treatment of complicated grief using virtual reality: a case report

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This article was downloaded by: [University of Teeside] On: 06 October 2014, At: 19:31 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Death Studies Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/udst20 Treatment of Complicated Grief Using Virtual Reality: A Case Report C. Botella a , J. Osma a , A. García Palacios a , V. Guillén b & R. Baños a a Universitat Jaume I, CIBER de Fisiopatologia de la Obesidad y Nutricion (CIBEROBN) , Spain b PREVI Clinical Center , Spain Published online: 06 Aug 2008. To cite this article: C. Botella , J. Osma , A. García Palacios , V. Guillén & R. Baños (2008) Treatment of Complicated Grief Using Virtual Reality: A Case Report, Death Studies, 32:7, 674-692, DOI: 10.1080/07481180802231319 To link to this article: http://dx.doi.org/10.1080/07481180802231319 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.

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Page 1: Treatment of Complicated Grief Using Virtual Reality: A Case Report

This article was downloaded by: [University of Teeside]On: 06 October 2014, At: 19:31Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

Death StudiesPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/udst20

Treatment of Complicated GriefUsing Virtual Reality: A CaseReportC. Botella a , J. Osma a , A. García Palacios a , V.Guillén b & R. Baños aa Universitat Jaume I, CIBER de Fisiopatologia de laObesidad y Nutricion (CIBEROBN) , Spainb PREVI Clinical Center , SpainPublished online: 06 Aug 2008.

To cite this article: C. Botella , J. Osma , A. García Palacios , V. Guillén & R. Baños(2008) Treatment of Complicated Grief Using Virtual Reality: A Case Report, DeathStudies, 32:7, 674-692, DOI: 10.1080/07481180802231319

To link to this article: http://dx.doi.org/10.1080/07481180802231319

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all theinformation (the “Content”) contained in the publications on our platform.However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness,or suitability for any purpose of the Content. Any opinions and viewsexpressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of theContent should not be relied upon and should be independently verified withprimary sources of information. Taylor and Francis shall not be liable for anylosses, actions, claims, proceedings, demands, costs, expenses, damages,and other liabilities whatsoever or howsoever caused arising directly orindirectly in connection with, in relation to or arising out of the use of theContent.

Page 2: Treatment of Complicated Grief Using Virtual Reality: A Case Report

This article may be used for research, teaching, and private study purposes.Any substantial or systematic reproduction, redistribution, reselling, loan,sub-licensing, systematic supply, or distribution in any form to anyone isexpressly forbidden. Terms & Conditions of access and use can be found athttp://www.tandfonline.com/page/terms-and-conditions

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Page 3: Treatment of Complicated Grief Using Virtual Reality: A Case Report

TREATMENT OF COMPLICATED GRIEF USINGVIRTUAL REALITY: A CASE REPORT

C. BOTELLA, J. OSMA, and A. GARCIA PALACIOS

Universitat Jaume I and CIBER de Fisiopatologia de la Obesidad yNutricion (CIBEROBN), Spain

V. GUILLEN

PREVI Clinical Center, Spain

R. BANOS

Universitat Jaume I and CIBER de Fisiopatologia de la Obesidad yNutricion (CIBEROBN), Spain

This is the first work exploring the application of new technologies, concretelyvirtual reality, to facilitate emotional processing in the treatment of ComplicatedGrief. Our research team has designed a virtual reality environment (EMMA’sWorld) to foster the expression and processing of emotions. In this study theauthors present a description of EMMA’s World, the clinical protocol, and a casereport. The treatment program was applied in eight sessions. We present a briefdescription of the session agendas including the techniques used. We offer short-term (from pre-test to post-test) and long-term (2-, 6- and 12-month follow-ups)efficacy data. Our results offer preliminary support of the use of EMMA’s Worldfor the treatment of Complicated Grief.

Most people experience intense sadness and anguish after thedeath of a loved one. Grief is a natural response to loss that hasa natural recovery process. However, for some individuals theduration and intensity of the symptoms exceed the naturalbereavement process. The symptoms acquire a clinical meaning

Received 10 April 2007; accepted 21 December 2007.The research presented in this paper was funded in part by the EU Fifth Framework

Programme Project called EMMA (IST-2001–39192-EMMA) Engaging Media for MentalHealth Applications (www.mindlab.org) and by Ministerio de Educaci�oon y Ciencia, Spain,PROYECTOS CONSOLIDER-C (SEJ2006-14301/PSIC). CIBER Fisiopatologia de laObesidad y Nutricion is an initiative of ISCIII.

Address correspondence to Cristina Botella, Dpt. Psicologia Basica, Clinica y Psicobio-logia, Universitat Jaume I., Avda Vicent Sos Baynat s=n., 12071 Castellon, Spain. E-mail:[email protected]

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Death Studies, 32: 674–692, 2008Copyright # Taylor & Francis Group, LLCISSN: 0748-1187 print/1091-7683 onlineDOI: 10.1080/07481180802231319

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and could be considered a mental disorder called complicated grief(CG; Lichtenthal, Cruess & Prigerson, 2004). This condition isassociated with social impairment, poor mental health, and otherindexes related to low quality of life (Silverman et al., 2000), andso it is a legitimate focus of therapy.

The empirical study of the efficacy of treatments for CG isscarce. Jordan and Neimeyer (2003) summarized the results ofseveral review studies in the field of interventions for thebereaved. The conclusions of those studies are not encouraging.Meta-analysis of both the adult (Kato & Mann, 1999) and childgrief therapy literature (Holland, Currier, & Neimeyer, 2007) sug-gest that bereavement interventions typically have weak effects,and leave much room for improvement. Shear, Frank, Houck,and Reynolds (2005) have reported encouraging data of theefficacy of a treatment program specifically designed for the treat-ment of CG. They conducted a randomized clinical trial compar-ing interpersonal psychotherapy (IPT) with a specific program forgrief called CG treatment (CGT). This treatment included aspectsof interpersonal psychotherapy like focus in restoration of a satis-fying life, but also procedures to address trauma-like symptoms,such as retelling the story. The results showed a higher efficacyof CGT vs. IPT. Other approaches like the one described inNeimeyer (2001) focus on the reconstruction of meaning afterthe loss, which could make further contributions to the treatmentof CG.

From the study of the literature related to CG we can con-clude that in the treatment of CG processing the loss of the lovedone, exploring and finding a meaningful sense to that loss to beable to continue with life seem to be useful strategies. This entailsworking with narratives, meanings, and symbols in therapy. Onthe other hand, it seems also important to address the trauma-likesymptoms by confronting the memories and situations avoided bythe bereaved. In this framework we believe that new technologies,and concretely virtual reality (VR), can help to improve thesetherapeutic tools.

VR is a new technology that creates computer-generatedsimulations of reality. The essence of VR is the illusion it givesusers that they are inside the computer-generated environment,as if they are ‘‘there’’ in the virtual world. In the field of clinicalpsychology, virtual reality has proven to be an effective tool

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for the delivery of exposure therapy in the treatment of phobias(see Anderson, Jacobs, & Rothbaum, 2004; Krijn, Emmelkamp,Olafsson, & Biemond, 2004; and Pull, 2005, for a review). VRis also used to treat an important stress-related disorder, PTSD.One of the active ingredients of cognitive-behavioral programsfor PTSD is imaginal exposure to the memories of the traumaticevent (Foa & Rothbaum, 1998). VR can enhance this techniqueby recreating the traumatic experience, that way it is not neces-sary to rely on the patient’s imagination skills; it can also preventcognitive avoidance, a phenomenon that could result in poortreatment outcomes. There are some preliminary data of theusefulness of this technique with PTSD sufferers who havegone through a specific trauma, such as exposure to combat(Rothbaum, Hodges, Ready, Graap, & Alarcon, 2001) and terror-ism (Difede & Hoffman, 2002). Our research group is also explor-ing the usefulness of a new VR environment called EMMA’sWorld in the treatment of stress-related disorders like PTSD,adjustment disorders, and CG (Botella et al., 2006). In the formerstudies that explore the usefulness of VR for PTSD, the approachis using VR to simulate with high realism the traumatic eventswith the aim of confronting the feared aspects of the trauma. Inour approach the aim is to design clinically significant environ-ments for each participant, but attending to the meaning of thetrauma and not to the simulation of the physical characteristicsof the context where the traumatic event took place. The aimis not realism but using customized symbols and aspects that helpto activate and process the trauma in a safe and protectiveenvironment. The flexibility of this VR environment allows treat-ing other stress-related disorders like CG. VR allows having atour disposal representations of the loss in a physical way, usingvirtual objects in a three-dimensional computer-generated space,objects that can change as long as the processing of the lossis achieved. Another therapeutic component in the treatmentof CG is exposure to treat the trauma-like symptoms. VR alsoallows reproducing and confronting the traumatic images,thoughts, and feelings. In this framework we believe that VRcan help to improve these therapeutic tools.

The aim of this work is to present our VR treatment programfor CG (EMMA’s World) and describe its application in a casestudy with results at post-treatment and at 1-year follow-up.

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Method

Participant

The participant, Ana, was a 24-year-old woman. She was singleand lived with her mother. She did not have any siblings. Shewas studying to become a nurse. Ana asked for help at Jaume IUniversity Emotional Disorders Clinic in Castellon, Spain.Although she did not trust psychological treatments she decidedshe needed help for her symptoms. She reported intense sadness,irritability, and difficulties concentrating. She said ‘‘I feel angryand guilty since my dad died’’. Her father was a medical doctorand he passed away in 2002. He had cancer since Ana was 11.After several successful treatments, in 2001 his cancer progressedto a generalized metastasis and after 1 year he died. Ana was study-ing in a different city but when her father relapsed she came backhome. Her mother (also a nurse) and Ana took care of him at homeuntil he died. In the moment of his death Ana was not at homebecause she was running errands and she regretted that. Afterhis death she reacted with anger against her father’s friends andfamily (she said ‘‘they never went to visit him’’). She returned toher usual life the day after her father’s death (she went to the uni-versity). In the last 2 years, since her father’s death, Ana had keptherself very busy, focusing on her studies in the mornings andworking in the afternoons and weekends. Ana reported that duringthis time she has been acting as if her father were not really dead,but only ‘‘on vacation.’’ Three months before coming to therapyshe quit her job to concentrate on other plans. She reported shehad more free time and started thinking more about the death ofher father. She reported feeling worse than before: ‘‘I only feelan extremely intense pain when I think about him’’. This was caus-ing a significant distress and impairment in her life. She had trou-ble sleeping, she was losing interest in activities and people, andshe had the feeling that her life was meaningless.

After one screening and two assessment sessions in our clinic,two clinicians (one an independent assessor) determined thatAna suffered from CG. She met the criteria for CG proposed byPrigerson and Maciejewski (2006). Her score in the Inventory ofCG (Prigerson et al., 1995) was 57. A score of 30 or more was con-sidered an inclusion criterion in a recent randomized clinical trial

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of CG (Shear et al., 2005). Both the therapist and the independentassessor considered the patient as ‘‘severely disturbed’’ in theGlobal Clinician Impression (Guy, 1976). As for DSM-IV criteria(American Psychicatric Association, 2000) she met the criteriafor adjustment disorder. She did not meet criteria for majordepressive disorder. She presented some posttraumatic symptomsbut she did not meet the full criteria needed for the diagnosis ofPTSD. Ana did not meet criteria for any other mental disorderand she had no history of any other mental disorder in the past.The independent assessor confirmed that CG was the principalproblem in this case.

Measures

Because of space constraints we will just mention the self-reportinstruments that are widely used and we will describe the othermeasures in more detail.

We used the Anxiety Diagnostic Interview Schedule IV(ADIS-IV; Di Nardo, Brown, & Barlow, 1994) for the diagnosis.CG symptoms were measured with the Inventory of ComplicatedGrief (ICG; Prigerson et al., 1995). Depression was measured withthe Beck Depression Inventory (BDI; Beck, Ward, Mendelson,Mock, & Erbaugh, 1961, adapted by Conde & Franch, 1984, forthe Spanish population). Positive and negative affect weremeasured with the Positive and Negative Affect Scale (PANAS;Watson, Clark & Tellegen, 1988). We used the fear and avoidancescales (adapted from Mark & Mathews, 1979) to measure fearand avoidance related with the loss. The patient and the therapistestablish two to four target behaviors or situations that the patientavoids related to the loss. Also, two to four intrusive images andthoughts related to the loss are established. The patient rates thelevel of avoidance on an 11-point scale, from 0 (I never avoid it)to 10 (I always avoid it); the level of fear is rated in another 11-pointscale, from 0 (No fear) to 10 (Extreme fear). The main negative orirrational thoughts related to the loss are specified. The degreeof belief in those thoughts is assessed on a scale from 0 to 10,where 0 means that the patient does not believe the content ofthe thought at all and 10 means that the patient believes thatthe thought is totally true. We use an instrument to measureimpairment, the Maladjustment Scale (MS; Echeburua, Corral,

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& Fern�aandez-Montalvo, 2000). This instrument assesses theimpairment that the problem causes in several areas of the parti-cipant’s life using an 11-point scale, from 0(none) to 10 (extreme).The scale has shown high internal consistency, discriminant andconcurrent validities, and it is sensitive to treatment outcome.(Echeburua et al., 2000). The therapist and an independentassessor rated the global severity of the patient using the ClinicianGlobal Impression (CGI; adapted from Guy, 1976) that includes ascale from 1 to 6, 1 (normal) and 6 (very seriously disturbed). Finallywe used the Expectations and Satisfaction with the TreatmentScale (adapted from Borkovec & Nau, 1972), designed to obtaininformation about the patient’s expectations and satisfaction withthe treatment. The questions were about how logical the treatmentseemed, to what extend it could satisfy the patient, if the patientwould recommend this treatment to other people, if it could beuseful to treat other problems, the usefulness for the patient’s prob-lem, and to what extent it could be aversive. The patient rated eachitem on 0 to 10 scales. The patient filled out the scale after she wasgiven the rationale for the treatment. Then she filled it out again atpost-treatment and at follow-ups. At post-test we included somequestions to evaluate the satisfaction with the specific elements ofEMMA’s World. The patient rated the questions on 0–10 scales.

Apparatus

The devices used for applying the treatment were two personalcomputers (PCs), a big screen where the environment is projected,two projectors, a wireless pad, and a system of speakers. Thesedevices were placed in a 5� 9 m room. PC#1 has the graphicaloutputs from its graphic card connected to two projectors (whichhave a resolution of 1024� 768 pixels and a power of 2000lumens). They are used to project the environment in a horizontalmetacrilate screen of 4� 1.5 m that is placed in the middle of theroom. A wireless pad is placed on a table in the other side ofthe room, and the patient sits next to it. From this perspective,the patient can view the virtual environment, and interact andnavigate using the wireless pad. The therapist sits next to PC#2,which is placed close to the patient. From this PC, the applicationand the features of the virtual environment that is shown to thepatient can be controlled. The sound system is composed of

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several speakers distributed in the room. In the first stages of thetherapy, the patient learns how to navigate and interact with the sys-tem by practicing in a neutral environment. Our VR setting is inno-vative because we don’t use a Head Mounted Display (HMD, orVR helmet) to immerse the patient in the VR world, but a bigscreen. We have data that support that the big screen achieved asimilar level of immersion than the HMD (Ba~nnos et al., 2004).

Virtual Environments

EMMA’s World is an adaptive display, a VR system that adjustsits presentation and actions to match the needs and abilities of theuser (Alca~nniz, Juan, Rey, & Lozano, 2006). The virtual environ-ment used to apply the treatment was designed within an EUFifth Framework Programme Project (IST-2001–39192-EMMAEngaging Media for Mental Health Applications, www.mindla-b.org). The goal of EMMA is to create an environment that offerspatients a special place where they can express and processemotions and where emotions have an effect on the environment(Figure 1).

A series of tools are available in the environment, and they areselected based on the therapist’s instructions. One of them is theDatabase Screen, where a listing of icons shows all the elementsthat a user can manipulate, including three-dimensional objects,sound, images, movies and texts. Another important tool is theBook of Life (Figure 1), a virtual book where the person can reflectupon feelings and experiences along different times. The objectiveis to represent the most important moments, people, and situationsin the person’s life (related to the loss). Anything that is meaningfulfor the patient can be incorporated in the system: photos, draw-ings, phrases, videos, and so on.

EMMA’s World also includes five different pre-definedscenarios or ‘landscapes’ (see Figure 1): a desert, an island, athreatening forest, a snow-covered town, and meadows. Theseenvironments were designed and developed to reflect differentemotions (relaxation, elation, sadness, etc.). Their specific usedepends on the context of the session and can be selected by thetherapist in real time. The aim is to reflect and enhance theemotion that the user is experiencing. It is possible to includemodifications in the scenario and to graduate their intensity to

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reflect the changes in the participants’ mood states. For example, inthe elation landscape, EMMA’s World is surrounded by green hillsand trees. It is a beautiful sunny day. The environment can bechanged by covering the sky with clouds and becoming graduallysunny. Also, we can make the landscape more colorful (with flow-ers) and livelier (with butterflies and birds). Besides the specificvariations for each emotional scenario, it is possible to modify

FIGURE 1 Image of EMMA’s World, the Book of Life, and different aspects ofthe virtual environment: the meadows, the desert, the island, the snow-coveredtown and the threatening forest.

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the environment according to the time (day or night) with the aimof reflecting or enhancing the participant’s mood state. The thera-pist can also create different effects in the environment such asrain, snow, earthquakes, etc.

The goal of the EMMA’s virtual environment is to workwith negative emotions related to the participants’ psychologicalproblem (e.g., anger, anxiety, sadness). All elements (3D objects,sounds, colors, lights, images, symbols, etc) are designed to helpthe person confront and manage the emotions and experiencesthat he=she has gone through previously in his=her life and is goingto experience in the therapy environment. EMMA’s World is alsodesigned to experience and process not only negative emotions,but also positive emotions like relaxation or elation.

Procedure

As mentioned before, the participant asked for help for her prob-lem at the Jaume I University Emotional Disorders Clinic. Ascreening session lasting around 50 minutes was conducted toscreen the main problem. Then two assessment sessions were con-ducted to determine the diagnosis and administer the assessmentprotocol instruments. In these sessions the target behaviors, intrus-ive thoughts and images, and irrational thoughts were also estab-lished. The behaviors were ‘‘Going to the cementery’’ and‘‘Talking with her mother about her father.’’ One of the intrusivethoughts was ‘‘doubts about how much her father suffered the lastdays.’’ And one of the irrational thoughts was ‘‘I won’t be able tobe happy.’’ The therapist then explained the results of the assess-ment, gave a general rationale for the treatment program, andasked the patient her consent to be a participant in our study. Athird assessment session was conducted by an independentassessor to confirm the diagnosis and assess the severity of theproblem using the CGI. The treatment lasted eight 60-minutesessions. The patient came to the clinic once a week.

After the treatment there was a post-treatment assessment ses-sion where the patient filled out the same assessment protocol thanat pre-test. We established three follow-up assessments at 2, 6, and12 months. The independent assessor rated the severity of theproblem at post-treatment and at 12-month follow-up afterlistening to the audiotapes of the sessions. The participant did

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not receive any other psychological or pharmacological treatmentduring the total length of the study.

Therapist

The therapist was a member of the research team (author J. Osma).He had 6 years of experience in the application of cognitive-behavioral programs for emotional disorders and in theapplication of VR therapy. The independent assessor (author A.Garcıa Palacios) had 10 years of experience in the application ofcognitive-behavioral programs and in the use of VR therapy.

Treatment

The treatment is a structured and manualized cognitive-behavioralprogram for the treatment of CG designed by our research teambased on Neimeyer’s (2000b, 2001) program for fostering meaningreconstruction in CG and including elements from Foa andRothbaum’s (1998) program to treat trauma-like symptoms, andfollowing the guidelines of Linehan (1993) for mindfulness strate-gies. It lasts between 8 and 12 sessions. The sessions are held oncea week. Each session lasts around 60 minutes. The main innovationoffered by our program to the treatment of pathological grief is thatit uses a new technology (VR) as a tool to apply the treatment. Theprogram includes the following components: education, slowbreathing training, exposure, cognitive restructuring, and mindful-ness strategies. The content of the sessions will be described in thenext section. The sessions were audiotaped for the patient to listento them at least once between sessions.

Clinical Description of the Therapy Sessions

The first therapy session was devoted to present the rationale forthe treatment and education about grief: common emotionalreactions to the death of a loved one, attachment and grief(Bowlby, 1982), and grief as a process. In this session the patientalso was trained in slow breathing as a means to alleviate distress.The homework of this session was to practice slow breathing train-ing 15–20 minutes a day and listen to the audiotape of the sessiononce. The second session was dedicated to introduce the virtual

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environment, EMMA’s World and the Book of Life. The main taskin the session was filling out the contents section of the book. Thegoal of this task was to transmit the idea of continuity, that is to say,life is like a book with different chapters. Some of them are alreadywritten and they contain different experiences, emotions, people,and so on. All chapters are important because they are part ofour unique lives. And also, there are many other chapters to bewritten yet, even if at the present moment it seems impossible,because it is like life cannot go on. The death of her father is achapter in itself and working on that chapter is the goal of the treat-ment program but it is important to highlight that there are chap-ters before and there will be chapters after. This task wasconducted in EMMA’s World. The book is a virtual book andwe can write on it, but also fill it with music, images, objects,videos, and pictures. In this session the patient chose the virtualelements that symbolized her father’s death: a rope, a picture ofa disorganized desk, the picture of a funeral, and the picture of acar accident. The VR environment includes a panel where apatient can see the different objects and choose the ones thatsymbolize the problem.

In the third session mindfulness strategies were introduced.The aim of mindfulness strategies in our treatment program wasto help the patient to be open to her emotional experiences as afirst step to be able to process them. We chose the mindfulnessstrategies designed by Dr. Linehan (1993). The goal is to learn to(a) observe the own external and internal experiences at thepresent time, with an open attitude, (b) describe those experiences,and (c) participate. Observe, describe, and participate withoutjudging, doing one thing at a time, and being effective. A mindful-ness exercise was conducted using EMMA’s World. We used theisland scenario (a beach with palm trees and the ocean) and thegoal was to observe the waves. The second part of the sessionwas dedicated to identify situations related with the patient’s fatherthat she had been avoiding. The Subjective Units of Discomfort(Wolpe, 1969) were also introduced. The avoided situations weregoing to the cemetery, talking with her mother about his father,attend family gatherings, and going to the soccer games she usedto go with her father. Homework included practicing breathingtraining and listen to the audiotape of the session once. Fromthe fourth session the main objective of the therapy was

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addressed: the process and assimilation of the loss. In EMMA’sWorld and by means of the symbols chosen, and use of music,the patient was exposed to the emotions related to the loss: anger,anxiety, and deep sadness. Irrational thoughts like ‘‘if I hadn’tleave that day he will be still alive’’, ‘‘I should have spent moretime with him,’’ and ‘‘I won’t be able to be happy ever again’’ wereaddressed with cognitive restructuring. Mindfulness strategies wereused to observe and describe the emotions, and to work on accept-ing those emotions. As the sessions went on, the patient was realiz-ing that those emotions were disturbing but not overwhelminganymore and that they were a sign of how much she loved herfather and how much she missed him. That is, the patient was find-ing new meaning in her loss. Self-exposure tasks were conducted ashomework assignments from the fourth session. The first situationwas talking about her father’s death with her mother. Other home-work included breathing training and listening to the audiotape ofthe session. In the next sessions the patient chose different scenar-ios and elements from the virtual environment to work on proces-sing the loss. In the fifth and sixth sessions the patient chose theisland scenario because it reminded her sailing with her father inthe summer time. The snow landscape was chosen to reflect deepsadness. In these sessions the most painful memories related to herfather’s death were recalled and processed: ‘‘my father fell down athome when he was already very weak’’, ‘‘the way to the cem-etery.’’ In processing the death of the loved one it was importantto talk about the deceased person, what he meant to her whenhe was alive and what he meant now that he was dead; thepatient’s life before and after her father’s death, including thefuture. In seventh session, a new exercise was introduced to pro-gress in the emotional processing: the life imprint (Neimeyer,2000b). The goal of this exercise was to think about the contribu-tions and influences of the deceased person in the patient’s life. Ashomework the patient was asked to write a letter of projectiontoward the future. The instructions were to ‘‘Imagine you can senda letter to yourself from the future, 5 years from now.’’ The goal ofthis exercise is to emphasize the idea of continuity, of life going onafter the loss. Ana could see herself opening her own podiatry clinicand working with her mother; she could also see herself having ameaningful relationship with her boyfriend in the near future.Finally, she could see herself having life problems in the future

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and facing and solving them. The eighth session was devoted toanalyzing the letter. The therapist and patient reviewed the progressachieved throughout the therapy sessions. As therapy went on, thepatient changed the elements and scenarios representing the lossusing EMMA’s World. The final metaphor was an organized house.The patient reported, ‘‘I believe that my father left strong founda-tions in me, my life is more organized, it has more sense and I haveovercome the chaos it has been in the last two years.’’ Sessions werescheduled for the post-treatment and follow-up assessments.

Results

In Figure 2 we offer the pattern of the evolution of the scoresrelated with the target behaviors: fear, avoidance, believe inirrational thoughts, and degree of fear and avoidance related withintrusive thoughts. The scores decreased in all measures achievingvery low scores at post-treatment and follow-ups. Table 1 showsthe decrement in the outcome measures from pre-treatment topost-treatment and 1-year follow up: CGI, BDI, Negative Affectsubscale of the PANAS, the impairment caused by the CG in

FIGURE 2 Target behaviors: Fear and Avoidance related with one of theavoided situations; Belief in irrational thoughts; and avoidance of intrusivethoughts and images. Scores at pre-treatment, after the psychoeducation session,at sessions 4, 6, and 8, at post-treatment, and at two, six, and twelve-month follow-up assessments.

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several life areas (work, social life, leisure, family, marital, and lifein general). The Positive Affect subscale of the PANAS increasedfrom pre-test to the last follow-up. The CGI rated by the therapistand by the independent assessor also decreased from pre-treatment to 1-year follow-up. Finally, the ratings regarding theexpectations and satisfaction with the treatment showed a goodacceptance and satisfaction with the treatment program. Thepatient rated all the expectation and satisfaction items above 7and she gave expected aversiveness a rating of 2 before receivingthe treatment and did not find the treatment aversive at all at post-test and follow-up assessments. At post-test we asked the patientmore specific questions about EMMA’s World. The first questionwas ‘‘to what extent do you think that EMMA’s World has helpedyou to overcome your problem?’’ The patient rated the benefits ofEMMA’s World as 10 on a 0–10 scale. She made comments suchas, ‘‘It has been very helpful that the system could reflect what I wasfeeling, it could understand my feelings.’’ The second question was‘‘To what extent do you think EMMA’s World is better thantraditional therapy to apply the therapeutic tools (cognitive

TABLE 1 Evolution of Scores in Outcome Measures from Pre-treatment to12-month Follow-Up

Measure Pre-treatment Post-treatment2-month

FU6-month

FU12-month

FU

ICG 57 26 18 6 7PANASþ 27 40 40 37 42PANAS� 31 19 13 11 12BDI 18 3 1 0 0Work impairment 6 4 1 0 0Social impairment 6 3 0 0 0Leisure impairment 6 3 0 0 0Marital impairment 8 2 0 0 0Family impairment 5 3 2 0 0Global impairment 5 3 1 0 0CGI T 5 2 2 1 1CGI IA 4 2 1

Note. ICG: Inventory of Complicated Grief; PANASþ: Positive and Negative AffectScale, Positive Affect subscale; PANAS�: Positive and Negative Affect Scale, NegativeAffect subscale; BDI: Beck Depression Inventory; CGI T: Clinician Global Impressionrated by the therapist; CGI IA: Clinician Global Impression rated by an independentassessor.

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restructuring, exposure, mindfulness)?’’ She rated this question as 8on a 0–10 scale. She added that, from her perspective, ‘‘EMMA’sWorld could achieve the same results as traditional therapy butmaking the work of the therapist and the patient easier becausethe program helps you to be more aware of your emotions.’’ Weasked the patient to rate how useful specific aspects of EMMA’sWorld were for her on 0–10 scales: Possibility of choosing andusing symbols: 8; EMMA’s World ability to reflect my emotions:8; possibility of choosing different environments: 10; possibilityof introducing personal items in the virtual world: 10; the bookof life: 9; Music: 10; and special effects (day, night, fog, rain,etc.): 10.

Discussion

Despite the disturbing symptoms and the impairment that CGcauses in the individuals’ quality of life empirical studies testingthe efficacy of treatment programs for this disorder are very scarceand the efficacy data for grief therapy in general are not veryencouraging (Jordan & Neimeyer, 2003). There is a need of researchin developing and testing treatment programs for this disorder.

The present work presents a description of an innovativetreatment program for CG using VR in a case report. The programis a structured cognitive-behavioral manualized program designedby our team that includes several elements from other programs(Foa & Rothbaum, 1998; Linehan, 1993; Neimeyer, 2000, 2001)that we believe are important for the treatment of CG: an edu-cational component to give information to the patient about thenature of the bereavement process; a breathing training techniqueto deal with physiological symptoms; an exposure component totreat the trauma-like symptoms present in CG, namely avoidanceof situations, thoughts, images, and emotions related to the deathperson, and re-experiencing symptoms; a cognitive restructuringcomponent to analyze and correct the meanings associated withthe death of the loved one and the bereavement process; and amindfulness component to promote awareness and acceptance ofinternal and external experiences. The most innovative aspect ofour program is the use of a new technology, VR as an aid to applythe components of our program. This is the first work describinga VR application for the treatment of CG.

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The patient was a young woman affected by CG. After eighttherapy sessions the symptoms decreased significantly and thetherapeutic outcomes were maintained and even improved atlong-term (12-month follow-up). The improvement in the measuredirectly related with CG, the ICG, was very significant. Our patientscored 57 in the ICG at pre-treatment. At post-treatment the scorewas 26, a decrement of 54%. The decrement was even higher at2-month follow-up (68.5%) and even more dramatic at 6- and12-month follow-up (more than 85%). The patient also showedan important improvement in the questionnaires measuring mood,the PANAS and the BDI. The impairment in important life areaslike work, social life, family, and global impairment obtained reduc-tions of around 80% from pre-treatment to one-year follow-up.Finally, at pre-treatment both the clinician and the independentassessor rated the severity of the patient’s problem as 5 (severely dis-turbed) in the CGI, and the independent assessor as 4 (quite dis-turbed). At 1-year follow-up the clinician and the independentassessor rated the patient’s problem as 1 (normal). The patient alsoreported being satisfied with the program as the ratings on theExpectations and Satisfaction with the Treatment Scale stated.The specific elements of EMMA’s World were evaluated by thepatient as very helpful. It is worth to highlight that one of the fea-tures that the patient liked more about the system was its abilityto reflect her emotions. EMMA’s World was able to show ‘‘empa-thy;’’ this means that virtual environments could be a powerful toolfor the therapist to build an effective therapeutic relationship.

In summary, our program was effective in the treatment of CGin our patient. The patient continued improving in the year after thetreatment completion without receiving any additional psychiatricor psychological treatment. In a recent randomized clinical trialof CG (Shear et al., 2005) the authors defined treatment responseas an independent evaluator score of 2 or lower on the CGI anda decrement of at least 20 points on the ICG. Following these cri-teria our patient can be considered a treatment responder.

We think that VR helped the patient and the therapist to workwith the meanings associated with the grief process in an easierway. EMMA’s world is an adaptive display, a new generation ofvirtual environments that allows using a variety of tools (objects,music, videos, words, etc.) with changes in real time (i.e., changingthe weather from sunny to cloudy). EMMA’s World becomes a

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physical timeless space where all the meanings associated with thedeath person can be actually seen and changed as long as the ther-apy advances. We think this promotes a better assimilation of theloss. The patient can see EMMA’s World as a place for resting andrecovering. Our program promotes the processing and acceptanceof the past and the opening of the future, a future with a wide num-ber of possibilities.

Our work presents some limitations that we would like tomention. This is only a case report and because of that we haveto be cautious about the efficacy of the program. These are verypreliminary data that encourage us to start a randomized con-trolled trial to test the efficacy of our program with a larger sampleand a control group. We would also like to test if our programwould be also as efficacious and effective without using new tech-nologies. Another limitation is that because of practical issues(schedule problems) the independent assessment was made by lis-tening audiotapes of the sessions at post-treatment and follow-up. Itwould be more accurate for the independent assessor to set assess-ment sessions with the patient. Another limitation is that we onlyconducted a diagnostic interview at pre-treatment. It would havebeen useful to conduct a diagnostic interview also at post-treatmentand at follow-up.

CG deserves more research to design effective treatment pro-grams to give a suitable response to individuals who suffer this dis-turbing problem. This work offers preliminary but encouragingdata of a cognitive-behavioral program supported by VR for thetreatment of CG.

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