Acceptability of an Online Emotional Therapy System to Apply Homework Assignments in

Adjustment Disorder: A Case Study

S. Quero1,3, M.A. Pérez-Ara1, C. Botella1,3, R. Herrero1, M. Molés1, S. Andreu-Mateu1& R.M. Baños2,3

1 Universitat Jaume I

2 Universidad de Valencia 3 CIBER de Fisiopatología de la Obesidad y Nutrición (CIBEROBN)

Abstract— Adjustment Disorders (AD) are a very important public health problem. However, only general treatment guidelines are available for this problem. Our research team has developed a Cognitive-Behavioral Treatment (CBT) supported by Virtual Reality (VR) that has shown its utility in the treatment of this problem. CBT approach gives a crucial role to homework assignments. So far studies that use Information and Communication Technologies (ICTs) for psychological treatments have been centred on how to use the technologies to deliver the treatment within the therapeutic context. No study is available in the literature that uses the ICTs to apply the homework assignments. TEO is a completely open Online Emotional Therapy system base on Web technology that allows in a simple and effective way to create personalized therapeutic material to present to the patient over the Internet. Therefore, the aim of the present work is to present preliminary data about the acceptability of TEO system in a case study with AD where VR EMMA system within the therapy sessions was joined with the use of other ICTs to apply homework assignments between sessions in the treatment of AD.

I. INTRODUCTION

According to the DSM-VI-TR [1], the primary feature of

Adjustment Disorders (AD) is the development of clinically significant emotional or behavioural symptoms in response to an identifiable stressor. Furthermore, symptoms must be developed within 3 months after the onset of the stressor. Both the symptoms (e.g., anxiety, depression, disruptive behaviours) and the precipitating events widely vary (e.g., divorce, loss of job, the diagnosis of a serious disease, family problems, bullying, complicated bereavement, etc.).

AD are an important health problem [2]. They are very prevalent, indicating the available data a percentage of adults suffering from AD in primary care ranging from 5% to 21%

[1],[2],[3]. Furthermore, AD is an important public mental health problem in economic terms. Very frequently the distress and activity deterioration associated with this problem result in a decrease of work performance, causing a high percentage of sick leaves [4].

However, only general treatment guidelines are available for this problem [5], [6], [7], [8]. Our research team has developed a Cognitive-Behavioral Treatment (CBT) program that utilizes Virtual Reality (VR) [9]. Specifically, we use EMMA’s World, an adaptive display whose content is adapted to every patient’s needs with the main objective of reflecting and evoking emotional responses in them to allow the emotional processing to occur [10]. In the specific case of AD, this open VR system canbe used to treat different stressful events relevant to the particular problem (e.g. the breakup of an intimate relationship, the death of a beloved one, work problems, family problems, bullying, etc.). This treatment protocol has already showed its efficacy in several preliminary studies with participants diagnosed of stress related disorders (including AD) [11], [12], [13]. One way to enhance the efficiency of AD treatment outcomes could be by using Information and Communication Technologies (ICTs) to apply homework assignments in order to consolidate learning between therapy sessions. As far as we know, there are no studies that use ICTs to apply this therapeutic component. Therefore, we considered interesting to develop a self-applied system which permits the patient to do the homework assignments at home over the Internet and combine this with the use of VR within the therapy sessions in the consulting room.

In order to do this we have designed a Web-based system called TEO (Emotional Therapy On-Line). TEO is a completely system open that allows therapists to create and

send personalized therapeutic material to patients via the Internet in an easy way (http://www.teo.uji.es). It makes possible to cover all types of needs and optimize therapy by homework assignments. The system has a database with media contents: audio, images, videos and texts. The therapists can access these materials from the therapist’s platform in order to combine them to create the different therapeutic homework sessions. In addition, TEO assesses several clinical variables (e.g., mood state) before and after each session and the therapist can access the reports resulting from any patient’s activity: assessment, content, assigned sessions, completed sessions, dates, etc. The aim of the present work is to present preliminary data about the acceptability of TEO system in a case study with AD.

II. METHODOLOGY

A. Participant

The participant was a 35 year old woman, divorced and with Colombian Nationality who was living in Spain for the last 2 years. At the moment of the assessment she was doing her doctorate. She met the DSM-IV-TR criteria [1] for AD with mixed anxiety and depression mood subtype due to work problems.

B. Measures

The measures used in the present study were specifically designed for this research.

Homework Assignments Preferences Questionnaire [14]. Before starting the treatment, the patient was given a brief explanation about the two ways of applying the homework assignments (using TEO or Traditional). After this explanation, she answered 4 questions concerning her preferences with regard to the homework assignments (TEO or Traditional). These questions were: 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?”. Finally, the therapist asked the patient the reasons of his preferences in each of these aspects according to her responses in the questionnaire.

Homework Assignments Assessment Questionnaire [15]. This measure was completed after treatment and includes two parts: 1) Traditional method assessment part in which the participant answered 3 items regarding her opinion about this way of applying homework assignments. The participant reported her level of agreement with the items on a Likert scale ranging from 1 (I totally agree) to 5 (I totally disagree): 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. 2) TEO method assessment part in which the participant reported her

level of agreement with the same items but referred to TEO system: the multimedia contents were useful to overcome her problem, having available at home the symbols and landscapes of EMMA’s World were useful to process the negative event and, other persons with similar problems should use this system. Also an item was included to assess how often she implemented the assignments per week. Finally, 5 additional items were included in order to assess other relevant questions regarding usability of the system (whether TEO was easy to use, easy to learn, easy to follow the instructions, comfortable and attractive).

Comparison Questionnaire of the two Methods of applying

Homework Assignments (Traditional versus TEO System) [16]. This questionnaire assessed the participant’s preferences (TEO system versus Traditional) after treatment by answering 4 questions: “What type of application would you rather use?” “Which one of them was more useful to overcome your problem?” “Which one was more useful to process the negative event”, and “which one seemed more attractive to you?”. The response scale was multiple choice with 3 alternatives: TEO, Traditional or No difference.

C. Design

The design was a case study with 2 experimental conditions: 1) Homework assignments using TEO system: 3 sessions

where the homework assignments were applied with TEO system.

2) Homework assignments in the traditional way: 3 sessions where homework assignments were applied in the traditional way (reading materials, writing tasks and session audio record).

D. Treatment

The participant received a CBT program for AD. The treatment protocol consisted of 6 weekly sessions with the following main therapeutic components: educational component, elaboration/processing of the stressful event with EMMA’s World (see a full description in [10], [12], [17], [18].), and relapse prevention. A detailed description of the CBT program can be found in [9].

E. Procedure

After the patient’s request for assistance, a screening interview was carried out, where the main relevant data about her and the problem she was seeking assistance for were collected. After this first interview, the evaluation phase started, which consisted on 2 one and a half hour-sessions each where the Homework assignments preferences questionnaire was applied. At post-treatment the participant was evaluated again using the same instruments as in the pre-treatment. She also filled in the questionnaires about the opinion of the Traditional way to apply the homework assignments and the opinion of the TEO system to apply them, as well as the comparison questionnaire between the two modes of applying the homework tasks.

III. TEO SYSTEM

TEO is a system based on Web technology

(http://www.psicologiaytecnologia.es/teo) and it includes 2 platforms: the therapist's platform and the patient’s platform.

1) Therapist platform (see Fig. 1): The therapist can manage and administer the users and the results of treatment of each user, create sessions and customize treatment protocols using the multimedia materials (pictures, texts, narratives, music and videos) included in the TEO multimedia base, view the content, and assign sessions as well as treatment and assessment protocols to the patients.

Fig 1: Screen shot of the therapist’ platform

2) Patient platform: Patients can complete the pre-session assessment protocol (see Fig. 2), they can visualize the homework sessions assigned by their therapist (see Fig. 3) and move around a virtual environment (they can choose a beach or a forest environment) at the end of each session to reflect on the session and their experience (see Fig. 4).

Fig 2: Screen shot of the assessment protocol.

Fig 3: Media element displayed in the patient’s platform.

Fig 4: Virtual Environments displayed in the patient platform.

IV. RESULTS

Results obtained before treatment in the Homework

Assignments Preferences Questionnaire are shown in Table I. The participant preferred TEO system over the traditional way. She also considered this option more effective and would recommend it to a friend. Finally, she also considered the traditional way more aversive than TEO.

TABLE I

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 one would you choose?

TEO

Which of these two ways do you consider was more effective to overcome your problem?

TEO

Which of these two ways do you consider more aversive?

Traditional

Which of these two treatments would you recommend to a friend in the case that he/she had the same problem?

TEO

Regarding the results obtained from the questionnaires

about the opinion of the 2 methods of applying homework assignments after the treatment, the participant showed a good opinion of both methods. However, she agreed more strongly that TEO system was useful, it helped her to process the negative event and, it should be used by other people with similar problems rather than the traditional way. In addition, she considered the system easy to use, easy to learn, very comfortable, and very attractive (see Table II).

TABLE II

RESULTS OBTAINED FROM THE HOMEWORK ASSIGMENTS 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 should use this method

Totally agree (1) Agree (2)

Days of the week the homework assignments were implemented

4-5 times per week 4-5 times per week

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) Finally, the results concerning the Comparison

Questionnaire of the two Methods at post-treatment showed that, once the participant implemented both methods, she continued to prefer the TEO system, she also continued to consider it more useful to process the negative event and more attractive, compared to the traditional method (see Table III).

TABLE III

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

V. CONCLUSIONS

Results obtained in the present study showed positive

expectations towards the TEO system. Before treatment, the participant preferred the TEO system over the traditional way to apply homework assignments, considering this new way of implementing homework more effective and less aversive.

Furthermore, the 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 (e.g., easy to use, easy to learn, comfortable). Finally, 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. In addition, 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.

Although the results obtained in the present study are promising, they must be taken carefully since it is only an uncontrolled case study being the external validity of these results compromised. Therefore, future research is needed in order to withdraw firmer conclusions.

In any case, the advantages and versatility of a system like TEO opens new possibilities to the clinicians. Firstly, as it has been presented in the present study, it permits the design of personalized homework assignments to practice at home what they have worked in the therapy sessions in a self-applied way using a computer. And secondly, it would also allow the design of 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.

ACKNOWLEDGMENTS

The research presented in this paper was funded in part by Ministerio de Ciencia y Tecnología (PSI2010-17563), Generalitat Valenciana, Conselleria de Educación Programa de Investigación de Excelencia PROMETEO (2008/157), and CIBER. CIBER de Fisiopatología de la Obesidad y Nutrición is an initiative of ISCIII.

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