Presentation of Workshop on Technology for Healthcare and Healthy Lifestyle 2011 Thursday 1st Dec 2011 Session IV http://www.tsb.upv.es/wths2011

1. III Workshop on Technology for Healthcare and Healthy Lifestyle
Valencia, December 2011
Acceptability of an Online Emotional
Therapy System to Apply Homework
Assignments in Adjustment Disorder:
A Case Study
S. Quero1, M.A. Pérez-Ara1, C. Botella1, R. Herrero1, M. Molés1, S.
Andreu-Mateu1 & R.M. Baños2
1Universitat Jaume I
2 Universidad de Valencia

2. INTRODUCTION
• People cope with diverse stressful and difficult
situations and, most of them, do this in a more o less
successful way.
• However, in some cases coping is not adequate. This
maladaptive, more intense and prolonged than
expected reaction is the base of Adjustment Disorders
(AD).
• AD are an important mental health problem.
• However, there is no agreement concerning its
diagnosis and no evidence-based assessment or
treatment protocols are available.

3. ICD-10
Adjustment Disorders
Neurotic disorders,
Secondary to stressful situations and somatoforms:
• Phobic anxiety disorders
• Other anxiety disorders
• Obsessive-compulsive disorder
• Reactions to severe stress and adjustment disorders
– Acute stress reaction
– Posttraumatic stress disorder (PTSD)
– Adjustment disorders
– Other reactions to severe stress
– Non otherwise specified severe stress reactions
• Dissociative disorders (conversion disorder)
• Somatoform disorders

4. DSM-IV-TR
Adjustment Disorders
• The essential feature of
Adjustment Disorder (AD)
is the development of
clinically significant
emotional or behavioural
symptoms in response to
an identifiable stressor
(APA, 2000).

5. DSM-IV-TR
Adjustment Disorders
• A debilitating reaction to a
stressful event or situation.
• When a person can't cope
with a stressful event and
develops emotional or
behavioural symptoms
• The stressful event can be
anything
• People with AD may have a
wide variety of symptoms
• Symptoms must be
developed within 3 months
after the onset of the
stressor.

6. DSM-V
Adjustment Disorders
Proposals:
• To include the AD in the wider category of
disorders related to trauma and stress.
• To add 2 new subtypes:
 AD with symptoms similar to PTSD
 Complicated grief
(http://www.dsm5.org/Pages/Default.aspx).

7. AD as an important health problem
• Very common disorders, that can affect anyone,
regardless of gender, age, or lifestyle.
 Incidence from 5 to 21% (APA, 2000; Despland, Monod & Ferrero,
1995; Fabrega, Mezzich & Mezzich, 1987)
 The most common diagnosis in primary care.
• Very frequent in people who suffer from medical
conditions (Strain et al., 1998)
 especially if they are serious diseases (e.g., approx. 35% of
oncologic patients).
• Associated with:
 significant impairment in social or occupational functioning
 Causing a high percentage of sick leaves (Van der Klink et al.,
2003).

8. AD: “Forgotten” disorders
• In last 25 years, less than 30
articles (Casey, Dowrick y
Wilkinson, 2001)
• No present in major part of great
epidemiological studies
• Almost absents in handbooks
and psychological guides
• Leading article and 2 articles in
Comprehensive Psychiatry
(2008)

9. Psychological treatment of AD
• In the literature we have found few studies which
matched different therapeutic approaches to different
types of patients (Barraza, 2004; Jojic & Leposari,
2005).
• Only 4 out of 10 of these studies were published in
prestigious journals with impact factor; two of them are
cases studies and the other two include experimental
groups.
• No specific protocol exists for AD, and the majority of
the studies about this issue have significant
methodological problems (Casey & Bailey, 2011).

10. The use of ICTs for the treatment of
AD
• AD: treatment protocol based on CBT procedures and
supported by the use of ICTs (specifically EMMA VR
system) (Botella, Baños & Guillén, 2008).
• EMMA’s World is an adaptive VR display whose content
is adapted to every patient’s needs.
It is a Sophisticated ICT-based system that helps to
produce emotional changes in individuals who have
suffered traumatic, disturbing or stressful experiences.

11. EMMA’s World
EMMA uses objects and
symbols to represent the
negative experience that the
individual needs to process:
• ... In order to enhance and
facilitate the process of
change.
• … Creating, at the same
time, a protected and safe
environment.

12. EMMA’s World
EMMA’s “room":
An architectonic structure
EMMA’s “world" : 5
landscapes around the
architectonic
structure

13. No HMD
Retro projected Big screen
Joystick

14. The use of ICTs for the treatment of
AD
• This treatment protocol has already showed its efficacy in
several preliminary studies with participants diagnosed of stress
related disorders (including AD) (Andreu-Mateu, Botella, Quero,
Guillén,& Baños, in press; Baños et al., 2008; Baños et al.,
2011) and in a controlled study that compared 3 experimental
conditions (Andreu-Mateu, 2011):
1. EMMA treatment condition
2. Traditional treatment condition
3. Waiting list condition
• One way to enhance the efficiency of AD treatment outcomes
could be by using ICTs to apply homework assignments in
order to consolidate learning between therapy sessions.

15. Homework Assignments in CBT
• Since the beginning of CBT the homework assignments are
considered very relevant:
 As a treatment component.
 It’s included in the Agenda of practically all treatment sessions at the
beginning and at the end: the homework assigned last week is
reviewed and new homework is assigned for the next week.
 They are assigned for each therapeutic component that is being
introduced in the treatment program.
 Traditionally they have included reading materials and writing tasks to
carry out between sessions, as well as practicing in real life the
different strategies that have been learned in session (e.g., exposure
tasks, social skills practice).

16. The use of ICTs for the treatment of
AD
• Studies that examine the utility of the application
of ICTs for the treatment of AD are needed.
So far, the studies that
use ICTs for psychological
treatments have been centred on
how to use these technologies to
apply the therapy.

17. Use of ICTs to apply homework
assignments
• The present work pretends to go one step beyond and join:
 the use of VR EMMA system within the therapy sessions and
 The use of other ICTs to apply homework assignments.
• To transfer the ICTs to the patient’s home: what the patient has
to do in the meantime between session is also important.
• First time that a homework assignments component that ca be
completely self-administered over the Internet is developed:
EMOTIONAL THERAPY SYSTEM ONLINE (TEO)

18. What is TEO?
• It is a completely open system based on Web technology which
permits in an easy and effective way to create personalized
therapeutic material and to offer and present this material to the
patients though the Internet.
https://www.teo.uji.es
• It is possible to cover different therapy needs and to optimize it.
• Allows the therapist to support the patient throughout the whole
therapeutic process, facilitating learning.
• To use TEO system an Internet connection and a Web browser are
needed.

19. What is TEO?
• The use of ICTs in order to carry out therapeutic homework
provides the patient and the therapist a more active role, more
involvement and a higher degree of control throughout the whole
treatment process
• TEO system includes 2 platforms:
1. Therapist platform (administrator)
2. Patient platform (user)

20. Therapist platform
• Manage and administer the database and treatment results.
• Manage, organize and label the therapeutic contents based on
multimedia materials (texts, videos, images and audios).
• Create personalized treatment sessions and protocols with
multimedia material, which can be assigned to one or several
patients who will be able to visualize them online in the patient’s
platform.
• Assign assessment protocols that allow the monitoring or
supervision of each patient.

21. TEO: Log in portal

22. Therapist platform menu

23. Therapist platform menu
• Users: adding a new patient, viewing patients and users list.
• Multimedia:
 Administer the multimedia contents (texts, videos, images and audio)
 He can add multimedia elements and view the list of elements
available in the database
• Sessions:
 Build up by a set of multimedia contents (organized in an strategic way
by the therapist) and the patient can view in his/her platform.
 He can add a new session, view the list of sessions available and
assign a session to a user or several users.
• Treatment protocol:
 Build up by a set of sessions grouped and ordered strategically
according to the specific psychological problems of the patients.
 He can add a new protocol, view the list of protocols and add a
protocol to a user or several users.

24. Therapist platform menu
• Assessment:
 Build up by several predetermined instruments that assess the
main clinical variables concerning AD.
 2 moments of use: Pre-post session made by the user.
 The therapist can view the existing assessment protocols and
assign them to a patient.
• Reports: the therapist has access to the download of
the reports derived from all activity carried out with the
following data:
 List of users and sessions
 Protocols contents
 Sessions contents
 Sessions made by the users.

25. Patient platform (user)
• Main function: to receive the sessions assigned
and sent by the therapist from the therapist
platform.
• The user access with a user an a password
received by e-mail once he/she is logged in by
the therapist.
• The user advances in a lineal way and the
system offers the different options with tutorials.

26. Patient platform (user): Pre-
assessment

27. Patient platform: select the virtual
environment

28. Patient platform: Select the session to
visualize

29. Patient platform: Visualizing the
session

30. Patient platform: walk through the
virtual environment

31. Patient platform: ending the session

32. Patient platform: post assessment

33. Objective
The aim of the present work is to present
preliminary data about the acceptability of
TEO system in a case study with AD

34. Participant
• 35 year old woman, divorced with Colombian
Nationality who was living in Spain for the
last 2 years.
• She was doing her doctorate.
• She met DSM-IV-TR (2000) criteria for AD
with mixed anxiety and depression mood
subtype.
• Stressful event: work problems.

35. Measures: pre-treatment
Homework Assignments Preferences Questionnaire
1. “If you could choose between the two ways of
applying the homework assignments, which one
would you choose?”;
2. “Which of these two ways do you consider more
effective to help you overcome your problem?”;
3. “Which of these two ways do you consider more
aversive?” and;
4. “Which of these two ways would you recommend
to a friend in case that he/she had the same
problem?
• .

36. Measures: post-treatment
Homework Assignments Assessment Questionnaire
• 2 parts:
1. Traditional method assessment:
• Level of agreement from 1 (totally agree) to 5
(totally disagree) with 3 items about her opinion:
– the reading materials were useful to overcome her problem
– the audio recorded sessions were useful to process the
negative event and,
– other persons with similar problems should use this
material.
• An additional item assessed how often she
implemented the assignments per week.

37. Measures: post-treatment
Homework Assignments Assessment Questionnaire
• 2 parts:
2. TEO method assessment:
• Level of agreement from 1 (totally agree) to 5 (totally disagree)
with 3 items about her opinion:
– the multimedia contents were useful to overcome her problem
– Having available at home the symbols and lanscapes of EMMA’s
World were useful to process the negative event and,
– other persons with similar problems should use the system.
• 5 additional usability items (e.g., easy to use, comfortable, …)
• Also include an item to assess how often she implemented the
assignments per week.

38. Measures: post-treatment
Comparison Questionnaire of the two methods:
• Assessed the participant’s preferences (TEO
system versus Traditional) after treatment with 4
questions:
1. “What type of application would you rather use?”
2. “Which one of them was more useful to overcome
your problem?”
3. “Which one was more useful to process the
negative event”, and
4. “Which one seemed more attractive to you?”.
The response scale was multiple choice with 3
alternatives: TEO, Traditional or No difference

39. Design
• Case study with two treatment conditions:
1. Homework assignments using TEO:
• 3 therapy sessions where homework
assignments were applied with TEO.
2. Homework assignments in the traditional
way:
• 3 therapy sessions where the homework
assignments were applied in the traditional way
(reading materials, writing tasks and session
audio records)

40. Treatment
• CBT program for AD (Botella, Baños &
Guillén, 2008).
• Components:
 Educational
 Elaboration/processing of the stressful event
• In vivo exposure
• Positive strategies
• Applied with VR (EMMA system)
 Relapse prevention

41. Procedure
• Screening interview
• Evaluation phase:
 Pre-treatment: 2 sessions (1 and a half hour
each)
• Homework Assignments Questionnaire
 Post-treatment:
• Homework Assignments Assessment Questionnaire
• Comparison Questionnaire of the two Methods
(Traditional versus TEO system).

42. Results obtained from the homework assignments
preferences questionnaire at pre-treatment
Questions Responses
If you could choose between the two ways of
implementing homework assignments, which TEO
one would you choose?
Which of these two ways do you consider was
TEO
more effective to overcome your problem?
Which of these two ways do you consider more
Traditional
aversive?
Which of these two treatments would you
recommend to a friend in the case that he/she TEO
had the same problem?

43. Results obtained from the homework assignments
assessment questionnaire at post-treatment
Item TEO Traditional
It is useful to overcome the problem Totally agree (1) Agree (2)
It helps to process the negative event Totally agree (1) Agree (2)
Other people with similar problems
Totally agree (1) Agree (2)
should use this method
Days of the week the homework
4-5 times per week 4-5 times per week
assignments were implemented
Easy to use Normal (3)
Easy to learn Agree (2)
Easy to follow the instructions Nor agree neither disagree (3)
Comfortable Very comfortable (5)
It is very attractive Totally agree (1)

44. Results obtained from the comparison questionnaire
of the two methods at post-treatment
Items Chosen option
I prefer to use it TEO
It is more useful to overcome the problem No difference
It is more useful to process the negative event TEO
It is more attractive TEO

45. CONCLUSIONS
• Results obtained showed positive expectations towards TEO system
• Participant’s opinion after treatment was, in general, very positive for
both methods.
• However, she reported a more positive opinion about TEO than the
traditional method.
• She also answered positively to the items referred to the usability of the
system.
• When she compared both methods, she continued to prefer the TEO
system over the traditional method.
• TEO is the first program developed that permits to apply the homework
assignments component using a computer and in a self-applied way.

46. TEO ADVANTAGES
• TEO offers a great adaptability and flexibility to adjust
the therapeutic homework on every patient’s
characteristics and needs, attending to the specific
meaning of his/her problem.
• Each session will be adapted to the patient’s needs.
Furthermore, because it is based on Web it will increase
the possibilities for therapy:
 it can be used in blended mode (complementing the therapy),
or in tele-assistance mode (being the own self-administered
therapy).
 It might also facilitate the patient’s treatment adherence and
the therapist’s work in designing homework assignments.

47. LIMITATIONS
• Uncontrolled case study
• External validity is compromised
• Future research with larger samples and
controlled studies are needed

48. CLOSING REMARKS
• The advantages and versatility of a system like
TEO opens new possibilities to the clinicians:
1. to design personalized homework assignments to
practice at home what they have worked in the therapy
sessions in a self-applied way using a computer.
2. To design entire therapeutic sessions or parts of
sessions that can be self-applied with a consequence of
a reduction of the costs and, as a result, an
improvement in the efficiency of the treatment.

49. Thank you very much
for your attention!

50. CONCLUSIONS
• La realidad virtual en la psicología. La realidad virtual en la psicología.
• La realidad virtual en la psicología.
• La realidad virtual en la psicología. La realidad virtual en la psicología.
• La realidad virtual en la psicología.
• La realidad virtual en la psicología.
• La realidad virtual en la psicología.
• La realidad virtual en la psicología.
• La realidad virtual en la psicología.
• La realidad virtual en la psicología.

51. TEO
• Sistema dirigido a las emociones, algo central en el enfoque actual
del tratamiento transdiagnóstico de Barlow (Barlow, Allen y
Choate, 2004; Ehrenreich, Goldstein, Wrighty Barlow, 2009; Ellard,
Fairholme, Boisseau, Farchione y Barlow, 2010; Brown y Barlow,
2009).
• Vulnerabilidad psicológica generalizada de base que comparten
grupos de trastornos como los trastornos emocionales:
 TCC centrado en la regulación emocional
 Uso de músicas para exponer a los pacientes a las emociones.
• TEO es más potente ya que utiliza otros recursos multimedia para
evocar, reflejar emociones positivas y negativas.

52. TEO
• TEO puede ser de utilidad a distintos niveles:
 como un laboratorio de investigación (inducción de emociones
en la línea de los parques de EMMA)
 para trabajar en distintos trastornos emocionales los
componentes de aceptación y mindfulness y aprender a
manejar las emociones y,
 para desarrollar protocolos de sesiones de recordatorio de
tareas para casa (aquí es por donde hemos empezado y en
TA, pero también se están preparando estos protocolos para
fibromialgia y para psicooncología)
• EN SUMA, Con TEO podemos crear contextos emocionales
relevantes desde un punto de vista de psicopatología y de
tratamiento.

53. TEO
• Sistema dirigido a las emociones, algo central en el enfoque actual
del tratamiento transdiagnóstico de Barlow (Barlow, Allen y
Choate, 2004; Ehrenreich, Goldstein, Wrighty Barlow, 2009; Ellard,
Fairholme, Boisseau, Farchione y Barlow, 2010; Brown y Barlow,
2009).
• Vulnerabilidad psicológica generalizada de base que comparten
grupos de trastornos como los trastornos emocionales:
 TCC centrado en la regulación emocional
 Uso de músicas para exponer a los pacientes a las emociones.
• TEO es más potente ya que utiliza otros recursos multimedia para
evocar, reflejar emociones positivas y negativas.

54. Advantages and disadvantages of the two methods
TEO TRAD
Interactive
Don’t need computer
ADVANTAGES More attractive
Easy to remember
More immersive
DISADVANTAGES Unclear interface Monotone