CyberSightings

In the Spotlight

Last week, while I was attending the last session of the Cybertherapy conference in Brussels (www.e-therapy.info/), I suddenly realized that 10 years have been passed since I started my journey into the world of Cyberpsychology. Luckily, today I can say that I look at this field with the same enthusiasm of the past. Nevertheless I feel that it is time to ponder what has been the impact of this approach on healthcare. Undoubtedly, the evolution of technological tools is the most remarkable progress that has characterized Cybertherapy in the last decade. Today, a virtual reality (VR) system can run on a cheap notebook, or even on a tablet PC. And thanks to the emergence of wearable displays (e.g., the Google Glass, https://plus.google.com/+projectglass/), the massification of augmented reality is right round the corner. What is more, the convergence between body computing and smartphones is providing therapists with new ways of unobtrusively collecting psychological, physiological, and behavioural data during patients' daily life activities, enabling more personalized interventions. Finally, social networks like PatientsLikeMe are making therapy a more participative process, allowing patients to contribute their expertise to one another and to play a proactive role in clinical research.

However, despite significant advances of cybertherapy technologies in the last decade, their actual adoption rate is still very low. To the best of my knowledge, a negligible number of centers in the world is offering virtual therapy/cybertherapy services. With few exceptions, the large majority of clinical professionals who are using cybertherapy are doing it within R&D projects supported by funding agencies. But what are the reasons behind low adoption of virtual therapy in clinical practice? According to Everett Rogers' Diffusion of Innovations theory (E. Rogers, Diffusion of Innovations, 4th edition, New York: Free Press, 1995), there are five factors that influence an individual's decision to adopt or reject an innovation: (a) relative advantage: the degree to which the innovation is perceived to be better than the existing solution/s; (b) compatibility: the level of compatibility that an innovation has with existing values and needs; (c) complexity: the difficulty of understanding and use; (d) trialability: how easily an innovation may be experimented with on a limited basis; and (e) observability: the extent that the results are visible and accessible to others; for example an innovation that is more visible will be more likely spread out among users' personal networks and will in turn create more positive or negative reactions.

If we look at the situation of virtual therapy in light of these factors, what considerations can be drawn? With regard to the first aspect, there is good news. Several meta-analyses have highlighted that, in terms of efficacy, VR based interventions are at least as good as conventional treatments. However, there is also evidence that VR may be more effective than standard therapeutic approaches, that is, reducing the number of therapeutic sessions, increasing acceptance, and providing more accurate and objective assessment tools. The discussion of the second issue (compatibility) is not as straightforward and requires some pondering. If, on the one hand, clinicians who have some experience with VR are generally persuaded of its potential, some therapists fear that technology could replace their role, sometimes expressing ethical and regulation concerns (e.g., as in the case of tele-therapy). Further, in rehabilitation settings, some patients may report difficulties in understanding the role of technologies and may not consider a game like experience to be “real” rehabilitation. The third issue of Rogers' model (complexity) leads, without doubts, to a negative statement. Current VR systems are not simple enough, and their use typically requires additional training, both for therapists and for patients. Despite the improvements in the ergonomics and usability of these interfaces that have been observed in recent years, VR therapy based tools are not yet easily used by clinicians. Issues of triability and observability have not been fully addressed either. Most virtual therapy systems are not available in shops and are still hidden in the laboratories of universities or in medical research centres, reducing their accessibility for interested clinicians. Further, the few companies that are developing and selling those systems are not internationally established and cannot offer in-office demonstrations of their products.

If this picture of the penetration of VR therapy is reliable, what strategy should the cybertherapy community adopt in order to foster a wider adoption of this approach? A possible way is to shift the focus from the first dimension of Rogers' innovation model—the relative advantage—to other factors that have been more overlooked. But how does this translate into practice?

In order to increase the level of compatibility, for example, one could promote more empirical research concerning values, expectations, and needs of both primary users (therapists) and secondary users (patients). Moreover, one could invest more effort in improving the usability of interfaces and dedicate more attention to participatory aspects of design (e.g., by involving therapists and patients from the very initial phases of the prototyping process). As far as triability and observability issues are concerned, the key challenge is how to make innovations in virtual therapy more visible and accessible for the interested clinicians. To address these issues, there should be more opportunities for making virtual therapy technologies visible and “triable” outside scientific conferences or workshops by providing more opportunities for public dissemination and experimentation of this approach.

I am aware that most of my colleagues are working hard to overcome the barriers of adoption of VR therapy. At the same time, I believe that it is useful to stress the importance of this issue in the hope that, 10 years from now, this column will be able to celebrate the progress of cybertherapy and its impact on clinical practice.

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