Paper Soledad Quero - Acceptability of an Online Emotional Therapy System to Apply Homework Assignments in Adjustment Disorder: A Case Study
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 ,,. Furthermore, AD is an important public mentalpublic health problem. However, only general treatment health problem in economic terms. Very frequently theguidelines are available for this problem. Our research team has distress and activity deterioration associated with this problemdeveloped a Cognitive-Behavioral Treatment (CBT) supported result in a decrease of work performance, causing a highby Virtual Reality (VR) that has shown its utility in thetreatment of this problem. CBT approach gives a crucial role to percentage of sick leaves .homework assignments. So far studies that use Information and However, only general treatment guidelines are availableCommunication Technologies (ICTs) for psychological for this problem , , , . Our research team hastreatments have been centred on how to use the technologies to developed a Cognitive-Behavioral Treatment (CBT) programdeliver the treatment within the therapeutic context. No study is that utilizes Virtual Reality (VR) . Specifically, we useavailable in the literature that uses the ICTs to apply the EMMA’s World, an adaptive display whose content ishomework assignments. TEO is a completely open Online adapted to every patient’s needs with the main objective ofEmotional Therapy system base on Web technology that allows reflecting and evoking emotional responses in them to allowin a simple and effective way to create personalized therapeutic the emotional processing to occur . In the specific case ofmaterial to present to the patient over the Internet. Therefore,the aim of the present work is to present preliminary data about AD, this open VR system canbe used to treat differentthe acceptability of TEO system in a case study with AD where stressful events relevant to the particular problem (e.g. theVR EMMA system within the therapy sessions was joined with breakup of an intimate relationship, the death of a beloved one,the use of other ICTs to apply homework assignments between work problems, family problems, bullying, etc.). Thissessions in the treatment of AD. treatment protocol has already showed its efficacy in several preliminary studies with participants diagnosed of stress I. INTRODUCTION related disorders (including AD) , , . One way to enhance the efficiency of AD treatment outcomes could be by According to the DSM-VI-TR , the primary feature of using Information and Communication Technologies (ICTs)Adjustment Disorders (AD) is the development of clinically to apply homework assignments in order to consolidatesignificant emotional or behavioural symptoms in response to learning between therapy sessions. As far as we know, therean identifiable stressor. Furthermore, symptoms must be are no studies that use ICTs to apply this therapeuticdeveloped within 3 months after the onset of the stressor. component. Therefore, we considered interesting to develop aBoth the symptoms (e.g., anxiety, depression, disruptive self-applied system which permits the patient to do thebehaviours) and the precipitating events widely vary (e.g., homework assignments at home over the Internet and combinedivorce, loss of job, the diagnosis of a serious disease, family this with the use of VR within the therapy sessions in theproblems, bullying, complicated bereavement, etc.). consulting room. AD are an important health problem . They are very In order to do this we have designed a Web-based systemprevalent, indicating the available data a percentage of adults called TEO (Emotional Therapy On-Line). TEO is asuffering from AD in primary care ranging from 5% to 21% completely system open that allows therapists to create and
send personalized therapeutic material to patients via the level of agreement with the same items but referred to TEOInternet in an easy way (http://www.teo.uji.es). It makes system: the multimedia contents were useful to overcome herpossible to cover all types of needs and optimize therapy by problem, having available at home the symbols andhomework assignments. The system has a database with landscapes of EMMA’s World were useful to process themedia contents: audio, images, videos and texts. The negative event and, other persons with similar problemstherapists can access these materials from the therapist’s should use this system. Also an item was included to assessplatform in order to combine them to create the different how often she implemented the assignments per week. Finally,therapeutic homework sessions. In addition, TEO assesses 5 additional items were included in order to assess otherseveral clinical variables (e.g., mood state) before and after relevant questions regarding usability of the system (whethereach session and the therapist can access the reports resulting TEO was easy to use, easy to learn, easy to follow thefrom any patient’s activity: assessment, content, assigned instructions, comfortable and attractive).sessions, completed sessions, dates, etc. The aim of thepresent work is to present preliminary data about the Comparison Questionnaire of the two Methods of applyingacceptability of TEO system in a case study with AD. Homework Assignments (Traditional versus TEO System) . This questionnaire assessed the participant’s preferences (TEO system versus Traditional) after treatment by answering II. METHODOLOGY 4 questions: “What type of application would you ratherA. Participant use?” “Which one of them was more useful to overcome your problem?” “Which one was more useful to process the The participant was a 35 year old woman, divorced and negative event”, and “which one seemed more attractive towith Colombian Nationality who was living in Spain for the you?”. The response scale was multiple choice with 3last 2 years. At the moment of the assessment she was doing alternatives: TEO, Traditional or No difference.her doctorate. She met the DSM-IV-TR criteria  for ADwith mixed anxiety and depression mood subtype due to work C. Designproblems. The design was a case study with 2 experimental conditions:B. Measures 1) Homework assignments using TEO system: 3 sessions where the homework assignments were applied with TEO The measures used in the present study were specifically system.designed for this research. 2) Homework assignments in the traditional way: 3 Homework Assignments Preferences Questionnaire . sessions where homework assignments were applied in theBefore starting the treatment, the patient was given a brief traditional way (reading materials, writing tasks and sessionexplanation about the two ways of applying the homework audio record).assignments (using TEO or Traditional). After thisexplanation, she answered 4 questions concerning her D. Treatmentpreferences with regard to the homework assignments (TEO The participant received a CBT program for AD. Theor Traditional). These questions were: 1) “If you could choose treatment protocol consisted of 6 weekly sessions with thebetween the two ways of applying the homework assignments, following main therapeutic components: educationalwhich one would you choose?”; 2) “Which of these two ways component, elaboration/processing of the stressful event withdo you consider more effective to help you overcome your EMMA’s World (see a full description in , , ,problem?”; 3) “Which of these two ways do you consider .), and relapse prevention. A detailed description of themore aversive?” and; 4), “Which of these two ways would you CBT program can be found in .recommend to a friend in case that he/she had the sameproblem?”. Finally, the therapist asked the patient the reasons E. Procedureof his preferences in each of these aspects according to her After the patient’s request for assistance, a screeningresponses in the questionnaire. interview was carried out, where the main relevant data about Homework Assignments Assessment Questionnaire . her and the problem she was seeking assistance for wereThis measure was completed after treatment and includes two collected. After this first interview, the evaluation phaseparts: 1) Traditional method assessment part in which the started, which consisted on 2 one and a half hour-sessionsparticipant answered 3 items regarding her opinion about this each where the Homework assignments preferencesway of applying homework assignments. The participant questionnaire was applied. At post-treatment the participantreported her level of agreement with the items on a Likert was evaluated again using the same instruments as in the pre-scale ranging from 1 (I totally agree) to 5 (I totally disagree): treatment. She also filled in the questionnaires about thethe reading materials were useful to overcome her problem, opinion of the Traditional way to apply the homeworkthe audio recorded sessions were useful to process the assignments and the opinion of the TEO system to apply them,negative event and, other persons with similar problems as well as the comparison questionnaire between the twoshould use this material. An additional item assessed how modes of applying the homework tasks.often she implemented the assignments per week. 2) TEOmethod assessment part in which the participant reported her
III. TEO SYSTEM TEO is a system based on Web technology(http://www.psicologiaytecnologia.es/teo) and it includes 2platforms: the therapists platform and the patient’s platform. 1) Therapist platform (see Fig. 1): The therapist canmanage and administer the users and the results of treatmentof each user, create sessions and customize treatmentprotocols using the multimedia materials (pictures, texts,narratives, music and videos) included in the TEO multimedia Fig 3: Media element displayed in the patient’s platform.base, view the content, and assign sessions as well astreatment and assessment protocols to the patients. 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 Fig 1: Screen shot of the therapist’ platform traditional way more aversive than TEO. TABLE I 2) Patient platform: Patients can complete the pre-session RESULTS OBTAINED FROM THE HOMEWORK ASSIGNMENTS PREFERENCESassessment protocol (see Fig. 2), they can visualize the QUESTIONNAIRE AT PRE-TREATMENThomework sessions assigned by their therapist (see Fig. 3) andmove around a virtual environment (they can choose a beach Questions Responsesor a forest environment) at the end of each session to reflect If you could choose between the TEOon the session and their experience (see Fig. 4). two ways of implementing homework assignments, which one would you choose? Which of these two ways do you TEO consider was more effective to overcome your problem? Which of these two ways do you Traditional consider more aversive? Which of these two treatments TEO would you recommend to a friend in the case that he/she had the same problem? 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 Fig 2: Screen shot of the assessment protocol. 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 methods she continued to prefer the TEO system over the RESULTS OBTAINED FROM THE HOMEWORK ASSIGMENTS ASSESSMENT traditional method. QUESTIONNAIRE AT POST-TREATMENT TEO is the first program developed that permits to apply Item TEO Traditional the homework assignments component using a computer and It is useful to overcome Totally agree (1) Agree (2) in a self-applied way. In addition, TEO offers a great the problem adaptability and flexibility to adjust the therapeutic homework It helps to process the Totally agree (1) Agree (2) on every patient’s characteristics and needs, attending to the negative event specific meaning of his/her problem. Each session will be Other people with similar Totally agree (1) Agree (2) adapted to the patient’s needs. Furthermore, because it is problems should use this based on Web it will increase the possibilities for therapy: it method can be used in blended mode (complementing the therapy), or Days of the week the 4-5 times per week 4-5 times per in tele-assistance mode (being the own self-administered homework assignments week therapy). It might also facilitate the patient’s treatment were implemented adherence and the therapist’s work in designing homework Easy to use Normal (3) assignments. Easy to learn Agree (2) Easy to follow the Nor agree neither Although the results obtained in the present study are instructions disagree (3) promising, they must be taken carefully since it is only an Comfortable Very comfortable uncontrolled case study being the external validity of these (5) results compromised. Therefore, future research is needed in It is very attractive Totally agree (1) 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 Finally, the results concerning the Comparison been presented in the present study, it permits the design ofQuestionnaire of the two Methods at post-treatment showed personalized homework assignments to practice at home whatthat, once the participant implemented both methods, she they have worked in the therapy sessions in a self-applied waycontinued to prefer the TEO system, she also continued to using a computer. And secondly, it would also allow theconsider it more useful to process the negative event and more design of entire therapeutic sessions or parts of sessions thatattractive, compared to the traditional method (see Table III). 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. TABLE III RESULTS OBTAINED FROM THE COMPARISON QUESTIONNAIRE OF THE TWO METHODS AT POST-TREATMENT ACKNOWLEDGMENTS Items Chosen option I prefer to use it TEO The research presented in this paper was funded in part by It is more useful to overcome No difference Ministerio de Ciencia y Tecnología (PSI2010-17563), the problem It is more useful to process the TEO Generalitat Valenciana, Conselleria de Educación Programa negative event de Investigación de Excelencia PROMETEO (2008/157), and It is more attractive TEO CIBER. CIBER de Fisiopatología de la Obesidad y Nutrición is an initiative of ISCIII. V. CONCLUSIONS REFERENCES  American Psychiatric Association. Diagnostic and statistical manual of Results obtained in the present study showed positive mental disorders DSM-IV-TR (4th ed., text revision). Washington, DC,expectations towards the TEO system. Before treatment, the APA, 2000.participant preferred the TEO system over the traditional way  J.N. Despland, L. Monod & F. Ferrero. Clinical relevance ofto apply homework assignments, considering this new way of adjustment disorder in DSM-III-R and DSM-IV. Comprehensive Psychiatry., vol. 36, pp. 454-460. 1995.implementing homework more effective and less aversive.  H. Fabrega, J.E. Mezzich & A.C. Mezzich. Adjustment disorder as a Furthermore, the participant’s opinion after treatment was, marginal or transitional illness category in DSM Archives of Generalin general, very positive for both methods. However, she Psychiatry., vol. 44, pp. 567–572.1987.reported a more positive opinion about TEO than the  J.L. Van der klink, R.W. Blonk, A.H. Schene & F.J. van Dijk. Reducing long term sickness absence by an activating intervention intraditional method. She also answered positively to the items adjustment disorders. Occupational and Environmental Medicine., vol.referred to the usability of the system (e.g., easy to use, easy 60, pp. 429-437. 2003.to learn, comfortable). Finally, when she compared both  A. Andrews. Treatment outlines for the management of anxiety status: The Quality Assurance Project. Australian and New Zealand Journal of Psychiatry, vol. 19, pp. 138-151. 1995.
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