people need to be able to integrate back to using technology but in healthy ways with appropriate boundaries. The work becomes about establishing and maintaining healthy relationships just as we have done with face-to-face clients for years.

Lowell Cremorne: Rapport-building is key for successful therapy – how best is that done online?

DeeAnna Nagel: Consideration should be given to the disinhibition effect. Online, people are less inhibited and likely to disclose information due to the person’s sense of anonymity. When working therapeutically, on the surface, this can be a plus in establishing rather quick rapport, but therapists also have a responsibility to prepare clients about disclosing personal information too quickly and then helping the client modulate the emotional intensity throughout the process.

Kate Anthony: The concept of “presence” is also important here – where is the client and where are you during the process? Most of my trainees agree post-training that the therapeutic work takes place somewhere between the two pieces of hardware (including mobile hardware) in Cyberspace. The mutual journey – and the rapport that goes with it – seems to take place in a nebulous arena, but actually the understanding by both client and counsellor as to how it exists for them facilitates the rapport.

Lowell Cremorne: How much real-world identification do you believe needs to occur prior to therapy commencing?

Kate Anthony: I think it essential for the client to be able to verify identity of the therapist, but this could be done via a third party – such as a professional organisation. Opinion varies widely from a client-identification point of view. Purists prefer to work with whatever the client is offering, subject to some legal identity checks in some places such as the client possibly being under age. The argument there is that the psyche that the client presents, via avatar or text, is a valid psyche to work with. Other practitioners prefer to make several checks as to how the client exists offline (we feel the phrase “real-world” is outdated, incidentally, so prefer to refer to online and offline). Personally, I feel that with a robust intake form and assessment procedure, further identification may simply get in the way of the therapeutic work which often depends on uniquely online societal norms (such as disinhibition and the perceived anonymity).

Lowell Cremorne: Is confirming real world gender / age / cultural identity important for good therapeutic outcomes online?

DeeAnna Nagel: Yes- as with face-to-face, the person’s identification is important to determine if the work between therapist and client is a good fit. Cultural differences should be taken on a case-by-case basis.

Kate Anthony: Yes, particularly with regard to age and informed consent.

Lowell Cremorne: What issues / mental health states would you feel uncomfortable dealing with online?

DeeAnna Nagel: For the most part, I am comfortable working with people online that have issues I am comfortable working with face-to-face. As long as I feel competent about the clinical issues and have the proper training, most mental health interventions can occur online. For me, it is difficult to work with someone who is obviously intoxicated or obviously decompensating and showing signs of delusional and irrational behavior- but this is whether the client is face-to-face or online. Certainly, when working via distance, the client’s geographical resources should be determined should crisis intervention become necessary.

Kate Anthony: And that exact point is how I train upcoming online mental health professionals– that with the Internet it is simple to explore a clients alternative crisis interventions based on their geographical location. Other concerns are working with people who are in a relationship that involves domestic violence. Safety issues for the victim come into play if he or she is using a computer that the perpetrator has access to and may be monitoring with a keystroke program.

Lowell Cremorne: Whether it be in a virtual world or via more traditional online methods, do you find you’re less likely to run into personal boundary issues, or is it just as much a challenge?

DeeAnna Nagel: For me, the boundaries are not blurred. I have always maintained boundaries in person and online but with the advent of social networking, I am consulting with more and more professionals who are struggling with this issue. What to do if a client friends their therapist on Facebook for instance and many times the dilemmas are ethical in nature- with regard to either confidentiality or dual relationships.

Lowell Cremorne: Are you aware of any formalised professional associations for online therapists to communicate and if not, how do you see the momentum developing so that this occurs?

Kate Anthony: There is the International Society for Mental Health Online (ISMHO) as mentioned, and more recently ACTO-UK (Association for Counsellors and Therapists Online – UK) – an organisation for UK based online therapists. The latter is holding it’s first conference (online and offline simultaneously) in April. Our fear is that many small organisations will crop up here and there with narrow ideas – what the Online Therapy Institute strives for is a global agreement as to how each of these associations can work together to disseminate knowledge and stimulate growth of the field to the greater good of online work, whether in virtual worlds or via other modalities.

DeeAnna Nagel: To that end we have developed the Ethical Framework for the use of Technology in Mental Health that offers Best Practice standards regardless of the practitioner’s geographic location.

Lowell Cremorne: What are your plans over the coming year for your Second Life work? Have you considered other worlds?

DeeAnna Nagel: We explore other worlds as they appear, and not always necessarily in an obvious way. For example, the Online Therapy Institute has a strong interest in the prevention and treatment of Cyberbullying, and a virtual world such as Club Penguin, for example, could be instrumental in that aim. Plans for the coming year is to explore those platforms that meet the Institute’s requirements for safe and secure client-therapist interaction, and continue to develop training for conducting therapy in virtual worlds.

The usually tabloid Second Life Herald have an interesting but short interview with a Dutch hypnotherapist who conducts therapy in Second Life.

Of course, there’s nothing new about therapy in Second Life – our sister site The Metaverse Journal interviewed two counsellors back in March 2007 – you can read that interview here.

If you run any form of counselling in a virtual world, we’d love to hear from you.

Although not directly health-related, I was struck by the power of the machinima below ( thanks to Mal Burns for the heads-up). It’s produced by Lainy Voom and you can read more about it here.

Have a look for yourself then read on below for some further thoughts:

Fall (Mini Project 3) from Lainy Voom on Vimeo.

There’s no doubting to power of music in therapy and imagery certainly plays its role as well. It’s not hard to foresee a growing interest in the creation of machinima as a therapeutic device. The ability to create content relatively cheaply opens up a range of new possibilities. Imagine family therapists, gestalt counsellors and those with a cognitive behavioural approach (to name three I’m very familiar with professionally) utilising virtual worlds as platforms for intervention and exploration with clients. Here’s one very basic example: systematic desensitisation.

Let’s say I’m terrified of spiders. I contact a psychologist who utilises a virtual world like Second Life. She does an initial session with me viewing virtual spiders from a distance. Then my avatar interacts with the spiders directly. The next step may be something like viewing real-life spiders on a virtual screen and so the process continues. It’s then filmed for playback by the as therapeutically indicated.

The applications for broader mental health, relationships counselling, addictions counselling, domestic violence and sexuality issues are a long way from being fully explored. What’s apparent however, is that there’s a significant opportunity that needs to be empirically investigated.

As always, I’d be interested in hearing from anyone doing research or currently working in the area – do you think this is likely to be a viable approach in the near-future?