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      What Role Can Avatars Play in e-Mental Health Interventions? Exploring New Models of Client–Therapist Interaction

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          Abstract

          In the burgeoning field of e-mental health interventions, avatars are increasingly being utilized to facilitate online communication between clients and therapists, and among peers. Avatars are digital self-representations, which enable individuals to interact with each other in computer-based virtual environments. In this narrative review, we examine the psychotherapeutic applications of avatars that have been investigated and trialed to date. Five key applications were identified (1) in the formation of online peer support communities; (2) replicating traditional modes of psychotherapy by using avatars as a vehicle to communicate within a wholly virtual environment; (3) using avatar technology to facilitate or augment face-to-face treatment; (4) as part of serious games; and (5) communication with an autonomous virtual therapist. Across these applications, avatars appeared to serve several functions conducive to treatment engagement by (1) facilitating the development of a virtual therapeutic alliance; (2) reducing communication barriers; (3) promoting treatment-seeking through anonymity; (4) promoting expression and exploration of client identity; and (5) enabling therapists to control and manipulate treatment stimuli. Further research into the feasibility and ethical implementation of avatar-based psychotherapies is required.

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          Most cited references27

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          Self-disclosure in computer-mediated communication: The role of self-awareness and visual anonymity

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            The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial

            Objective To evaluate whether a new computerised cognitive behavioural therapy intervention (SPARX, Smart, Positive, Active, Realistic, X-factor thoughts) could reduce depressive symptoms in help seeking adolescents as much or more than treatment as usual. Design Multicentre randomised controlled non-inferiority trial. Setting 24 primary healthcare sites in New Zealand (youth clinics, general practices, and school based counselling services). Participants 187 adolescents aged 12-19, seeking help for depressive symptoms, with no major risk of self harm and deemed in need of treatment by their primary healthcare clinicians: 94 were allocated to SPARX and 93 to treatment as usual. Interventions Computerised cognitive behavioural therapy (SPARX) comprising seven modules delivered over a period of between four and seven weeks, versus treatment as usual comprising primarily face to face counselling delivered by trained counsellors and clinical psychologists. Outcomes The primary outcome was the change in score on the children’s depression rating scale-revised. Secondary outcomes included response and remission on the children’s depression rating scale-revised, change scores on the Reynolds adolescent depression scale-second edition, the mood and feelings questionnaire, the Kazdin hopelessness scale for children, the Spence children’s anxiety scale, the paediatric quality of life enjoyment and satisfaction questionnaire, and overall satisfaction with treatment ratings. Results 94 participants were allocated to SPARX (mean age 15.6 years, 62.8% female) and 93 to treatment as usual (mean age 15.6 years, 68.8% female). 170 adolescents (91%, SPARX n=85, treatment as usual n=85) were assessed after intervention and 168 (90%, SPARX n=83, treatment as usual n=85) were assessed at the three month follow-up point. Per protocol analyses (n=143) showed that SPARX was not inferior to treatment as usual. Post-intervention, there was a mean reduction of 10.32 in SPARX and 7.59 in treatment as usual in raw scores on the children’s depression rating scale-revised (between group difference 2.73, 95% confidence interval −0.31 to 5.77; P=0.079). Remission rates were significantly higher in the SPARX arm (n=31, 43.7%) than in the treatment as usual arm (n=19, 26.4%) (difference 17.3%, 95% confidence interval 1.6% to 31.8%; P=0.030) and response rates did not differ significantly between the SPARX arm (66.2%, n=47) and treatment as usual arm (58.3%, n=42) (difference 7.9%, −7.9% to 24%; P=0.332). All secondary measures supported non-inferiority. Intention to treat analyses confirmed these findings. Improvements were maintained at follow-up. The frequency of adverse events classified as “possibly” or “probably” related to the intervention did not differ between groups (SPARX n=11; treatment as usual n=11). Conclusions SPARX is a potential alternative to usual care for adolescents presenting with depressive symptoms in primary care settings and could be used to address some of the unmet demand for treatment. Trial registration Australian New Zealand Clinical Trials ACTRN12609000249257.
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              Virtual reality exposure therapy for anxiety disorders: A meta-analysis.

              There is now a substantial literature investigating virtual reality exposure therapy (VRET) as a viable treatment option for anxiety disorders. In this meta-analysis we provide effect size estimates for virtual reality treatment in comparison to in vivo exposure and control conditions (waitlist, attention control, etc.). A comprehensive search of the literature identified 13 studies (n=397) that were included in the final analyses. Consistent with prediction the primary random effects analysis showed a large mean effect size for VRET compared to control conditions, Cohen's d=1.11 (S.E.=0.15, 95% CI: 0.82-1.39). This finding was consistent across secondary outcome categories as well (domain-specific, general subjective distress, cognition, behavior, and psychophysiology). Also as expected in vivo treatment was not significantly more effective than VRET. In fact, there was a small effect size favoring VRET over in vivo conditions, Cohen's d=0.35 (S.E.=0.15, 95% CI: 0.05-0.65). There was a trend for a dose-response relationship with more VRET sessions showing larger effects (p=0.06). Outcome was not related to publication year or sample size. Implications are discussed.
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                Author and article information

                Contributors
                Journal
                Front Psychiatry
                Front Psychiatry
                Front. Psychiatry
                Frontiers in Psychiatry
                Frontiers Media S.A.
                1664-0640
                18 November 2016
                2016
                : 7
                : 186
                Affiliations
                [1] 1National eTherapy Centre, Centre for Mental Health, Swinburne University of Technology , Melbourne, VIC, Australia
                [2] 2Research School of Psychology, College of Medicine, Biology and Environment, Australian National University , Canberra, ACT, Australia
                [3] 3Monash Alfred Psychiatry Research Centre, Monash University Central Clinical School and The Alfred , Melbourne, VIC, Australia
                Author notes

                Edited by: Jérôme Favrod, University of Applied Sciences and Arts of Western Switzerland, Switzerland

                Reviewed by: Andrew Molodynski, Oxford University, UK; Gaudelus Baptiste, Centre Hospitalier Le Vinatier, France

                *Correspondence: Neil Thomas, neilthomas@ 123456swin.edu.au

                Specialty section: This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry

                Article
                10.3389/fpsyt.2016.00186
                5114267
                27917128
                92224fd1-286b-46c4-b192-0f7798cc0644
                Copyright © 2016 Rehm, Foenander, Wallace, Abbott, Kyrios and Thomas.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 20 September 2016
                : 03 November 2016
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 34, Pages: 6, Words: 5116
                Categories
                Psychiatry
                Mini Review

                Clinical Psychology & Psychiatry
                avatars,virtual environments,virtual reality,e-mental health,digital mental health,human–computer interaction,computer-mediated communication

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